Every finding on record at Northridge Health and Rehabilitation

Based on observations, staff interviews, and review of the facility-provided dietary recipes, the facility failed to ensure dietary staff followed recipes for preparing pureed meals to conserve the nutritive value and flavor for eight of eight residents (R) who received a puree diet from a total of 82 residents who received an oral diet from the kitchen.Findings include:Review of the facility-provided recipe for Vegetable Blend Capri Pureed Thick revealed the Ingredient and Instructions section included Capri Vegetable Blend and food thickener. 1. Remove portions required from the regular prepared vegetables (drain liquid). 2. Add drained vegetables to food processor and process until smooth in texture. 3. Add a food thickener. Process briefly until mixed, scraping sides of bowl.Review of the facility-provided recipe for Mashed Potato Insta Prep (Flakes) revealed the Ingredient and Instructions section included Water boiling, skim milk, potato granules, unsalted butter, and salt. 1. Pour water and milk into a large bowl. 2. Add instant potato flakes, butter, and salt.Observation on 7/22/2025 at 11:01 am with Certified Dietary Manager (CDM) MM revealed dietary staff preparing mixed vegetables. Assistant Kitchen Manager MM measured 4 and a half scoops of carrots, which she revealed was an 8-ounce scoop that was enough to prepare nine pureed meals, and added it to the pureed bowl. She pureed the vegetables and added hot water to the bowl with the pureed vegetables. She stated that she wanted to make sure the carrots were pureed completely. She turned the machine on again and pureed a second time. She then added a scoop of thickener and continued to puree. She then removed the lid and the pureed vegetables, placing them in a metal container covered with plastic wrap and placed it in a warmer.Observation on 7/22/2025 at 11:20 am revealed CDM MM preparing the pureed mashed potatoes. She stated that she had 4 cups of hot water in a metal container and added salt to the water. She then opened a bag of potato flakes, pouring them into the water, and mixing with a whisk. After mixing the potato mixture, she covered it with plastic wrap and then placed it in the warmer.In an interview on 7/22/2025 at 11:47 am, CDM MM stated that when liquid needed to be added to the vegetable pureed mixture, she would add vegetable broth. She further stated that she did not need to add broth to the vegetables. When asked how much potato flakes were added to the water, she stated maybe 2 cups. When asked if the recipe included milk, she stated she should have followed the recipe and added milk when preparing the potatoes. In an interview on 7/22/2025 at 11:50 am, the Division Dietician revealed that when pureeing food, the recipe should be followed.

Based on resident and family interviews, staff interviews, record review, and review of the facility policy titled, Patient Trust Fund, the facility failed to provide quarterly resident trust fund statements to one of 33 sampled residents (R) (R68).Findings include:Review of the facility policy titled, Patient Trust Fund, review date 12/27/2024, revealed the Guideline section included, . The patient and/or his/her designee. shall have reasonable access, upon written approval, to the record of this patient's account. Quarterly statements should be provided in writing within thirty (30) days after the end of the quarter. Put the statements in a binder in alphabetical order and have the patient sign his/her statement acknowledging accuracy of statement. If the patient is unable to sign, make a copy and mail to the responsible party for signature. Stamp on the original that it was mailed and put the date mailed.Review of the Annual Minimum Data Set (MDS), dated [DATE], for R68, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 15 (indicating little to no cognitive impairment. Section E (Behaviors) documented no behaviors were exhibited. Review of facility-provided documents titled Trust Fund for R68 revealed a document dated 1/30/2025 with the resident's signature on it. Review of documents dated 4/29/2025 and 7/21/2025 revealed that neither document had a signature. In an interview on 7/21/2025 at 1:45 pm, R68 revealed he has not been able to receive his quarterly statements for his trust fund account. He stated he wanted to know the balance, but he does not receive it. He further stated that when his daughter sent a check, it was given to the office, but he was unsure if it went to where it should go because he had not received any type of follow-up.In a telephone interview on 7/23/2025 at 12:23 pm, R68's daughter stated she was unsure of the account balance, and she had not received any financial statements from the facility regarding R68's account balance. In a joint interview on 7/23/2025 at 2:14 pm, the Financial Services Assistant and the Financial Controller revealed that the facility provided resident trust statements every three months and stated the resident signed a form stating they received it. The Financial Controller stated R68 received his resident trust account statements. The Financial Services Assistant stated R68 had not signed the statements because he disagreed with the contents. The Financial Controller or Financial Services Assistant was unable to provide documentation that R68 refused to sign the statements.

Based on observations, staff interviews, record reviews, and review of the facility policy titled, Infection Prevention Plan, the facility failed to ensure infection control practices were followed for three of 33 sampled residents (R) (R19, R74, and R10). This deficient practice had the potential to increase the risk of infection due to cross-contamination of the residents. Findings include:Review of the facility policy titled, Infection Prevention Plan, revised 12/30/2022, revealed the Intent section included, The infection prevention plan provides an overview of the infection prevention practices of the center that is charged with the promotion of a healthy and safe environment to reduce the risk of infections in patients, staff, visitors and others in the health care environment. Epidemiological principles and an interdisciplinary approach shall be employed to focus on surveillance, prevention and control of infections. 1. Observation on 7/23/2025 at 9:50 am, of Registered Nurse (RN) CC performed a fingerstick blood sugar test on R19 with a glucometer (a reusable machine used to check blood sugar) and returned the glucometer to the medication cart without sanitizing it. 2. Observation on 7/23/2025 at 11:55 am, of RN CC revealed her to place an insulin pen, glucometer, alcohol wipes, and a cotton ball into a plastic rectangular container to transport to R74's room. Observation revealed RN CC did not line the container with a protective barrier. Further observation revealed RN CC placed the container on the resident's bedside table without a protective barrier or sanitizing the table. She performed a fingerstick blood sugar test on R74 and placed the glucometer, blood-stained cotton ball, and alcohol wipe on the resident's bedside table without placing a protective barrier on the table. She then placed all supplies into the rectangular container and returned to the medication cart. Further observation revealed RN CC sanitized the glucometer and returned it to the same rectangular container without sanitizing the container or placing a barrier in the container. 3. Observation on 7/23/2025 at 3:30 pm revealed Licensed Practical Nurse (LPN) JJ administering medications to R10 via a gastric tube. Observation revealed LPN JJ placed a barrier on the resident's bedside table and placed the supplies on the barrier. After administering the medications, she removed the supplies from the table. She did not sanitize the table before or after placing the supplies on it. In an interview, she confirmed she did not sanitize the table before or after placing the supplies on it and stated she presumed that housekeeping cleaned the table frequently. In an interview on 7/23/2025 at 1:05 pm, the Infection Preventionist (IP) stated reusable medical equipment should be cleaned before and after use, and a protective barrier should be placed on surfaces before placing equipment on them. In an interview on 7/23/2025 at 5:30 pm, the Director of Nursing (DON) stated that her expectation was for bedside tables to be sanitized before use, and a protective barrier should be used on surfaces. The DON further stated that her expectation was for reusable medical equipment, such as glucometers, to be sanitized before and after use, and dwell time adhered to for drying.

Based on observations and staff interviews, the facility failed to provide a safe/clean/comfortable/homelike environment for five rooms on one of three halls. These rooms contained dirty bathroom ceiling exhaust fan vent covers and a dirty, damaged Packaged Terminal Air Conditioner (PTAC) unit. The facility census was 82 residents. Observation on 2/27/2024 at 10:50 am and 2/28/2024 at 9:30 am in room [ROOM NUMBER] revealed the bathroom ceiling exhaust fan vent cover was dirty with a dusty gray substance. Observation on 2/27/2024 at 11:00 am and 2/28/2024 at 9:35 am in room [ROOM NUMBER] revealed the bathroom ceiling exhaust fan vent cover was dirty with a dusty gray substance. Observation on 2/27/2024 at 11:11 am and 2/28/2024 at 9:40 am in room [ROOM NUMBER] revealed the bathroom ceiling exhaust fan vent cover was dirty with a dusty gray substance. Further observation revealed a dirty, damaged PTAC unit cover needing repair. Interview conducted on 2/28/2024 at 12:40 during walking rounds with the Assistant Maintenance Director (AMD) confirmed bathroom ceiling exhaust fan vent covers was dirty with dusty gray substances in rooms 110, 111, 113 and a dirty, damaged PTAC unit cover needing repair in room [ROOM NUMBER]. The AMD stated it had been the responsibility of the housekeeping crew in the past to ensure the residents' bathrooms were clean including the ceiling exhaust fan grilles. AMD stated the conditions of the bathrooms were unacceptable and needed immediate attention to address all of them getting cleaned. Interview conducted on 2/28/2024 at 1:45 pm with Administrator and Maintenance Director (MD) revealed the facility has an in-house electronic logbook to report and assign staff cleaning assignments through Direct Supply TELS every month. MD stated this documentation ensures all exhaust fans are cleaned and operating properly. MD provided an example copy of the logbook report done on December 4, 2023. MD stated he was not aware of any Maintenance policy. The Administrator confirmed the facility do not have a Maintenance policy. The Administrator asked the Maintenance Director to immediately correct and address the damaged items in each room.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Patient's Plan of Care, the facility failed to follow the care plan for two of 45 sampled Residents (R) (R27 and R41) by not assisting the residents with Activities of Daily Living (ADL's). Specifically, the facility failed to provide nail care as evidenced by long, broken, and jagged fingernails. Findings include: Review of the undated facility's policy titled Patient's Plan of Care, under section titled, Guidelines revealed, Each patient will have a person - centered comprehensive care plan developed and implemented to meet his or her other preferences and goals, and address the patient's medical, physical, mental, and psychosocial needs. 1. Review of R27's Electronic Medical Record (EMR) revealed diagnoses that included but were not limited to diabetes, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and legally blind. Review of R27's Quarterly [NAME] Data Set (MDS) dated [DATE] revealed Section C-Cognitive Patterns: a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. Section GG- Functional Abilities and Goals: required partial/moderate assistance for personal hygiene. Review of R27's care plan dated 2/20/2024 revealed that he had the potential for self-care deficit and interventions that included but were not limited to assisting with Activities of Daily Living (ADL's) as needed. Observation and Interview on 2/27/2024 at 10:14 am with R27 stated that he gets showers about once a week but could not remember the last time he had his fingernails cut. R27 fingernails were noted to be longer than a 1/2 (half) to one inch long and had jagged edges on a few of his long fingernails. The resident then stated that he needed his fingernails cut. R27 stated, I have refused my shower at times because I don't feel good, but I have never refused to have my fingernails cut or trimmed. Observation and Interview conducted on 2/29/2024 at 10:31 am revealed R27 lying in bed with fingernails that remained longer than a 1/2 inch to one inch long and two of his fingernails were jagged. The resident at that time stated that no one had offered to trim his fingernails. An interview on 2/29/2024 at 10:48 am with Certified Nursing Assistant (CNA) AA stated that R27 usually wouldn't refuse care unless he was not feeling good. She stated that nail care should be completed as needed. She then stated that she would check residents' fingernails once a week. She verified that R27 had long jagged fingernails. CNA AA offered to clean and trim R27 fingernails, and R27 stated that he would allow her to do it. An interview on 2/29/2024 at 2:10 pm with the Director of Nursing (DON) revealed that she expects staff to check resident's fingernails daily. She also stated that she expects staff to trim nails at a safe length, and no longer than 1/4 inch in length. DON stated nails should be soaked, washed thoroughly and then trimmed. 47146 2. Review of R41's EMR revealed that he was admitted with diagnoses that included, but were not limited to Alzheimer's disease, hemiplegia and hemiparesis affecting the right side, need for assistance for personal care and Parkinson's disease. Review of R41's Quarterly MDS dated [DATE] revealed Section C-Cognitive Patterns: a BIMS score of 14, which indicated intact cognition. Section GG- Functional Abilities and Goals: revealed the resident had impairment on one side and required partial/moderate assistance with personal hygiene. Review of R41's care plan dated 7/6/2023 revealed that he had a self -care deficit. Interventions for this deficit included but were not limited to assisting with Activities of Daily Living (ADL's) as needed. Interview conducted on 2/29/2024 at 10:39 am with R41 when asked about his fingernails revealed, they had not been trimmed and were still long. Observation and Interview conducted on 2/27/2024 at 11:06 am with R41 stated that he doesn't get a shower, but maybe once a week. He stated he needed his fingernails trimmed. Observation of R41's fingernails revealed one was broken and most of his nails were longer than a half inch in length. An interview was conducted on 2/29/202 at 10:52 am with CNA AA revealed that R41 usually wouldn't refuse care unless he wanted to get some rest. She stated that fingernail care was to be completed as needed. She then stated that she would check fingernails once a week. She verified that R41 had long fingernails and a broken nail. CNA AA offered to clean and trim R41 fingernails, and R41 stated that he would allow her to do it. Cross Reference F677

Based on observations, resident and staff interviews, and record review, the facility failed to ensure that Activities of Daily Living (ADL) care was provided for two of 45 sampled Residents (R) (R27 and R41). Specifically, the facility failed to provide nail care for R27 and R41. This failure had the potential to affect the resident's comfort, body image and increase the risk for infection. Findings include: 1. Observation and Interview conducted on 2/27/2024 at 10:14 am with R27 stated that he gets showered once a week but could not remember the last time he had his fingernails cut. R27 fingernails were observed to be longer than 1/2 (half inch) to one inch long and had jagged edges on a few of his long fingernails. R27 stated, I have refused my shower at times because I don't feel good, but I have never refused to have my fingernails cut or trimmed. Review of the Electronic Medical Record (EMR) for R27 revealed diagnoses that included but were not limited to diabetes, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and legally blind. Review of the Quarterly [NAME] Data Set (MDS) dated [DATE] for R27 revealed Section C-Cognitive Patterns: a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. Section GG- Functional Abilities and Goals: revealed R27 required partial/moderate assistance for personal hygiene. Review of the care plan dated 2/20/2024 for R27 revealed that he had the potential for self-care deficit with interventions that included but not limited to assisting with Activities of Daily Living (ADL's) as needed. Observation and Interview conducted on 2/29/2024 at 10:31 am revealed R27 lying in bed with fingernails that remained longer than a 1/2 (half) inch and two had jagged nails. The resident at that time stated that no one had offered to trim his fingernails. Interview conducted on 2/29/2024 at 10:48 am with Certified Nursing Assistant (CNA) AA stated that R27 usually wouldn't refuse care unless he was not feeling good. She stated that nail care should be completed as needed. She then stated that she would check fingernails once a week. She verified that R27 had long jagged fingernails. CNA AA offered to clean and trim R27 fingernails, and R27 stated that he would allow her to do it. 2. Observation and Interview conducted on 2/27/2024 at 11:06 am with R41 stated that he doesn't get a shower, but maybe once a week. He stated that he needed his fingernails trimmed. Observation of R41's fingernails revealed one was broken and most of his nails were longer than a half inch in length. Review of the EMR for R41 revealed that he was admitted with diagnoses that included, but were not limited to Alzheimer's disease, hemiplegia and hemiparesis affecting the right side, need for assistance for personal care and Parkinson's disease. Review of the Quarterly MDS dated [DATE] for R41 revealed Section C-Cognitive Patterns: a BIMS score of 14, which indicated intact cognition. Section GG- Functional Abilities and Goals: revealed R41 had impairment on one side and required partial/moderate assistance with personal hygiene. Review of the care plan dated 7/6/2023 for R41 revealed that he had a self -care deficit with interventions for this deficit that included but are not limited to assisting with Activities of Daily Living (ADL's) as needed. Observation and Interview conducted on 2/29/2024 at 10:39 am revealed R41 laying on his left side in bed. He was asked about his fingernails, and the resident stated that his fingernails were still long and needed to be trimmed. Interview conducted on 2/29/202 at 10:52 am with CNA AA stated that R41 usually wouldn't refuse care unless he wanted to get some rest. She stated that fingernail care was to be completed as needed. She then stated that she would check fingernails once a week. She verified that R41 had long fingernails and a broken nail. CNA AA offered to clean and trim R41 fingernails, and R41 stated that he would allow her to do it. Interview conducted on 2/29/2024 at 2:10 pm with the Director of Nursing (DON) revealed that she expects staff to check resident's fingernails daily. She also stated that she expects staff to trim nails at a safe length, and no longer than 1/4 inch in length. DON stated nails should be soaked, washed thoroughly and then trimmed. Cross Reference F656

Based on observations, interviews, document reviews, and review of facility policy titled, Department Organization, undated, the facility failed to employ enough kitchen personnel to fully carry out the functions of the kitchen. Specifically, the facility failed to have enough staff to wash dishes for the 106 residents who ate meals from the kitchen, therefore, residents were using disposable dinnerware. Findings include: The facility policy titled, Department Organization, undated, revealed, Guidelines: The center should provide adequate staffing to carry out the functions of the Dining and Nutrition Services Department. The Dining and Nutrition Services Department should collaborate with all disciplines to ensure the patient's needs are met based on patient centered care. A review of the facility's Center Contingency Plan revealed as of 3/21/22, the facility had three open positions for full-time dietary aides, one open position for a full-time morning shift cook, and two open positions for full-time evening shift cooks. A review of the kitchen schedule for 4/5/22 revealed two cooks, a Dish room aide and Certified Dietary Manager (CDM) GG were scheduled to work the morning shift. A carts aide slot was listed on the schedule; however, there was no carts aide scheduled to work during the day shift on 4/5/22. During concurrent observations and interviews in the kitchen on 4/5/22 at 9:37 a.m., staff were observed serving meals in Styrofoam tableware. In the interview, CDM GG stated, We are 100% Styrofoam due to the staffing in the kitchen. There is no one here that can wash over 100 plates and silverware for each meal. A review of the kitchen schedule for the evening shift on 4/6/22 revealed one cook and a Dish room aide were scheduled to work. A carts aide was not scheduled to work on 4/6/22. Observation on 4/6/22 at 5:00 p.m., staff were observed in the kitchen plating the dinner meal. Further observation revealed Cook JJ and CDM GG were working in the kitchen. In addition, Housekeeper II, and Laundry Aide (LA) HH were present working in the kitchen in place of the dietary aides. Continued observation at 5:03 p.m., revealed dinner was being served in a 3-compartment clam shell Styrofoam container with a pre-packaged plastic cutlery set. During an interview at 5:07 p.m. on 4/6/22, Cook JJ revealed it was easier for kitchen staff to use to-go containers; otherwise, they would be working until after 10:00 p.m. washing dishes because there were only two kitchen staff. During an interview on 4/6/22 at 5:23 p.m., Cook JJ revealed the staffing situation became worse about three months ago when a new business opened in town and the kitchen staff quit to go work there. During an interview on 4/6/22 at 5:42 p.m. Cook JJ and CDM GG revealed it was often only the two of them during the evening and while Cook JJ was plating food, the CDM had to take food carts to the resident units. During an interview on 4/8/22 at 12:42 p.m., the DON revealed the facility initially began using Styrofoam during the COVID-19 pandemic. The DON stated the goal was to have more staff apply to work in the kitchen and go back to what they were doing prior (referring to using china and flatware.) During an interview on 4/8/22 at 1:29 p.m., the Administrator revealed it was a convenience for the facility to use Styrofoam due to the low number of staff working in the kitchen. The Administrator stated they looked forward to the day when the facility would go back to using china and flatware.

Based on observations, interviews, document reviews, review of Centers for Disease Control (CDC) guidelines, and review of the facility's policies, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 106 of 110 residents that received meals from the kitchen. Specifically, the facility failed to ensure proper hand hygiene practices were utilized during meal distribution, failed to ensure hot and cold foods were held and served at appropriate temperatures, failed to ensure cross contamination of ice from clothing, failed to ensure hair was covered in the food preparation area of the facility and failed to ensure food preparation equipment was properly maintained. Findings include: 1. Review of the facility policy titled, Food Preparation and Distribution, dated 2/2/03, revealed, It is the intent of this center to prepare and distribute food in a manner that minimizes the risk of food borne illnesses and promotes safe food handling practices. The policy further revealed good hand washing techniques should be practiced and gloves should be changed between tasks. A review of the training records revealed a training dated 1/6/20, titled, Hand Washing. The syllabus for the in-service training indicated hands and arms should be scrubbed vigorously for 10-15 seconds. This training did not meet the current guidelines. This was the last documented training for hand washing that was found. Review of the Techniques for Washing Hands with Soap and Water, retrieved from: https://www.cdc.gov/handhygiene/providers/index.html, dated 1/8/21, revealed the following: When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers; Rinse your hands with water and use disposable towels to dry. Use towel to turn off the faucet; Avoid using hot water, to prevent drying of skin; Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds; Either time is acceptable. The focus should be on cleaning your hands at the right times. Observations in the facility kitchen on 4/6/22 from 5:00 p.m. until 6:12 p.m., revealed Cook JJ was plating the food on the tray line. She was using an 8-ounce scoop to plate the soup in a Styrofoam container and using her gloved hand to pick up a biscuit and place it in the container. At 5:18 p.m., Cook JJ was observed picking up a biscuit with her gloved hand, then adjusted her mask, touched her hair, and adjusted her hair net, picked up the temperature logbook and a pen, and was then carrying trays back to the tray line. She came back to the tray line where she resumed picking up biscuits with her gloved hand. Cook JJ did not remove and/or change her gloves or wash her hands. At 5:21 p.m., she left the tray line to bring back sandwiches from the walk-in cooler, still wearing the same gloves. Observation in the facility kitchen on 4/6/22 at 5:57 p.m., revealed Housekeeper II was helping in the kitchen and dropped her glasses on the kitchen floor. Observations further revealed she picked up her glasses and, without washing her hands, proceeded to bring food items back to the tray line. At 6:02 p.m., Housekeeper II was observed washing her hands for nine seconds. When throwing out the paper towel used to dry her hands, she dropped one of the paper towels on the floor. She picked up the paper towel off the floor, placed it in the trash, and did not wash her hands again. Further observations in the kitchen on 4/6/22 at 6:12 p.m. revealed Cook JJ was observed washing her hands for approximately 11 seconds. She stated she was trained to sing the Happy Birthday song two times while scrubbing her hands with soap. She stated she did not sing the Happy Birthday song, nor did she wash her hands for at least 25 seconds. . Concurrent observation and interview on 4/7/22 at 12:35 p.m., while in the kitchen, Regional Certified Dietary Manager (RCDM) AAA was observed washing his hands for seven seconds. When interviewed, he stated he thought he had washed his hands for 30-60 seconds. RCDM could not state how he was trained to wash his hands and was unable to produce evidence that he had attended hand-washing training. During an interview with Cook JJ on 4/6/22 at 5:21 p.m., revealed she did not realize how many things she had touched with her gloved hands and then returned to the tray line and touched the biscuits with the same gloved hand. She then proceeded to remove her gloves, wash her hands, and don a new pair of gloves. Certified Dietary Manager (CDM) GG provided Cook JJ with tongs to use to pick up the biscuits. During an interview on 4/6/22 at 6:02 p.m. Housekeeper II revealed she was not sure but thought she was supposed to wash her hands for about 15 seconds. She stated she touched the clean part of the paper towel when she picked it up off the floor and that her hands were clean. During an interview on 4/8/22 at 5:03 p.m., with Regional Nurse (RRN) LL and Assistant Director of Nursing (ADON) WW, RRN LL stated any handwashing training the dietary staff received should be in their individual transcript from the facility online training system. ADON LL stated personal protective equipment (PPE) training should have been assigned to all employees in their online training system and the PPE training included handwashing. A review of the transcripts provided, and the facility in-person training records indicated the last time the kitchen had received a designated hand-washing training was on 1/6/20. 2. The facility policy titled, Food Preparation and Distribution, dated 2/2/03, revealed, It is the intent of the center to prepare and distribute food in a manner that minimizes the risk of food borne illness and promotes safe food handling practices. Tray line: Hot foods should be held at [greater than or equal to] 135 [degrees] F [Fahrenheit]; Cold food should be held at [less than or equal to] 41 [degrees] F. Corrective Action: Hot items should be pulled from the tray line and re-heated until an internal temperature of 165 [degrees] F for 15 seconds is reached. Items should be re-checked, and proper temperature verified before beginning to serve. Observations in the kitchen on 4/6/22 at 5:00 p.m., the temperature log was reviewed for the dinner meal. The dessert was an ambrosia salad and the temperature of the salad had not been checked. Interview with CDM GG at the time of the observation stated she did not understand why the cold dessert needed to be temped when it came straight out of the cooler. An observation revealed four trays of ambrosia salad were on a rack near the tray line. At 5:13 p.m., CDM GG checked the temperature of the ambrosia salad, and it was 44 degrees F. The trays were returned to the cooler. She confirmed that one of the ingredients of the ambrosia salad was whipped cream and should be refrigerated and maintained below 41 degrees F. Concurrent observation and interview on 4/6/22 at 5:40 p.m. in the kitchen, revealed cold deli sandwiches were being placed on top of a resident's Styrofoam lid and then placed in the insulated meal cart. The temperature of the sandwiches was not checked when they were removed from the cooler or prior to being placed on the tray line. Interview with CDM GG on 4/6/22 at 5:40 p.m., revealed she could not explain how she would ensure the cold deli sandwiches would be served at 41 degrees or below. She stated that would be up to the staff on the units to get the trays passed as soon as possible. During concurrent observations and interviews in the kitchen and on the 100 Hallway on 4/6/22 between 5:42 p.m. and 6:32p.m., a test tray was prepared, followed, and temped. The 100 Hallway was the last hallway to be served. The facility was serving their meals using a 3-compartment clam shell lid Styrofoam container. Dinner was a cream-based tortellini soup and a biscuit. On the steam table at 5:42 p.m., the soup was 168 degrees Fahrenheit (F). The test tray was plated by Cook JJ at 5:56 p.m., and the temperature was 158.5 degrees F. This was the first tray to be loaded onto the 100 Hallway cart. Twenty-two residents lived on the 100 Hallway. All other trays were plated, and the cart left the kitchen at 6:12 p.m. The cart arrived on the 100 Hallway at 6:16 p.m. Trays started getting passed to the residents at 6:20 p.m. With four trays left on the cart for those who were awaiting assistance with dining, the test tray was pulled from the cart, and at 6:32 p.m., the temperature of the tortellini soup was 120 degrees F. Certified Dietary Manager (CDM) GG was present during the observation and stated the food was palatable, but not hot. CDM GG stated hot food was supposed to be served at 135 degrees F or higher. During concurrent observations and interviews in the kitchen and on the 100 Hallway on 4/7/22 between 12:25 p.m. and 12:57 p.m., a test tray was prepared, followed, and temped. The 100 Hallway was the last hallway to be served. The facility was serving fried chicken, steamed carrots, steamed broccoli, and cheesecake for dessert. The test tray was plated by Cook JJ at 12:26 p.m., and the temperatures were as follows: fried chicken was 178 degrees F, steamed carrots were 176 degrees F, steamed broccoli was 146 degrees F, and the cheesecake was 37 degrees F. The cart with the test tray left the kitchen at 12:40 p.m. The last tray off the cart on the 100 Hallway was at 12:57 p.m. The test tray temperatures were obtained as follows: fried chicken was 133 degrees F, steamed carrots were 127 degrees F, broccoli was 102.7 degrees F, and the cheesecake was 54.5 degrees F. During an interview on 4/7/22 at 12:25 p.m. with Regional Certified Dietary Manager (RCDM) AAA, revealed it was his expectation for the hot food to be served at 135 degrees F and the cold food to be served at 41 degrees F or below. Concurrent observation and interview on 4/7/22 at 12:25 p.m. in the kitchen, four trays of cheesecake were observed on a rack and not on ice or refrigerated during preparation of the meal. During an interview on 4/7/22 at 12:25 p.m., RCDM revealed that only one tray should be removed from the cooler at a time, and they should not use it if it went above 41 degrees F. Continued observation of the test tray on 4/7/22, revealed the cheesecake dessert was 37 degrees F when it was plated and when the temperature was checked for service, it was 54.5 degrees F. During an interview on 4/8/22 at 12:42 p.m., the Director of Nursing (DON) confirmed the kitchen started using the all-disposable trays (clam shell Styrofoam boxes, prepackaged cutlery, Styrofoam cups, and Styrofoam bowls) during the COVID-19 pandemic. She stated it was her expectation that when the tray carts arrived on the floors it was an all hands-on deck situation, and trays were to be passed as soon as possible to keep the food hot. 3. Observation on 4/6/22 at 6:00 p.m., revealed Laundry Aide (LA) HH was assisting in the kitchen. She was asked to fill up four Styrofoam cups with ice and iced tea. She was wearing a large baggy sweatshirt and the sleeve came below her wrists. LA HH was observed scooping ice into the four cups. Each time she put the scoop down into the ice chest, the sleeve from her sweatshirt was also touching the ice. During an interview on 4/6/22 at 6:00 p.m., CDM GG stated the laundry and housekeeping staff who were helping had not been specifically trained for duties in the kitchen. The facility was unable to produce a policy regarding the handling of ice. 4. Review of the policy titled, Personal Appearance and Conduct, not dated, revealed, A hairnet and/or beard restraint should be worn while in the food prep, production and serving areas. Concurrent observation and interview in the kitchen on 4/7/22 at 12:33 p.m., revealed Dietary Aide (DA) DDD was assembling the trays for the lunch tray line. She was wearing her hair in a bun on top of her head. DA DDD had whisps of hair that came down over the back of her neck, ears, and face that were not covered by a hair net. DA DDD was wearing a hair net that only covered the bun part of her hair. The additional whisps of hair were all exposed from under the hair net. Interview with the RCDM at this time, revealed he did not even notice that her hair was not all up in the hairnet. A review of the in-service completed on 4/6/22 indicated DA DDD had attended and signed off on an in-service titled, Personal Hygiene. On the syllabus of the in-service, it indicated, #3 Hair Restraints: all associates should always wear a clean hat or hair restraint when in the kitchen and all hair including bangs, must be underneath the hat if all hair isn't restrained. This in-service was taught by the RCDM. 5. Review of the policy titled, Food, Supply, and Equipment Purchasing and Maintenance, dated 2/2/09, revealed, It is the intent of the center to have the necessary food, supplies, and equipment available for patient meal service. Organization approved reputable vendors will be utilized for food and supply ordering. Small wares and capital equipment will be coordinated by the center, with assistance provided by organizational support staff, as needed. During observations during the initial tour of the kitchen, on 4/5/22 at 9:30 a.m., revealed cutting boards on a storage rack. There were two red cutting boards with gouges and worn areas in the center of the board so that it was no longer red, two green cutting boards with gouges and worn areas in the center of the board so that it was no longer green, one blue cutting board with gouges and worn areas in the center of the board so that it was no longer blue, and one yellow cutting board with gouges and worn areas in the center of the board so that it was no longer yellow. During an interview with CDM GG on 4/5/22 at 9:30 a.m. revealed it was at least two years since the facility had ordered new cutting boards. CDM GG stated, My expectation is they [the cutting boards] would be replaced when they looked this rough.

Based on observations, interviews, and review of the facility policies Personal Protective Equipment PPE and COVID-19 Visitation Guidelines, the facility failed to ensure that staff wore masks appropriately. Seven staff members were not wearing a mask appropriately covering the nose and mouth. This failure had the potential to affect all residents. Findings include: Review of the facility policy titled Personal Protective Equipment (PPE), updated February 2022, revealed, PPE should be used in accordance with infection prevention guidelines. Review of the facility policy titled COVID-19 Visitation Guidelines, updated February 2022, revealed, Core Principles of COVID-19 Infection Prevention: 3. Face covering or mask (covering mouth and nose). 1. Observation on 4/5/22 at 8:30 a.m. while entering the facility, all surveyors were screened by Secretary SS. She wore a surgical mask under their nose and mouth throughout the entire screening process. Observation on 4/5/22 at 11:57 a.m. Secretary SS was at the front desk screening staff and visitors as they entered. Her surgical mask was noted to be under their nose and mouth while screening people into the building. During an interview conducted on 4/5/22 at 12:56 p.m., Secretary SS stated that they had received training on how to wear a mask properly. She also stated that she had allergies and suffered facial skin breakouts from the mask. Secretary SS did place the surgical mask over their nose and mouth after being questioned about the mask. 2. Observation on 4/5/22 at 11:54 a.m. Environmental Services (EVS) QQ was walking down the 400 Hallway on the first floor to give an item to another staff member. She was seen with a KN95 mask being worn under her nose, only covering their mouth. During an interview on 4/5/22 at 11:54 a.m., EVS QQ acknowledged that she was not wearing her mask correctly. She confirmed the facility had instructed them how to wear a mask properly. EVS QQ apologized and placed her mask over her nose. 3. During a concurrent observation and interview on 4/5/22 at 1:04 p.m., Registered Nurse (RN) RR was observed for two full minutes, standing at the medication cart in the hallway with her N95 mask resting below her nose. RN RR stated that she was drinking water and forgot to pull her mask back into position. She then placed her mask in the correct position after the interview. Observation on 4/5/22 at 3:55 p.m., revealed RN RR was in the hallway near the nursing station with an N95 mask below their nose. 4. Observation on 4/5/22 at 11:35 a.m., revealed Certified Nursing Assistant (CNA) AA walking down the 100 Hallway with a child. Neither CNA AA nor the child were wearing a mask. During an interview conducted on 4/5/22 at 11:35 a.m., CNA AA, stated she had just returned from lunch and forgot to get a mask. 5. Observation on 4/7/22 at 5:30 a.m., Licensed Practical Nurse (LPN) DD was in the hallway at the medication cart preparing medications for administration and was not wearing a mask. There was a mask sitting on top of the medication cart. Further observation of LPN DD on 4/7/22 at 5:38 a.m., revealed she was still working at the medication cart and was not wearing a mask. During an interview on 4/7/22 at 5:38 a.m., LPN DD stated they just removed their mask to get some air. 6. During an observation on 4/7/22 at 5:58 a.m., LPN EE was sitting at the nurses' desk on the second floor and was not wearing a mask. When the surveyor approached the desk, LPN EE put the mask on over her nose and mouth. During an interview on 4/7/22 at 5:58 a.m. LPN EE revealed they had just returned from the bathroom and forgot to put their mask back on. 7. During an observation on 4/7/22 at 9:11 a.m., LPN FF was sitting at the nurses' desk on the second floor wearing a face shield and an N95 mask below her chin. When the surveyor walked up to the desk, she pulled the mask over their nose. During an interview on 4/7/22 at 9:11 a.m. LPN FF revealed they had trouble breathing and was claustrophobic. She stated she removed the mask for a minute or two to catch their breath. During an interview on 4/8/22 at 11:33 a.m. the Director of Nursing (DON) revealed their expectations were that all staff should wear masks properly and the mask should cover the nose and mouth. She stated all staff, including EVS and dietary personnel, were to wear masks. The DON stated that in-servicing was provided often regarding the proper way to wear masks. During an interview on 4/8/22 at 1:24 p.m., the Administrator revealed that the expectation was that all staff were to wear masks. The Administrator stated there were no exceptions for staff wearing masks. When asked what the correct way to wear a mask was, the Administrator stated masks should always be worn by staff and should be over the nose and mouth.

Based on observations, interviews, review of the facility's Center Contingency Plan, and review of the facility policy titled, Meal Service, the facility failed to treat residents with dignity by ensuring meals were not served on disposable dinnerware. This had the potential to affect 106 out of 110 residents served meal trays from the kitchen. Findings include: A facility policy titled, Meal Service, not dated, revealed, Associates will promote and maintain patient's dignity and respect during meal service. A homelike environment will be upheld during meal service. The center will provide meals and hydration that conserve nutritive value, flavor, and appearance, and that are palatable, attractive, and a safe and appetizing temperature. Review of the facility's Center Contingency Plan, dated 11/16/21, revealed that the use of disposables for all meals was related to staffing. A notification was to be documented on the use of disposables. On 1/12/22, there was no change. The facility was to continue using all disposables, except for water cups. A notification and documentation were to be in place with Resident Council. On 2/2/22, the plan was to continue with disposables. It was recommended to visit more patients to see if they were okay with disposables. On 3/14/22, the facility visited more patients regarding disposables, and they would start using regular silverware on two halls related to complaints. On 3/29/22, the plan indicated the facility was using all disposables. Notification and documentation were to be in place with Resident Council. On 3/31/22, the facility was continued to use disposables related to staffing. Staff were to check in with patients for concerns with disposables and change to regular dishware if needed for those patients. During concurrent observation and interview with the Certified Dietary Manager (CDM) GG on 4/5/22 at 9:25 a.m., the facility was serving all its meals using disposable dinnerware. This included a 3-compartment clam shell Styrofoam container, Styrofoam bowls, Styrofoam cups, and pre-packaged plastic cutlery sets. At 9:37 a.m., CDM GG stated, We are 100% Styrofoam due to the staffing in the kitchen. There is no one here that can wash over 100 plates and silverware for each meal. She stated it was voted on and approved at the Resident Council meeting. Six months of Resident Council meeting minutes were reviewed without mention of the residents voting to approve the use of disposable dinnerware. During an interview on 4/5/22 at 11:36 a.m., Resident (R) #82, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14, stated they did not like eating from the disposable plates and utensils and wished they could eat with china and silverware. During an interview on 4/5/22 at 12:07 p.m., R#38, who was cognitively intact with a BIMS score of 13, stated that meals were served on Styrofoam. During an interview on 4/5/22 at 12:12 p.m., R#34, who was cognitively intact with a BIMS score of 13, stated that meals were served on Styrofoam. During an interview on 4/5/22 at 12:17 p.m., R#55, who was moderately cognitively impaired with a BIMS score of 9, stated that meals were served on Styrofoam. During the Resident Council meeting on 4/6/22 at 3:02 p.m., two alert and oriented residents stated there was never a vote brought before the Resident Council to approve the use of the Styrofoam/disposable dinnerware. They stated it was hard to cut meat with the plastic utensils and they would prefer eating off real plates with real silverware. During an interview on 4/6/22 at 5:07 p.m., Cook JJ stated it was easier for the kitchen staff to use the to-go containers. She stated there were a lot of evenings when it was only herself and CDM GG, and if they had to stay and wash dishes, they would not leave the facility until after 10:00 p.m. During an interview on 4/6/22 at 5:23 p.m., Cook JJ stated that the staff situation became worse about three months ago when a new business opened in town and the kitchen staff quit to go work there. During an interview on 4/7/22 at 12:30 p.m., the Regional Certified Dietary Manager RCDM AAA stated I'm going to have to get back to you on those answers, when asked about the prolonged use of Styrofoam containers. During a test tray observation on 4/7/22 at 12:57 p.m., the RCDM AAA stated the plastic knife made it hard to cut into the fried chicken due to the flimsiness and stated, I hope the residents were able to cut their food. During an interview on 4/8/22 at 12:42 p.m., the Director of Nursing (DON) stated that the use of the Styrofoam originally started during the COVID-19 pandemic. The DON stated their goal was to go back to what they were doing prior to the COVID -19 pandemic (referring to using china and flatware). During an interview on 4/8/22 at 1:29 p.m., the Administrator stated there was a convenience to using the Styrofoam due to the low number of staff working in the kitchen. She also stated she looked forward to the day when the facility would go back to using the china and flatware, that she preferred the appearance of real dishes versus the Styrofoam, and it was easier to eat a meal off a china plate versus a disposable plate.

Based on observations, record review, interviews, and review of a facility policy titled, ADL (Activities of Daily Living) Plan of Care, the facility failed to ensure ADL care related to nail care and shaving was provided for three of four sampled residents (Resident (R) #55, R#73, and R#91) reviewed for ADL care. Findings include: A review of the facility's policy titled, ADL Plan of Care, dated 2020, indicated, 1. Resident's ADL needs are assessed on admission and are addressed on the Baseline Care Plan and communicated to staff. 2. Nursing develops the patient's ADL care plan and will communicate the level of assistance required for the patient. 1. A review of the Face Sheet revealed R#55 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed R#55 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. Further review of the MDS revealed R#55 was totally dependent on one staff for personal hygiene and totally dependent on two staff for bathing. A review of the Care Plan, with a review date of 8/25/21, revealed R#55 had limited mobility and required assistance with activities of daily living (ADL) and had a self-care deficit related to ADLs. The resident required staff intervention to remain clean, need, and free of body odors. Interventions included assisting with ADLs as needed. The ADL task sheet for personal hygiene and bathing for 3/22 was reviewed and indicated the resident received personal hygiene care for six of 31 days. Observation on 4/5/22 at 12:17 p.m., R#55 was lying in bed, on their back with the head of the bed elevated. R#55 had facial hair that was approximately 1/4 inch long. R#55 stated they always shaved at home and if the surveyor would just provide the resident with a razor, they would shave themself. Observation on 4/6/22 at 12:08 p.m., revealed R#55's appearance had not changed from the observation made on 4/5/22. Observation on 4/7/22 at 6:10 a.m., R#55's appearance had not changed from the observation made on 4/5/22. R#55 stated, They still haven't shaved me. Observation on 4/8/22 at 8:37 a.m., revealed that R#55 had been shaved by the facility staff last night and gave them a bath. During an interview on 4/6/22 at 4:06 p.m., Certified Nursing Assistant (CNA) AA stated that CNA's were responsible for shaving residents. She stated the resident was shaved whenever the resident requested their pricklies to be gone. CNA AA and the surveyor entered the resident's room. She acknowledged the resident had facial hair, and R#55 requested to be shaved. During an interview on 4/6/22 at 4:11 p.m., Nursing Assistant (NA) BB stated that any CNA that was assigned to the resident was responsible for shaving the resident. She also stated that she noticed that the resident had facial hair today, and that the resident's bed bath was scheduled tomorrow. She also stated, When it's days like today, I can't do them. I'm just really busy. During an interview on 4/6/22 at 4:21 p.m., Licensed Practical Nurse (LPN) CC stated the CNA should shave the resident's facial hair on their shower days and indicated R#55 received bed baths two times per week, on Tuesdays and Fridays. She stated CNA KK was responsible for shaving the residents and was at the facility four days a week. She also stated that if CNA KK was not able to provide the care, then any CNA should provide the care on the resident's shower days. During an interview on 4/7/22 at 4:21 p.m., CNA KK stated the resident should be shaved on their shower days, and that the resident should get three showers a week. During an interview on 4/8/22 at 12:13 p.m., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) stated that all staff were to ensure that residents had good hygiene, and R#55 should be shaved as often as needed. The DON stated that if staff observed the need, then staff should provide the care. She also stated that staff were to chart ADL care in a point of care (POC) system and should be charting every shift. During an interview on 4/8/22 at 1:14 p.m., the Administrator stated that CNA's were responsible for shaving the resident and did not know how often R#55 should be shaved. The expectation was that if a resident had facial hair, they should be cleaned. 2. A review of the Face Sheet revealed R#73 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a quarterly MDS, dated [DATE], revealed R#73 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. Further review of the MDS revealed the resident required limited assistance of one person for personal hygiene and bathing. A review of the Care Plan, with a review date of 3/30/22, revealed R#73 had limited mobility and required assistance with activities of daily living (ADL) and had a self-care deficit related to ADLs. Interventions included assisting with ADLs as needed. The ADL task sheet for personal hygiene and bathing for 3/22 was reviewed and indicated the resident received personal hygiene care for 10 of 31 days. During an observation on 4/5/22 at 11:14 a.m., R#73 was lying in bed, on their right side. The resident had facial hair. The resident declined to be interviewed at this time. The resident's nails were not visible, as they were tucked underneath their head. A concurrent observation and interview on 4/6/22 at 12:17 p.m., R#73 was lying in bed, and their nails were approximately 1/4 inch long, with brown debris underneath all the resident's nails. The resident was still unshaven. The resident stated staff trimmed their nails for them and they had not trimmed them in awhile. Observation on 4/7/22 at 6:00 a.m., revealed that R#73 had the same appearance as the previous day with an unshaved face and long fingernails with debris underneath. During an interview on 4/6/22 at 4:03 p.m., CNA AA stated they were agency staff, and that CNAs were responsible shaving residents and for nail care, unless the resident was diabetic. She also stated they were unaware of how and when to chart that the resident was provided care. At this time, CNA AA and the surveyor went into the resident's room. CNA AA stated there was a bunch of dirt under the resident's nails. During an interview on 4/6/22 at 4:13 p.m., NA BB stated that any CNA that was assigned to the resident was responsible for shaving the resident and the resident normally had it done on the resident's shower day. The resident's shower days were Tuesday, Thursday, and Saturday. She stated CNA KK provided the resident's nail care and CNA KK came in one day a week. NA BB stated that CNA KK was responsible for providing nail care for the whole building and only had eight hours to do the entire building. During an interview on 4/6/22 at 4:24 p.m., with LPN CC stated that the CNA should shave the resident's facial hair and cut the resident's nails on their shower days. She also stated that CNA KK was responsible for providing nail care and shaving the residents and was at the facility four days a week. She then stated that if CNA KK was not able to provide the care, then any CNA should provide the care on the resident's shower days. During a concurrent interview and observation on 4/7/22 at 9:24 a.m., R#73 was lying in bed, alert, and stated that their fingernails were cleaned but they still haven't shaved me. During an interview on 4/7/22 at 4:21 p.m., CNA KK stated the resident should be shaved on their shower days, and that the last time they provided nail care and shaved the resident was approximately a week ago from 4/7/22. She also stated they were on light duty and completed nail care, passed meal trays, shaved residents, and answered the phone on the evening shift. CNA KK stated there was a notebook on each unit that indicated the resident's shower and if they were to receive nail care. It was revealed that they took a copy off each unit, crossed the resident's name out after the ADL task completed, and did not chart it in the electronic health record. CNA KK stated they provided the list of residents whose care was completed to the ADON for them to review. A concurrent interview and observation on 4/8/22 at 8:34 a.m., revealed R#73 was lying in bed, alert, and stated that the facility gave him a shower last night and finally shaved me. During an interview on 4/8/22 at 12:13 p.m., the DON and ADON, revealed that all staff were to ensure residents have good hygiene, and R#73 should be shaved as often as needed. The DON stated that if staff observed the need, then staff should provide the care. She also stated that staff were to chart ADL care in a point of care (POC) system and should be charting every shift. During an interview on 4/8/22 at 1:18 p.m., the Administrator stated CNAs were responsible for shaving the resident and providing nail care. The Administrator stated their expectation was that if a resident had facial hair, they should be cleaned. 3. A review of the Face Sheet revealed R#91 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a significant change MDS, dated [DATE], revealed R#91 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment. Further review of the MDS revealed R#91 required extensive physical assistance of one person for personal hygiene and was totally dependent on two plus persons for bathing. A review of the Care Plan, with a review date of 9/21/21, revealed R#91 had limited mobility, required assistance with activities of daily living (ADL), and had a self-care deficit related to ADLs. Interventions included assisting with ADLs as needed. The ADL task sheet for personal hygiene and bathing for 3/22 was reviewed and indicated the resident received personal hygiene care for 11 of 31 days. Observation on 4/5/22 at 10:37 a.m., R#91 was lying in bed, with their eyes closed. The resident had facial hair. Observation on 4/8/22 at 8:32 a.m., R#91 was lying in bed, and their appearance related to the facial hair had not changed from 4/5/222. The resident's hands were under the covers, so the resident's nails could not be seen. During an interview on 4/6/22 at 3:58 p.m., CNA AA stated that she guessed the CNA was responsible for the resident to be shaved. She also stated that she did not know how often the resident had been shaved, and that she had never shaved the resident. She revealed that she did not know who provided nail care to the residents or how often. At this time, CNA AA and surveyor went into the resident's room and CNA AA stated the resident had a few nails that were long and jagged, with debris underneath them. She stated the resident had facial hair but was not aware if it was the resident's choice because the resident got confused. During an interview on 4/6/22 at 4:09 p.m., NA BB stated that any CNA that was assigned to the resident was responsible for shaving the resident and normally had it done on the resident's shower day. She stated that she did not know how often the resident was shaved. It was also revealed that CNA KK provided the resident's nail care and CNA KK came in one day a week. She stated that CNA KK was responsible for providing nail care for the whole building and only had eight hours to do the entire building. During an observation on 4/7/22 at 7:50 a.m., R#91 was lying in bed, and their appearance had not changed from 4/5/22. The resident still had facial hair. During an interview on 4/7/22 at 4:21 p.m., CNA KK stated the resident should be shaved on their shower days. She stated she had never shaved the resident and that the CNA had asked the resident a few times and the resident declined. She also stated they provided nail care to the resident the previous week. A review of the electronic health record revealed there was no documentation indicating the resident had declined or refused to be shaved. Observation on 4/8/22 at 8:32 a.m., R#91 was lying in bed, and their appearance related to the facial hair had not changed from 4/5/222. The resident's hands were under the covers, so the resident's nails could not be seen. During an interview on 4/8/22 at 12:13 p.m., the DON and ADON stated that all staff were to ensure that residents had good hygiene, and R#91 should be shaved as often as needed. The DON stated that if staff observed the need, then staff should provide the care. The DON stated that staff were to chart ADL care in a point of care (POC) system and should be charting every shift. During an interview on 4/8/22 at 1:19 p.m., the Administrator stated that CNA's were responsible for shaving the resident and providing nail care. The expectation was that if a resident had facial hair, they should be cleaned.

Based on observations, interviews, and review of the facility policy titled, Meal Service, the facility failed to ensure food was served at palatable temperatures. This had the potential to affect 106 out of 110 residents served meals from the kitchen. Findings include: A facility policy titled, Meal Service, undated, revealed, The center will provide meals and hydration that conserve nutritive value, flavor, and appearance, and that are palatable, attractive, and a safe and appetizing temperature. During an interview on 4/5/22 at 12:07 p.m., Resident (R) #38, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13, stated that breakfast was ice cold that morning. During an interview on 4/5/22 at 12:12 p.m., R#34, who was cognitively intact with a BIMS score of 13, stated that the food was sometimes cold, mainly at dinner. During an interview on 4/5/22 at 12:17p.m., R#55, who was moderately cognitively impaired with a BIMS score of 9, stated that the food was sometimes cold. During an interview on 4/5/22 at 3:47 p.m., R#207, who was cognitively intact with a BIMS score of 15, stated the food was always cold. During concurrent observations and interviews in the kitchen and on the 100 Hallway on 4/6/22 between 5:42 p.m. and 6:32p.m., a test tray was prepared, followed, and temped. The 100 Hallway was the last hallway to be served. The facility was serving their meals using a 3-compartment clam shell lid Styrofoam container. Dinner was a cream-based tortellini soup and a biscuit. On the steam table at 5:42 p.m., the soup was 168 degrees Fahrenheit (F). The test tray was plated by Cook JJ at 5:56 p.m., and the temperature was 158.5 degrees F. This was the first tray to be loaded onto the 100 Hallway cart. Twenty-two residents lived on the 100 Hallway. All other trays were plated, and the cart left the kitchen at 6:12 p.m. The cart arrived on the 100 Hallway at 6:16 p.m. Trays started getting passed to the residents at 6:20 p.m. With four trays left on the cart for those who were awaiting assistance with dining, the test tray was pulled from the cart, and at 6:32 p.m., the temperature of the tortellini soup was 120 degrees F. Certified Dietary Manager (CDM) GG was present during the observation and stated the food was palatable, but not hot. CDM GG stated hot food was supposed to be served at 135 degrees F or higher. During concurrent observations and interviews in the kitchen and on the 100 Hallway on 4/7/22 between 12:25 p.m. and 12:57 p.m., a test tray was prepared, followed, and temped. The 100 Hallway was the last hallway to be served. The facility was serving fried chicken, steamed carrots, steamed broccoli, and cheesecake for dessert. The test tray was plated by Cook JJ at 12:26 p.m., and the temperatures were as follows: fried chicken was 178 degrees F, steamed carrots were 176 degrees F, steamed broccoli was 146 degrees F, and the cheesecake was 37 degrees F. The cart with the test tray left the kitchen at 12:40 p.m. The last tray off the cart on the 100 Hallway was at 12:57 p.m. The test tray temperatures were obtained as follows: fried chicken was 133 degrees F, steamed carrots were 127 degrees F, broccoli was 102.7 degrees F, and the cheesecake was 54.5 degrees F. Regional Certified Dietary Manager (RCDM) AAA was present during the observation and stated the food was not served at proper temperatures. The hot food should be served at 135 degrees or higher and the cold food should be served at 41 degrees F or lower.

Based on observations, record reviews, interviews, and review of the facility policy Patient's Plan of Care, the facility failed to ensure the care plan for two of 25 residents (R) R#48 and R#74 was implemented to prevent falls from occurring and failed to ensure one of 25 resident care plans were developed for R#41 to address vision impairment. Findings include: A review of the facility policy titled, Patient's Plan of Care, dated 2020, revealed, Each patient will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the patient's medical, physical, mental, and psychosocial needs. 1.A review of R#48's Consolidated Order, revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS) for R#48, dated 2/10/22, revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. The MDS revealed the resident was unsteady during transitions and walking, required extensive assistance from staff for ambulation and toilet use, required limited assistance from staff for transfers, and utilized a wheelchair as a mobility device. Further review of R#48's MDS revealed the resident had sustained two or more no injury falls and one fall with injury since the resident's last MDS assessment, which was dated 11/17/21. A review of R#48's Care plan, last updated on 1/10/22, revealed the resident was at risk for falls related to poor safety awareness, tremors, impulsive behavior, [CONDITION(S)], unsteady gait, and impaired cognitive status. The care plan review revealed the facility developed fall prevention interventions that included keeping the call light in reach, providing a wheelchair with anti-tip bars, a Dycem (non-slip material to prevent sliding) to the wheelchair, and a mat at the bedside. Observation on 4/5/22 at 10:51 a.m., revealed R#48 was sitting in a wheelchair in the resident's room, looking out the window. The observation revealed the resident's call light was not in reach. Observation on 4/6/22 at 11:33 a.m., revealed R#48 was in bed. There was no fall mat next to the resident's bed. Observation on 4/7/22 at 8:02 a.m., revealed R#48 was in a wheelchair in the hallway. Observation of the wheelchair revealed there were no anti-tip bars on the wheelchair. During an interview on 4/7/22 at 8:06 a.m., Certified Nursing Assistant (CNA) TT stated the staff becomes aware of what interventions were needed for fall prevention for residents based on the handheld POC (Point of Care). During an interview on 4/7/22 at 8:28 a.m., when asked what interventions were in place to prevent falls for R#48, CNA TT stated a fall mat and low bed were the interventions for R#48. During an interview on 4/7/22 at 8:20 a.m., CNA VV confirmed the handheld POC showed the staff what interventions were in place for fall prevention. During an interview on 4/7/22 at 8:47 a.m., CNA VV stated the resident was to have a fall mat and confirmed that interventions along with anti-tip bars and low bed were not on the POC. During an interview on 4/7/22 at 9:27 a.m., with MDS Nurse UU revealed they did not know how information from a resident's comprehensive care plan was transmitted to POC, and when residents were moved from different rooms or different units, sometimes things get missed. She confirmed there were no anti-tip bars on the R#48's wheelchair. During an interview on 4/7/22 at 10:34 a.m., the Director of Nursing (DON) stated they talked about each fall event in the PAR meeting where care plans were updated, and interventions were added to the care plan. However, the DON also stated they were not sure how resident care plan interventions were put into the POC system. The DON confirmed there were no anti-tip bars on the resident's wheelchair. During an interview on 4/7/22 at 10:34 a.m., with the Assistant Director of Nursing (ADON), it was revealed that the facility conducted huddle meetings with staff when interventions changed. According to the ADON, not all interventions from a care plan automatically moved to POC and had to be entered manually by management team members. The ADON also confirmed there was no dycem or anti-tip bars on the resident's wheelchair at that time. During an interview on 4/8/22 at 1:24 p.m., the Administrator stated they were not aware how information was communicated to the CNAs regarding interventions put in place by the PAR team. 2. A review of Resident (R) #74's Consolidated Order, included but are not limited to pain in right hip, pain in left hip, unspecified dementia, displace fracture of base of neck of right femur, [CONDITION(S)], and (CDD) cervical disc disorder. A review of the quarterly MDS for R#74, dated 2/26/22, revealed the Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. The MDS also revealed the resident required extensive assistance from staff for ambulation and transferring and utilized a wheelchair and a walker as a mobility device. According to the MDS, the resident had sustained two falls with injury. A review of R#74's care plan, updated on 3/25/22, revealed the resident was at risk for falls related to poor safety awareness and dementia. Interventions in place for fall prevention included but were not limited to winged mattress, non-skid tape next to bed, and anti-roll backs on the wheelchair. Observation on 4/6/222 at 11:40 a.m., revealed R#74 was in bed. There were no non-skid strips on the floor on either side of the bed. Observation on 4/7/22 at 8:25 a.m., revealed R#74 was in a wheelchair in the hallway. Observation of the resident's bedroom revealed there was a winged mattress on the resident's bed; however there continued to be no nonskid strips on the floor next to the bed. During an interview on 4/7/22 at 8:06 a.m., Certified Nursing Assistant (CNA) TT stated the staff becomes aware of what interventions were needed for fall prevention for residents based on the handheld POC (Point of Care). At 8:28 a.m., when asked what interventions were in place to prevent falls for R#74, she stated a low bed and to check frequently. During an interview on 4/7/22 at 8:17 a.m., with LPN XX, it was revealed that CNAs were told about interventions in place for residents on fall precautions through education and in-services. She stated fall mats, non-skid socks, call lights, and close monitoring should be in place for residents who were high risk for fall. During an interview on 4/7/22 at 8:20 a.m., CNA VV confirmed the handheld POC showed the staff what interventions were in place for fall prevention. At 8:23 a.m., CNA VV stated there were no extra interventions for safety for R#74. During an on 4/7/22 at 10:34 a.m.,with the ADON , it was revealed care plan information had to be entered manually into POC. The ADON stated management team members entered the information into POC; however, confirmed R#74 had no nonskid strips on the floor. During an interview on 4/7/22 at 10:34 a.m., the DON confirmed there were no nonskid strips on the floor on either side of the bed for R#74. The DON was not sure how resident care plan interventions were put into the POC system. 3. A review of R#41's Face Sheet revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R#41's annual MDS, dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating no impaired cognition. The MDS revealed R#41 had impaired vision and used corrective lenses. A review of the active Care Plan for R#41, revealed there was no documented evidence the facility developed a care plan regarding R#41's visual impairment, nor the need for corrective lenses. During an interview on 4/5/22 at 3:36 p.m. with R#41, it was revealed the resident stated they had poor vision and wanted new glasses. The resident stated they had been to the eye doctor and had [CONDITION(S)]. Observation and interview with R#41 on 4/6/22 at 11:34 a.m., revealed R#41 lying in bed. R#41 continued to state they wanted glasses because it was hard to see most things. A review of paperwork provided by the Social Worker (SW) for R#41 revealed the resident had a revisit exam for [CONDITION(S)] on 3/22/22. The exam note revealed the resident's [CONDITION(S)] were not mature enough for surgical evaluation. The document further stated a follow-up exam for [CONDITION(S)] was scheduled for five months. There was no documented evidence the exam addressed the resident's need for glasses. During an interview on 4/8/22 at 11:53 a.m., MDS Nurse UU confirmed there was no care plan initiated for R#41 regarding the resident's vision concerns. The MDS nurse stated there should be a care plan related to the resident's use of glasses and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review, interviews, and review of the facility policies Patient's Plan of Care and Fall Management, it was determined that the facility failed to ensure the care plan for one of 25 residents (R) R#48, reviewed for care planning was revised to prevent future falls from occurring. Findings include: A review of the facility policy titled, Patient's Plan of Care, dated 2020, revealed, The patient's care plan should be reviewed after each MDS (Minimum Data Set) assessment and revised based on changing goals, preferences and needs of the patient and in response to current interventions. The comprehensive care plan should also be updated as ongoing clinical assessments identify changes. A review of the facility policy titled, Fall Management, dated 2020, revealed, If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. A review of R#48's Resident Consolidated Order revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly MDS for R#48, dated 2/10/22, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. Further review of the MDS revealed R#48 was unsteady during transitions and walking, required extensive assistance from staff for ambulation, required limited assistance from staff for transfers, and utilized a wheelchair as a mobility device. The MDS also revealed R#48 had sustained two or more no injury falls and one fall with injury since the resident's last MDS assessment, which was dated 11/17/21. A review of R#48's care plan, last updated on 1/10/22, revealed the resident was at risk for falls related to poor safety awareness, tremors, impulsive behavior, [CONDITION(S)], unsteady gait, and impaired cognitive status. The care plan review revealed the facility developed fall prevention interventions that included keeping the call light in reach; placing anti-tippers, a drop seat, a dycem (cushion to prevent sliding from a wheelchair), and anti-roll backs to the wheelchair; toileting and encouraging the resident to call for assistance; providing footwear or non-skid socks; keeping the bed in low position; bringing the resident out of the room to the nurses' station when up; placing a mat at the bedside; and keeping personal items within reach. A review of an Event-Initial Note for R#48 revealed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The note indicated the resident stood up to pick something up and tripped over the wheel on the wheelchair. Further review of the note revealed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the note, R#48 had severely impaired cognition, impaired judgement, and the inability to understand directions. A review of PAR (Patient's Area of Risk) Review notes for R#48 dated 1/7/22 revealed the root cause of the fall was related to the resident transferring unassisted and the long-term intervention to prevent further falls was to verbally explain surrounding to resident. Continued review of R#48's care plan revealed even though the resident was cognitively impaired, and the facility determined the resident had the inability to understand directions, the facility revised the care plan on 1/7/22 with an intervention to verbally explain surroundings to the resident to prevent further falls. A review of an Event-Initial Note for R#48, dated 1/8/22, revealed the resident got up unassisted, walked to the roommate's bed and fell at 4:01 p.m. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of R#48's care plan revealed the intervention was added on 1/8/22. A review of an Event-Initial Note for R#48 revealed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff found the resident on their buttocks and the roommate stated the resident hit their head on a wheelchair. The note stated the resident had no injury. The staff assisted the resident into a wheelchair and brought R#48 to the nurse's station for observation. The note revealed the new intervention added to prevent future falls was to place the resident in open area for maximum observation opportunities, even though this was the same intervention implemented after the resident's fall on 1/8/22 and was not effective at preventing this fall. Continued review of Event-Initial Note for R#48 revealed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The note stated the resident was ambulating to the bathroom unassisted and fell . According to the note, the resident hit their head; however, the note revealed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of R#48's care plan revealed no documented evidence the resident's care plan was revised to include the interventions. During an interview on 4/8/22 at 11:53 a.m., MDS Nurse UU confirmed the care plans were not accurately revised after R#48 sustained falls and some of the interventions were ineffective. During an interview on 4/8/22 at 11:33 a.m. with the Director of Nursing (DON), revealed their expectations included care plans being updated regularly, being resident-centered, and focused on details. The DON stated care plans should be updated after falls for fall prevention. During an interview on 4/8/22 at 1:24 p.m., the Administrator stated they were not sure who was responsible for updating resident care plans. The Administrator stated it was the expectation that care plans should be updated after falls and the care plan should be person-centered.

Based on observations, interviews, record review, and review of the facility's policy titled Moving A Patient Up in Bed, it was determined the facility failed to ensure one of one sampled resident (R) #90, received treatment and care in accordance with the resident's comprehensive person-centered care plan. Specifically, the facility failed to ensure R#90 maintained proper body alignment while in a geriatric chair (Geri-chair). Findings include: A review of the facility's policy titled, Moving A Patient Up in Bed, dated 2020, revealed, The intent of this center is to provide patients with care that promotes good body alignment. A review of R#90's Face Sheet revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS), dated [DATE], indicated R#90 sometimes understood others and sometimes made self-understood. The resident had a Brief Interview for Mental Status (BIMS) score of three, indicating the resident had severely impaired cognition. Further review of the MDS revealed the resident required extensive assistance of two staff members for bed mobility (how a resident moves to and from lying positions, turns side to side, and positions body while in bed or alternate sleep furniture). A review of R#90's care plan, reviewed by the facility on 9/7/21, revealed the facility developed an intervention to position patient (resident)properly and to utilize pressure reducing or pressure relieving devices (pillows, positioning wedges) if indicated. Further review of the resident's care plan, last reviewed 3/13/22, revealed the facility also developed interventions to assist the resident with activities of daily living as needed and to provide the appropriate level of assistance to promote safety of the resident. Observation on 4/7/22 at 7:40 a.m., of R#90 occurred in the sunroom of Hall C. The resident was seated in a Geri-chair, slumped over to the left side of the Geri-chair. A pillow was behind the resident's head, but it was not providing any support since the resident's upper body was leaning off the Geri-chair arm. Observation on 4/7/22 at 8:13 a.m., revealed R#90 had slid further down the chair and their head was hanging off the arm of the chair. The resident's neck was observed hyperextended, with their face positioned toward the ceiling. Observation on 4/7/22 at 9:00 a.m. revealed R#90 was in a Geri-chair in their bedroom. The resident had a pillow to their back and had slid down in the Geri-chair. The resident's head was resting on the left armrest. Further observation on 4/7/22 at 9:19 a.m., revealed the resident was observed still slumped over the left side on the armrest of the Geri-chair. Observation on 4/7/22 at 9:27 a.m., R#90 was in the day room. A pillow was observed partially under the left side of the resident's head; however, the resident was leaning off the left side of the Geri-chair. Observation on 4/7/22 at 10:01a.m., R#90 was slumped over. A small corner of a pillow was under the left side of the resident's face while the resident's face was resting on the arm of the Geri-chair. Observation on 4/7/22 at 10:49 a.m., R#90 was lying diagonally across the Geri-chair with the right leg hanging off the right side of the chair and the resident's head resting on the left armrest of the Geri-chair. A corner of a pillow was under the resident's cheek. Observation on 4/7/22 at 11:07 a.m., a staff member was observed lifting R# 90 to a more upright position and the right leg was placed back on the Geri-chair. A pillow was behind the resident's head and left shoulder; however, the resident was still leaning to the left. Further observation on 4/7/22 at 11:36 a.m., revealed the R#90's position remained unchanged. Observation on 4/7/22 at 11:53 a.m. of R#90, staff transferred the resident outside to the porch; however, no repositioning was provided for the resident. Observation on 4/7/22 at 12:58 p.m., R#90 was at the dining table being assisted with eating. The head of the Geri-chair was upright, and the resident was leaning on the left arm of the Geri-chair. Observation on 4/7/22 at 1:33 p.m., R#90 was in the sunroom in a Geri-chair. The resident's head was slumped to the left and resting on the resident's upper arm that was lying on the arm of the Geri-chair. Observation on 4/7/22 at 1:39 p.m., revealed staff had placed a pillow behind the resident's back; however, the pillow did not provide support for the resident's head and shoulders and the resident's head had slumped to the left and was resting on the armrest of the Geri-chair. During an interview on 4/7/22 at 1:57 p.m., with Certified Nursing Assistant (CNA) AA, revealed R#90 usually leaned to the left when seated in a Geri-chair. CNA AA stated she was not aware of any interventions to provide proper body alignment for the resident. Observation on 4/8/22 at 8:30 a.m., R#90's head and left arm were observed hanging off the left side of the Geri-chair. On 4/8/22 at 9:05 a.m., the Assistant Director of Nursing (ADON) and Director of Nursing (DON) were asked to observe the resident whose head and left arm remained hanging off the left side of the chair. They stated they thought the resident was comfortable with the armpit on the arm rest and the resident's head hanging over the chair without support. The interview with the DON revealed the facility had tried placing a pillow behind the resident's head; however, the resident returned to the left side. According to the DON, no other positioning devices had been attempted. She stated that R#90 had stated that they were comfortable in that position. The DON asked the resident if the resident was comfortable. The resident mumbled a response that sounded like yes. The DON asked the resident if they wanted to be repositioned. The resident again mumbled a response that sounded like, Yes, repositioned. The DON asked the resident again if that was how the resident was comfortable. The resident again mumbled a response that sounded like yes. During an interview on 4/8/22 at 1:30 p.m., the DON revealed her expectation was that staff would evaluate and find a way to keep the resident in the chair, if a resident was consistently leaning off their Geri-chair. During an interview on 4/8/22 at 3:55 p.m., with CNA KK revealed R#90 constantly leaned to the left side. The CNA stated the resident should have had positioning pillows, such as a wedge, on the left side to prevent the resident from leaning off the left side of the Geri-chair.

Based on observations, record reviews, interviews, and review of the facility policy, Fall Management, the facility failed to ensure that falls were thoroughly investigated, and appropriate interventions were put into place to prevent falls for two residents, Resident (R) #48 and R#78, of five residents reviewed for falls. Findings include: A review of the facility policy titled, Fall Management, revealed, Each patient is assisted in attaining/maintaining his or her highest practicable level of function. Each patient's risk for falls is evaluated by the interdisciplinary team (IDT). A care plan is developed and implemented based on this evaluation with ongoing review. If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. When a fall occurs: Review the event and patient status at the next scheduled PAR (Patient at Risk) or UR meeting as indicated. 1. A review of the Face Sheet revealed the facility admitted R#74 on 2/3/21. Diagnoses included, but were not limited to, pain in right hip, pain in left hip, unspecified dementia, displace fracture of base of neck of right femur, [CONDITION(S)], and cervical disc disorder (CDD). A review of the quarterly Minimum Data Set (MDS) for R#74, dated 2/26/22, revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. Further review of the MDS revealed R#74 required extensive assistance of one staff for ambulation and transferring and utilized a wheelchair and a walker as a mobility device. Further review of the MDS revealed R#74 sustained two or more falls with injury since the prior MDS, which was dated 12/3/21. A review of the Care Plan, updated 3/25/22, revealed the resident was at risk for falls related to poor safety awareness and dementia. Interventions in place for fall prevention included, but were not limited to, winged mattress, non-skid tape next to the bed, and anti-roll backs on the wheelchair. A review of the Electronic Health Record (EHR) indicated R#74 sustained falls on 1/18/22, 2/15/22, and 3/24/22. A review of the Event notes for a fall which occurred on 1/18/22 indicated R#74 was ambulating unassisted in the hallway. Injuries included a skin tear to the right wrist and a wound to the forehead. Interventions put into place immediately included to keep the resident in full observation. A review of the Patient at Risk (PAR) investigation revealed the new recommendations for the care plan interventions included providing activity. A review of the Event notes for a fall which occurred on 2/15/22 indicated R#74 was found on the floor next to the bed with pillows under their head. The immediate intervention added after the event was to add a fall mat to the right side of the bed and the left side of the bed. A review of the PAR investigation revealed the new recommendations for the care plan included a winged mattress. A review of the Event notes for a fall which occurred on 3/24/22 indicated R#74 tried to get up from the wheelchair and slid down to the floor. This incident occurred in the resident's room. There was pain to the right leg. A follow-up x-ray indicated a fracture of the right hip. The resident was transported to the hospital for surgical repair. The immediate intervention added after the event was to add a fall mat to the right side of the bed. This intervention was added as a short-term intervention after the fall on 2/15/22. A review of the PAR investigation revealed the new recommendations for the care plan interventions included adding nonskid tape to the floor near the bed. The document also indicated the response to previous interventions had been good. Observation on 4/7/22 at 8:25 a.m., R#74 was in a wheelchair in the hallway outside their room. There were no nonskid strips on the floor next to the bed. During an interview on 4/7/22 at 8:06 a.m., Certified Nursing Assistant (CNA) TT revealed that the staff becomes aware of what interventions were needed for fall prevention for residents based on the handheld Point of Care (POC). During an interview on 4/7/22 at 8:17 a.m., LPN XX stated the CNA's were told about interventions in place for residents on fall precautions through in-services and education. She stated fall mats, non-skid socks, call lights, and close monitoring were in place for R#74. During an interview on 4/7/22 at 8:20 a.m., CNA VV confirmed the handheld POC showed the staff what interventions were in place for fall prevention. At 8:23 a.m., she stated there were no extra interventions for safety for R#74. During an interview on 4/7/22 at 8:28 a.m., with CNA TT, was asked what interventions were in place to prevent falls for R#74. She stated a low bed and to check frequently. During an interview on 4/7/22 at 10:34 a.m., with the Director of Nursing (DON), she stated the CNAs received a verbal report and would know what fall precautions were in place for residents through that report. When asked how interventions were put into the POC system, the DON stated they were not sure. She confirmed there were no nonskid strips on the floor on either side of the bed for R#74. She also stated each fall event was talked about in the PAR meeting where care plans were updated, and a root cause analysis was completed. The interventions were added to the care plan at that time. During an interview on 4/7/22 at 10:34 a.m., the Assistant Director of Nursing (ADON) stated they conducted huddle meetings with staff whenever the interventions changed. The POC information had to be entered manually, as not all interventions from the care plans moved over to the POC if it was outside the scope of practice for CNAs. When asked who entered information manually into the POC, the ADON stated management team members put information in. During an interview on 4/8/22 at 11:33 a.m., the DON revealed that expectations included care plans being updated regularly and should be resident centered. The goal was to provide great care and the DON stated interventions should be in place. She then stated communication to the CNA's and education was essential in providing good care. She also stated the expectation of fall prevention was to find the root cause of falls to prevent further falls. When asked if they thought the current fall risk program was adequate, the DON stated that the facility tried our best to ensure the safety of our patients. During an interview on 4/8/22 at 11:53 a.m., MDS Nurse UU confirmed the care plans were not updated accurately after falls for R#74. The fall mat intervention was not initiated on the care plan. During an interview on 4/8/22 at 1:24 p.m., the Administrator revealed that the nursing and facility leadership were responsible for the fall risk prevention. The Administrator stated they were not aware of how information was communicated to the CNA's regarding interventions put in place by the PAR team. The Administrator stated the expectation of the facility regarding falls and resident safety was to limit falls. 2. A review of the Face Sheet for R#48 revealed the facility admitted the resident with diagnoses that included, but were not limited to, Alzheimer's disease, history of falling, [CONDITION(S)], restlessness, and agitation, unsteady on feet, (CDD) cervical disc disorder, and tremor. A review of the quarterly MDS for R#48, dated 2/10/22, revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. Further review of the MDS revealed R#48 required extensive assistance of one staff for ambulation and utilized a wheelchair as a mobility device. The MDS also indicated R#48 sustained two or more falls without injury and one fall with injury since the prior MDS, which was dated 11/17/21. A review of the Care Plan, updated 1/10/22, revealed the resident was at risk for falls related to poor safety awareness, tremors, impulsive behavior, [CONDITION(S)], unsteady gait, and impaired cognitive status. Interventions in place for fall prevention included, but were not limited to, a mat at the bedside (implemented 12/7/21), wheelchair within reach when in the bathroom (implemented 12/06/2021), bed in low position (implemented 9/22/21), anti-roll backs on wheelchair (implemented 12/22/21), dycem (material to help keep cushion in wheelchair seat in place; implemented 10/01/19), and to keep the resident near the nurse's station (implemented 12/28/21). A review of the EHR indicated R#48 sustained falls on 12/05/21, 12/7/21, 12/21/21, 1/4/22, 1/8/22, 1/15/22 and 1/18/22. A review of the Event notes for a fall which occurred on 12/5/21 indicated R#48 decided to sit on the floor while ambulating to the bathroom. There was no injury. The immediate intervention added after the event was to maintain the wheelchair in reach of the resident. A review of the PAR investigation revealed the new recommendations for the care plan interventions included maintain the wheelchair in reach. A review of the Event notes for a fall which occurred on 12/7/21 indicated R#48 was found sitting next to their bed on the floor. The report indicated there was an injury, a skin tear to the left arm. The skin tear received treatment at the facility. The immediate interventions added included bed in low position, call light in reach, mat at bedside, offer snacks, and redirect. There was no PAR investigation for this fall provided. A review of the Event notes for a fall which occurred on 12/21/21 indicated R#48 was found at the nurse's station on the floor in front of their wheelchair. There was no injury. The intervention added at the time of the incident included encouraging the patient to call for assistance and implement a toileting schedule. A review of the PAR investigation revealed the new recommendations for the care plan interventions included adding anti-tip bars to the wheelchair (bars added to the front or back of the wheels of the wheelchair that prevent the chair from tipping backwards) and medication review. A review of the Event notes for a fall which occurred on 1/4/22 indicated R#48 was found sitting in the hallway in the wheelchair. The resident stood and bent down to pick up something off the floor and tripped over the wheel of the wheelchair. There was no injury. The intervention added at the time of the incident included other. A review of the PAR investigation revealed the new recommendations for the care plan interventions included to verbally explain surroundings to the resident and assist the resident to the chair. The document also indicated the response to previous interventions had been good. A review of the Event notes for a fall which occurred on 1/8/22 indicated R#48 got up unassisted and walked to the roommate's bed and fell . There was no injury. The intervention added at the time of the incident included to place the resident in open area for maximum observation opportunities. There was no PAR review for this fall. A review of the Event notes for a fall which occurred on 1/15/22 indicated R#48 ambulated to the bathroom unassisted and fell . The staff assisted the resident into a wheelchair and brought R#48 to the nurse's station for observation. There was no injury. The intervention added at the time of the incident included to place the resident in open area for maximum observation opportunities. This was also the intervention added after the 1/8/22 fall. There was no PAR review for this fall. A review of the Event notes for a fall which occurred on 1/18/22 indicated R#48 ambulated to the bathroom unassisted and fell . There was no injury. The intervention added at the time of the incident included bed in low position, call light in reach, and declutter room. A review of the PAR investigation revealed the new interventions included assess needs, take the resident to the bathroom, assist the resident to the wheelchair, and winged mattress (mattress with built up edges to help prevent falls). The document also indicated the response to previous interventions had been good. Observation on 4/5/22 at 10:51 a.m. R#48 was sitting in the room in a wheelchair, looking out the window. There was no call light in reach, as the wheelchair was at least five feet from the bed. There was a fall mat by the bed. Observation on 4/6/22 at 11:33 a.m. revealed R#48 was in bed with the bed in low position, and there was no fall mat next to the bed. Observation on 4/7/22 at 8:02 a.m., R#48 was sitting in a wheelchair in the hallway, with a breakfast tray in front of the resident on an overbed table. There were no anti-tip bars on the wheelchair. During an interview on 4/7/22 at 8:06 a.m., CNA TT stated the staff becomes aware of what interventions were needed for fall prevention for residents based on the handheld POC. During an interview on 4/7/22 at 8:17 a.m., LPN XX revealed that the CNAs were told about interventions in place for residents on fall precautions through in-services and education. LPN XX stated fall mats, non-skid socks, call lights, and close monitoring were in place for R#48. During an interview on 4/7/22 at 8:20 a.m., CNA VV confirmed the handheld POC showed the staff what interventions were in place for fall prevention. During an interview on 4/7/22 at 8:28 a.m., CNA TT was asked what interventions were in place to prevent falls for R#48. She stated a fall mat and low bed were the interventions for R#48. During interview on 4/7/22 at 8:47 a.m., CNA VV revealed the resident was to have a fall mat and confirmed that interventions along with anti-tip bars and low bed were not on the POC. During an interview on 4/7/22 at 9:27 a.m., MDS Nurse UU stated she had worked at the facility as the MDS nurse for nine years. She confirmed there were no anti-tip bars on the wheelchair for R#48. When asked how the information and interventions from the care plans were transmitted to the POC, MDS Nurse UU stated they did not know. She also stated when residents were moved from different rooms or different units, sometimes things get missed. During an interview on 4/7/22 at 10:34 a.m., the DON revealed the CNA's received verbal reports and would know what fall precautions were in place for residents through that report. When asked how interventions were put into the POC system, the DON stated they were not sure. She confirmed there were no anti-tip bars on the wheelchair for R#48. She also stated each fall event was talked about in the PAR meeting where care plans were updated, and a root cause analysis was completed. The interventions were added to the care plan at that time. During an interview on 4/7/22 at 10:34 a.m., ADON stated they conducted huddle meetings with staff whenever the interventions changed. The POC information had to be entered manually, as not all interventions from the care plans moved over to the POC if it was outside the scope of practice for CNA's. When asked who entered information manually into the POC, the ADON stated management team members put information in. The ADON also confirmed there was no dycem in the wheelchair and no anti-tip bars on the wheelchair for R#48. During an interview on 4/8/22 at 11:53 a.m., the MDS Nurse UU confirmed the care plans were not updated accurately after falls for R#48. She also stated the interventions were sometimes duplicated and some were not resident-centered. When asked why there were no PARs for falls occurring on 12/7/21, 1/8/22, and 1/15/22 for R#48, MDS UU stated she did not know. When asked if they thought the interventions in place for R#48 regarding falls were appropriate and resident-centered, she stated no.

Based on record review, interviews, and review of the facility policy titled, Pharmacy Services - Antimicrobial Stewardship Program Center Mission and Commitment Statement, the facility failed to implement antibiotic use protocols related the Antibiotic Stewardship Program for one resident (R) #101, of six sampled residents whose clinical records were reviewed for the use of unnecessary medications. Specially, R#101 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the facility policy titled, Pharmacy Services - Antimicrobial Stewardship Program Center Mission and Commitment Statement, dated 2019, revealed, We are committed to the prudent use of antimicrobials on behalf of all patients we serve through a sustainable antimicrobial stewardship program. We will fuel the day-to-day needs of the program by supporting our physicians, nurses, and pharmacists, and we will ensure they have the time, tools, staff, budget, and education necessary to promote the safe and appropriate use of antibiotics with the goal of decreasing utilization and antibiotic resistance. Review of the Face Sheet revealed R#101 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident had a Brief Interview for Mental Status (BIMS) score of 6, indicating the resident had severe cognitive impairment. The MDS further revealed the resident required extensive assistance of two staff for toileting and was occasionally incontinent of bladder and frequently incontinent of bowel. A Nurse's Progress Note, dated 3/22/22 at 12:16 p.m., indicated the resident had been complaining of back pain. The resident had three episodes of vomiting and was complaining of pain when urinating. A urinalysis (UA) was collected by clean catch, using aseptic technique. The physician and family were notified. They were awaiting results. The resident's vital sign records, dated between 3/22/22 and 4/5/22, indicated the resident's temperatures were within the base line range of 97.2- and 98.6-degrees Fahrenheit (F), with one exception. On 3/22/22 at 9:26 p.m., the resident's temperature was 99.1 degrees F. A urine analysis result, dated 3/25/22, indicated the resident's urine contained Leukocytes 3+, bacteria 2+, and the culture growth indicated Escherichia coli (E. coli) greater than 100,000. A handwritten note at the bottom of the page indicated no ABT [antibiotic] ordered and there was no date on the note. Also, another handwritten note at the bottom of the page revealed a note ordering [MEDICATION(S)] (an antibiotic) 500 milligrams (mg), to be administered three times a day, orally, for five days. There was no date on the note. The clinical record contained no additional documentation the facility had continued to assess the resident for signs and symptoms of a urinary tract infection ([CONDITION(S)]) between 3/22/22 and 4/5/22. There was no indication the resident had continued to complain of painful urination or had run an elevated temperature. There was no evidence in the record that an Infection Report Form - Urinary Tract Infections form was completed. A Nurse's Progress Note, dated 4/5/22 at 9:48 a.m., indicated the facility started the resident on [MEDICATION(S)] (antibiotic or antimicrobial medication) for a urinary tract infection ([CONDITION(S)]). During an interview on 4/7/22 at 9:33 a.m., R#101 denied having bladder pain or the need for an antibiotic. During an interview on 4/8/22 at 10:54 a.m., the Administrator revealed that the nurses did not determine if a resident needed to be placed on antibiotic therapy; the physician did that. She was asked if the facility had some guidelines or utilized an algorithm to help determine if a resident should be treated with an antibiotic. The Administrator stated that the facility did not have guidelines, or an algorithm and that the physician determined whether a resident needed antibiotics or not. She stated the reason the resident was not started on antibiotics until 4/5/22 was because the physician wanted to see the resident before starting antibiotics. She was asked why the physician had ordered antibiotics. She stated she did not know. During an interview on 4/8/22 at 12:41p.m., the Director of Nurses (DON) and the Assistant Director of Nurses (ADON) were asked about the facility's Antibiotic Stewardship Program. They were asked what signs and symptoms R#101 had exhibited on 3/22/22 through 4/5/22 that would warrant the use of an antibiotic. The DON stated the resident complained of painful urination on 3/22/22 so a clean catch UA was obtained. The ADON stated the nurse would assess the resident and fill out a facility Infection Report Form - Urinary Tract Infection form that had an algorithm to help determine if the resident should receive an antibiotic. She was asked if the form was part of the facility's Antibiotic Stewardship Program. The ADON stated it was. She was asked if the facility had completed the assessment form for R#101 on 3/22/22 or at any other time before starting the resident on the antibiotic. They did not answer. They were asked to provide any information related to an assessment for the need for an antibiotic for R#101; however, no information was provided prior to exit. During the same interview, the DON was asked why the physician had ordered antibiotics for the resident on 4/5/22. She stated it was for a [CONDITION(S)]. She was asked what information the facility had provided to the physician about the resident's symptoms. She stated she did not know. She was asked who determined the resident should be administered an antibiotic. She stated the physician determined that. During an interview on 4/8/22 at 3:47 p.m., the Infection Control Preventionist Licensed Practical Nurse stated he was not directly involved in deciding if a resident met the criteria to receive antibiotics. He stated, I don't know if the nurses are filling out the [CONDITION(S)] infection Control Criteria Form or any other antibiotic stewardship form. I just review the labs and physician orders for antibiotics at the end of the month and provide the information to the DON.

Based on facility record review, staff and resident interviews, it was determined the facility failed to ensure two residents (R) (R#121 and R#55) from a sampled 57 residents were free from physical and psychological abuse. R#121 was subjected to a painful failed urinary catheter insertion along with verbal threats from a staff member. Five days later on 12/23/18, R#55 was subjected to painful dis-impaction removal of stool by the same employee. On 1/8/19, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and the Regional Nurse Consultant and Regional Nurse Consultant were informed of the immediate jeopardy on 1/8/19 at 5:14 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 12/18/18. The immediate jeopardy continued through 1/9/19 and was removed on 1/10/19. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); 42 CFR 483.12(b)(1)?(4), Develop/Implement Abuse/Neglect, etc. Policies (F607, Scope/Severity: J); 42 CFR 483.12(c)(2)?(4) Alleged Violations-Investigate/Prevent/Correct (F610, Scope/Severity: J); 42 C.F.R. 483.21(b)(3)(i), Professional Standards (F658, Scope/Severity: J); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: J). Additionally, Substandard Quality of Care was identified at: F600, Freedom from Abuse, Neglect and Exploitation F607, Develop/Implement Abuse/Neglect, etc. Policies F610, Alleged Violations-Investigate/Prevent/Correct A Credible Allegation of Compliance was received on 1/10/19. Based on observations, record reviews, interviews and review of the facility's policies and staff training as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 1/10/19. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of staff treatment of [REDACTED]. Observation and interviews were conducted with staff and residents to ensure they demonstrated knowledge of facility Policies and Procedures governing identifying and reporting Abuse, Neglect and Exploitation of residents. The Immediate Jeopardy is outlined as follows: 1. The facility's failure to protect R#121 from abuse were related to lack of a complete investigative procedures of the multiple attempts to insert an indwelling urinary catheter for R#121. During the initial tour of the facility on 1/7/19 the surveyor conducted a family interview and was informed that on 12/18/18 a urinary catheter insertion was attempted at least nine times on R#121. Interviews with staff revealed that during the failed attempts R#121 was screaming spank them . The nurse replied to the resident, I will spank you. The facility did not conduct a full investigation when this incident of alleged abuse was reported to the Director of Nursing (DON) and Administrator by Resident (R) #121's family member and three Certified Nurse Aides (CNA) who were present in the room with R#121 when the incident occurred. The alleged perpetrator, Licensed Practical Nurse (LPN) II, continued to work at the facility until dismissed on 1/9/19. 2. On 1/9/19 the surveyor was made aware during staff interviews of R#55 receiving a forceful dis-impaction by the same nurse on 12/23/18. The nurse continued to digitally dis-impact the resident when he yelled out in pain Can we take a break, the nurse replied to R#55, We don't take breaks here. The alleged perpetrator refused to stop attempts to dis-impact stool from R#55's rectum when the resident yelled and told the nurse he needed a break because she was hurting him. The resident has a [DIAGNOSES REDACTED].#55 received digital stimulation by LPN II without a physician's orders [REDACTED]. Findings Include: 1. Interview conducted on 1/7/19 at 10:00 a.m. with the family of R#121 revealed approximately the week before last she was walking down the hall to R#121's room when the family heard R#121 screaming bloody murder. The family member walked into the room of R#121 and there were two Certified Nursing Assistant (CNAs) at the head of the resident's bed and Licensed Practical Nurse (LPN) II was attempting to insert a catheter. The family member also stated LPN II tried at least six times while the resident was still screaming. LPN II told family to get out of her way. The family member left the room to get LPN EE to put the catheter in. The family further stated they felt LPN II had abused R#121 because LPN II wouldn't stop even when R#121 was screaming in pain. The family was asked if they had told anyone and they stated yes, they had spoken to the Director of Nursing (DON), and LPN II is still working here. The family was questioned if LPN II had been assigned to the resident since the incident had occurred? They stated, No, we requested that nurse not be allowed to take of R#121. An interview was conducted with the Administrator and DON in the Administrative office outer room on 1/7/19 at 3:30 p.m. The Administrator and DON were informed of R#121's family's allegation of abuse concerning the insertion of R#121's urinary catheter by LPN II. The DON and Administrator stated they both were aware of the catheter incident with LPN II and they had investigated the incident and did not consider it to be abuse, but rather a personality conflict. The DON and Administrator stated the family never told them it was abuse. The Administrator further stated they would begin another investigation related to abuse and report to the State as such. Review of the resident's face sheet revealed R#121 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the Brief Interview for Mental Status (BIMS) indicated R#121 was severely cognitively impaired. A review of Section E, Behaviors, indicated the resident did not exhibit physical behavioral symptoms directed towards others (such as hitting, kicking, pushing, scratching and grabbing), verbal behavioral symptoms directed towards others(such as threatening, screaming or cursing at others) and Other behavioral symptoms not directed at others ( physical symptoms such as hitting or scratching self, .verbal/vocal sounds such as screaming and making disruptive sounds). A review of R#121's functional status indicated the resident was totally dependent for all activities of daily living (ADLs), with assistance from two or more people. This includes but is not limited to bed mobility, transfers, dressing, eating, toilet use and personal hygiene. A review of Section H, Bowel and Bladder indicated the resident had an indwelling catheter. Review of R#121's care plan, dated 10/17/18, problem: urinary catheter related to obstructive and reflux [MEDICAL CONDITION] as evidenced by indwelling catheter. Goal: patient will be free of complications of indwelling catheter through the review period. Interventions: assess for bladder distention, small frequent voids, dribbling, resident complaint of bladder feeling full, care/changing of urinary catheter as ordered, confer with physician regarding the continued need of urinary catheter, consider the risks and benefits of continuing the long-term use of an indwelling urinary catheter and remove it as soon as possible if indicated, keep catheter tubing placed below of bladder, maintain closed, sterile system, tubing free of kinks, medications as ordered, observe and report any signs and symptoms of urinary tract [MEDICAL CONDITION], observe output, observe urine appearance, amount, odor, clarity, secure catheter tubing, and Urology consult as ordered. The care plan did not indicate R#121 was difficult to insert a urinary catheter. Review of physician's orders [REDACTED]. Review of the grievance log for 8/1/18 through 1/7/19 and facility's reported incidents since last annual survey on 1/7/18 did not reveal any reports were made to the DON concerning R#121 and R#55. Review of the staff statements provided by the facility revealed the following: Review of CNA FF's signed statement dated 12/18/18 indicated that R#121 was agitated and screaming spank them, spank them, spank them! LPN II leaned down and told R#121 I'll spank you back. LPN II looked at R#121, and CNA FF and CNA HH we need to drug R#121 up because I can't deal with the screaming. R#121 is way too agitated, you won't be to hold R#121's legs open. CNA HH left the room, LPN II told me, you need to go and get someone to help hold R#121's hands while you hold R#121's legs. I don't have time for this, I have other things that I have to do. LPN II proceeded to try and insert the catheter into the clitoris and the vagina around eight times. family walked into room and asked what was going on. I explained the situation and the family came over to help. LPN II put a gloved hand up to the R#121's family members chest and told them to step away, you're in my light. The family immediately was agitated with LPN II and came to my side to help calm R#121. LPN II attempted to insert the catheter at least seven more times. The family and I told CNA GG to go and get LPN EE. LPN EE came in and asked what was going on? LPN II replied it won't go into R#121's meatus. LPN EE immediately took over and easily inserted the catheter on the first try. Review of CNA GG's signed statement dated 12/18/18 indicated that CNA GG was asked by CNA FF to help both CNA FF and LPN II insert a new catheter for R#121 because the resident's old catheter was clogged. LPN II attempted to insert the catheter into the clitoris around eight times. The resident's family entered the room and was wondering what was going on, CNA FF began to explain the catheter was clogged and it was being replaced. The family member stepped over near the bed by LPN II, when LPN II put her hand up and told the family Stay away, you are in my light. LPN II continued to put the catheter into R#121's vagina at least six more times and I was told by both the family and CNA FF to go get LPN EE. LPN EE inserted the catheter. Review of CNA HH's hand written statement, dated and signed on 12/18/18 indicated that CNA FF and CNA HH were changing R#121, when they noticed the resident's catheter was clogged and all the urine was going into the brief. CNA FF went and told LPN II about the catheter and LPN II agreed it needed to be changed. R#121 had become very agitated and was yelling slap them, slap them. LPN responded I'll slap you back. LPN II also got a little tense and told CNA FF and me that we need to drug R#121 up before I do this. CNA HH told LPN II No and CNA FF told LPN II that she could hold resident's legs open for LPN II to insert the catheter. At this time, I was so mad at the situation I walked out of the room to calm down. The facility provided no other witnesses statements/interviews from LPN EE, LPN II, Social Worker (SW) or, resident's family member or any other documentation related to this incident. The facility presented LPN II's written statement (undated) to the survey team on 1/8/19 after LPN II came to the facility and spoke to the Administrator. An interview was conducted with LPN EE on 1/7/19 at 4:20 p.m. in the Unit 1A nursing station. LPN EE was asked if she recalled the incident with R#121 and LPN II? LPN EE stated, Yes, CNA HH and R#121's family came out of room to get LPN EE. They stated LPN II was hurting R#121. When I went into the room, R#121 was sweating and appeared to be in pain. I was able to insert the urinary catheter, everything was visible. LPN II should have asked for help. LPN EE was asked how many times did it take her to insert the urinary catheter and did you have any difficulty inserting the urinary catheter? LPN EE stated, I was able to insert the catheter on the first attempt, I didn't have any difficulties and could visualize R#121's anatomy without any problems. Who did you report this to? The LPN stated, the Social Worker and DON. An interview was conducted with LPN JJ, the Unit Manager for Units 1A and 1B, on 1/7/19 at 4:39 p.m. at the Unit 1B nursing station. LPN JJ stated, The family came out of R#121's room upset about LPN II trying to insert the urinary catheter while the resident was yelling. The family told me not to let LPN II go back into resident's room. LPN JJ was asked what she did next? LPN JJ stated, I immediately informed the DON. Interview with the SW was conducted on 1/7/19 at 5:00 p.m. in the basement hallway. SW stated LPN EE called and told her what happened and told LPN EE to bring family down to talk to SW. The family told her that they had walked in when LPN II was attempting to insert the catheter. The family said they told LPN II to stop, do not touch her anymore. I took her to the DON's office to speak to the DON and Administrator. The SW was asked if there was any documentation of R#121's family and the SW's conversation? The SW stated, 'No. The SW was questioned who handles the complaints and grievances and who is the Abuse Coordinator? The SW replied, Complaints and grievances are handled by the SW, DON and Administrator. The Administrator is the Abuse Coordinator. An interview was conducted with Director of Nursing (DON) on 1/8/19 at 1:30 p.m. in the basement classroom. The DON was questioned when did the incident related to R#121 occur and what prompted her to obtain statements from CNA FF and CNA GG? The DON stated, the incident occurred on 12/18/18, R#121's family came to the DON's office and told the DON that LPN II had tried to insert the urinary catheter five or six times. The family member told the DON that they had offered to help but LPN II told her I have been a nurse for [AGE] years, I know what I am doing. The DON was asked what actions did she take? The DON stated, I took statements, spoke with and counseled LPN II and removed LPN II from R#121's care. The DON was asked why after reading the CNA's written statement and spoke with the family did the facility not report the incident or initiate an investigation? The DON stated, After speaking with LPN II, I did not feel the incident was abuse but a customer service issue. The DON was questioned if there was anything else included in the facility's investigation of the incident? The DON stated, No, I only have the CNA's statements. There were no statements from other nursing staff, family, other resident or LPN II's counseling included in the documentation provided to the survey team on 1/8/19. A review of the staffing reports from the date of incident on 12/18/18 until 1/8/19 revealed that LPN II continued to work at the facility either on the same or adjacent unit where R#121's room was located. A telephone interview was conducted on 1/8/19 at 5:29 p.m. with LPN II. LPN II was asked to describe the incident on 12/18/18 concerning R#121's catheter insertion. LPN II stated that she was passing medications when a CNA told her that R#121's catheter was occluded (blocked). LPN II went to resident's room and assessed the catheter, there was a white milky substance in catheter tubing. LPN II decided that it needed to be changed and went out to gather supplies. R#121 was agitated and yelling, LPN II asked the CNA FF to go get a second CNA to help while she stood at beside patting resident's hand and telling her what she was going to do. LPN II asked the CNAs to position R#121 so she could insert the catheter. The resident had a different anatomy, the meatus (urethral opening) is inside her vagina. LPN EE came into room to ask if she could help. LPN EE inserted catheter without difficulty. LPN II was asked how was R#121's demeanor at the time of the catheter insertion? LPN II stated that the resident was laughing, saying spank you, spank you and she replied to resident I'll spank you back. LPN II was asked how was the family during this procedure? The LPN stated the family did not appear to be upset. LPN II was asked how many times did you attempt to insert the catheter? The LPN stated two to three times, I stopped after the third attempt. LPN II was asked if she would do anything different the next time? The LPN stated In hindsight, it would have been better to get help. An interview was conducted on 1/9/19 at 8:40 a.m. with CNA HH in Unit 1B nursing station. CNA HH was questioned if she recalled the incident with R#121 and LPN II? CNA HH stated, Yes, CNA FF and I laid R#121 down after lunch to change her. The resident was agitated. While changing the resident's brief they noticed the urinary catheter appeared nasty and needed to be changed. CNA FF told R#121's nurse, LPN II. R#121 was very agitated and was yelling, smack you, smack you. LPN II told R#121 I'll smack you back. CNA HH was so upset she left the room and reported it to LPN EE. CNA HH was asked if LPN II was joking with R#121 when she said, I'll smack you back? CNA HH stated, No, LPN II was agitated and serious when LPN II said it. CNA HH was asked if she had ever witnessed any inappropriate treatment or responses by LPN II? The CNA stated, LPN II is always rude with other residents and has a bad attitude. CNA HH did she think LPN II was being abusive towards the resident? CNA HH stated Yes, LPN II had no patience and was verbally abusive to the resident. CNA HH was questioned what happened after she reported it to LPN EE? CNA HH stated, LPN II went to the DON's office, when she came back LPN II went right back to work. CNA HH was questioned if LPN II went back to taking care of R#121? CNA HH stated, No, LPN EE took over the care of the resident, but LPN II still work on the unit. Interview was conducted on 1/9/19 at 9:07 a.m. with CNA FF in Unit 1B nursing station. CNA FF stated remembering the incident with R#121 and LPN II. The resident was very agitated, yelling and clapping her hands. CNA HH and I were changing R#121's brief because the resident had a bowel movement and noticed the urinary catheter was clogged and there was no urine output. I went to tell her nurse, LPN II. LPN II came to room and assessed the catheter and agreed it needed to be changed. R#121 was yelling spank you, spank you when LPN II told R#121 I am going to spank you. CNA FF was asked if LPN II said this in a joking manner? CNA FF stated No, LPN II was very irritated with the resident, it did not come off as a joke but as a threat. This is when CNA HH left the resident's room. LPN II told me I needed to get some help and I asked CNA GG to come in to help. LPN II was struggling to get the urinary catheter inserted when R#121's family walked into the room. When the family stated, let me help, LPN II put her dirty hand up and told the family they needed to back up. At one-time LPN II stated, We need to drug R#121 up because she is too agitated. I felt I needed to stay in R#121's room or LPN II would hurt her. An interview was conducted with CNA GG on 1/9/19 at 9:25 a.m. in Unit 1B nursing station. The CNA was questioned if the CNA recalled the incident with R#121 concerning the urinary catheter insertion on R#121? The CNA stated, Yes, I do. The CNA stated, CNA FF asked if I could help with R#121. LPN II had tried to insert the urinary catheter about 10 times. CNA FF told LPN II that the nurse needed to go up higher. LPN II told CNA FF I know what I am doing. The family came in and LPN II put her hand up in front of family and told them, they were in the way. R#121 was getting more agitated and sweatier, CNA FF told me to go get LPN EE. LPN EE came in inserted the urinary catheter in one attempt. A telephone interview was conducted on 1/10/18 at 11:25 a.m. with the facility's Medical Director (MD). The MD was asked what level of competency for nursing with placing a Foley (urinary) catheter do you expect? The MD stated, Only difficulty I am aware of have been anatomical, i.e., men with [MEDICAL CONDITIONS]. If the catheter is difficult to place then we would send resident next door to the hospital, but I can't remember any instances. What are your expectations if the nurse is having difficulty inserting catheter? The MD stated, Even if proficient, if you realize you can't place the catheter, don't continue, ask for help, use good decision making. Related to R#121's incident what are your thoughts? R#121 anatomy is a little difficult (legs are contracted), the resident has had a catheter for four to five years. She not only gets agitated she can get really wound up. Need to limit people giving care, the nurse should have stopped, she lost control. 2. During an interview conducted with CNA GG on 1/9/19 at 9:25 a.m. in Unit 1B nursing station. CNA GG was asked if LPN II was involved in any other incident regarding resident care? CNA GG stated, Yes, about a month ago, CNA GG was in R#55's room holding him on his side so LPN II could remove stool from R#55's rectum. During the procedure, R#55 told LPN II I need a break. LPN II told R#55, We don't take breaks, I have other residents to take care of. CNA GG stated after LPN II had finished removing stool from the resident's rectum, I went to LPN EE and let her know what had happened. LPN EE and I both wrote statements of what happened. An interview was conducted with LPN EE in Unit 1B hallway on 1/9/19 at 9:45 a.m. LPN EE stated CNA GG came to me and told me that LPN II had refused to stop the dis-impaction when the resident had yelled and told LPN II he needed a break. I immediately went into the resident's room and did an assessment. There were no injuries. CNA GG and I both wrote statements and I placed them on the DON's desk. LPN EE was asked if she had done any dis-impactions at the facility? LPN EE stated, No, I will try other interventions such as medications, suppositories and rectal massage but not dis-impaction. If none of that worked, then I would contact the physician. The facility could not produce any written statements for 12/23/18 incident written by the staff. An interview was conducted with R#55 at the resident's bedside on 1/9/19 at 10:15 a.m. R#55 was asked if he recalled LPN II and initially he stated, No. R#55 was then questioned if he has a problem with constipation and ever needed any help to have a bowel movement? The resident was hesitating to reply but stated Yes, I do have constipation and sometimes I ask for help. The resident was asked what does staff usually do to help with the constipation? R#55 stated the nurse usually gives me some pills to help. R#55 was questioned if he recalled an incident before Christmas where he yelled at a nurse helping him to stop, he needed a break? The resident stated, Yes, he did recall that incident, the nurse was very rough with me. R#55 was asked why he had yelled and asked the nurse for a break? R#55 stated, Because she was hurting me. When questioned if he could recall who the nurse was, R#55 stated No I don't recall her name. R#55 was asked if he reported the incident to anyone? The resident stated, No, but the other nurse came in and checked me. An interview was conducted with the DON on 1/9/18 at 4:15 p.m. in the basement classroom. The DON was asked what the expectation of the nursing staff and treating a resident with constipation? What should have LPN II done when R#55 asked the nurse to stop because it hurt? The nursing staff is expected to administer medications first, if no results than notify the Physician. LPN II should have not have been dis-impacting the resident because we don't do dis-impaction of stool. The nurse should have notified the Physician for further orders. The DON made the survey team aware that LPN II was let go. When the DON was questioned what was the reason for letting the LPN go? The DON stated it was based on not following professional standards related to the dis-impaction of R#55. There were no concerns expressed prior to (MONTH) concerning LPN II. On 1/10/19 at 10:00 a.m. and at 11:30 a.m. two failed attempts were made to contact LPN II for an interview related to R#55. There was no answer and the voice mailbox was full. Record review revealed R#55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission MDS dated [DATE], indicated R#55's BIMS of 14 indicating the resident was cognitively intact. Review of the resident's functional status indicated R#55 required extensive assistance with bed mobility, toilet use and personal hygiene with an assistance of two or more persons. Review of section HH, Bowel and Bladder, indicated the resident was frequently incontinent of bowel and bladder but did not indicate the resident currently has a [MEDICAL CONDITION]. A review of the physician's history and Physical dated 11/9/18 indicated R#55 had a [MEDICAL CONDITION] repair, hemicolectomy with [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. [MEDICATION NAME] EC 5 mg tablet, delayed release, one tablet by mouth one time per day as needed for constipation. Order dated 11/12/18 for [MEDICATION NAME] sodium 100mg capsule, 1 capsule one time per day for constipation A review of the nursing notes dated 12/23/18 indicates R#55 was administered [MEDICATION NAME] EC 5mg tablet at 9:02 a.m. and reassessed the resident at 12:11 p.m. as having no results. Further review of the nursing note did not indicate that LPN II notified the Physician of the resident's condition or to receive Physician orders [REDACTED].#55's stool impaction at 1:25 p.m. During a telephone interview on 1/10/19 at 11:25 a.m. with the facility's Medical Director (MD), the MD was asked if there is a standing order for nursing to dis-impact a resident? Is nursing supposed to dis-impact a resident? The MD stated, not unless they communicate with the Physician. Dis-impaction should not be a first choice, there should be orders for stool softener/laxative. Questioned what are the risks of dis-impaction? Stated rectal exam is a low risk, in general with dis-impaction could develop a tear. The MD was questioned concerning R#55's incident related to dis-impaction. Did you recall if LPN II called you about R#55 and dis-impacting the resident? The MD stated, I don't recall anyone asking me about dis-impaction. I recently added a new medication for R#55, he has had a problem in the past. Dis-impaction is not something I would encourage and is not commonly done. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Associate LPN was immediately suspended from services until investigation is completed. 2. Interview was conducted with resident #121 daughter in law by Administrator on 1/7/2018. No concerns around patient care was expressed at this time. Patient #55 was interviewed and did not recall any concerns with the nurse: patient states he trusted the nurse however patient did state that during the middle of the procedure he did ask her to stop and because she was in the middle, she did not immediately stop but did shortly after. 3.1/8/2019 resident #121 and #55 received a complete body assessment by unit manager. No signs of adverse. were noted. Resident #121 unable to be interviewed. No signs of emotional distress were noted during assessment or have been reported by staff. On 12/23/2018 resident #55 received an assessment post procedure to look for signs of injury and none were noted by change nurse statement. Reason for post assessment by different change nurse was due to a CNA voice concerns around the treatment resident #55 had just received. 4. On 1/8/2019 All 78 current residents with a BIM score of one or higher were interviewed by Social Services Coordinator and Admissions Coordinator regarding abuse. Two of 78 residents were interviewed, indicated concerns that are currently under investigation. The two concerns that were voiced where: 1) CNA handled a resident rough during a shower and 2) resident claimed that she was handled rough CNA delivering care. Both incidents have been self-reported as allegations of abuse. All 73 current residents with a BIM score of nine or lower were given full body assessments by ADON, MDS, Unit Managers and wound care nurse, and education coordinator. No evidence of abuse was identified (0/73). 5. As of 1/8/2019 review of Resident #121's care plan was conducted by DON and Regional Nurse. Changes were made to resident #121's care plan to reflect current behavior of crying, yelling, and pinching. Interventions were added to reflect anxiety/agitation is demised by watching TV, and if resident displays anxiety/agitation to stop care and re-approach. The sections of the care plan on obstructive and reflux [MEDICAL CONDITION] had interventions added to ensure visualization of urethra before attempting to place Foley catheter. 6. Beginning 1/8/2019 staff education was provided by the education coordinator to associates currently on duty regarding recognition and reporting abuse/neglect. This education included Activities (4/4), Administration (9/10), Dietary (23/23), Social Services (2/2), RN's (11/11), LPN's (24/25), CNA's (54/60), Environmental Services (5/6) and Maintenance (2/2) associates. In total 95% (134/141) of associates have been educated on abuse and neglect. Associates that have not received the education will be in-serviced before returning to work. 7. As of 1/8/2019 physician and Medical Director was notified of incidents related to patients #55 and #121 with no new orders indicated. 8. Ad-hoc QAPI meeting was held 1/9/2019 at 8:00 am to discuss finding from patient interviews, finding from body assessments, professional standards of care. The QAPI policy was discussed for process improvement. No changes were made to the current policy on abuse, professional standards of care, or QAPI. Systemic Changes 1. Beginning 1/8/19 staff education was provided by the education coordinator to associates currently on duty regarding recognition and reporting of abuse/neglect. This education included Activities (4/4), Administration (9/10), Dietary (23/23), Social Services (2/2), RN's (11/11), LPN's (24/25), CNA's (54/60), Environmental Services (5/6) and Maintenance (2/2) associates. In total 95% (143/141) of associated have been educated on abuse and neglect. Associates that have not received the education will be in-serviced before returning to work. 2. On 1/8/2019 The Social Service Director and admissions director conducted patient interviews for all 78/78 interviews for all 78/78 interview able residents to determine if there are concerns involving abuse. On 1/8/2019 all 73/73 non-interviewable residents received a full body assessment from ADON, MDS, Wound Nurse, education coordinator, and unit managers. These results were submitted to the QAPI committee. 3. 78/78 interviewable residents received verbal education on how to report abuse, neglect, and /or exploitations by Unit Mangers on 1/9/2019, 151/151 residents received a printout on how to contact the abuse preventive officer for suspected abuse. On, 1/9/2019 a letter was mailed to 73/73 on interview able residents responsible parties o (TRUNCATED)

Based on interviews, review of the facility's abuse investigation, and review of facility policy titled Abuse Prohibition, it was determined the facility failed to implement abuse interventions for two alleged abuse incidents involving residents (R) R#121 and R#55 by the same employee. The facility failed to implement a thorough investigative process for R#121. The facility failed to implement a monitoring system of the alleged perpetrator thereby leading a second abuse incident involving R#55. The survey sample was 57 residents. On 1/8/19, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and the Regional Nurse Consultant and Regional Nurse Consultant were informed of the immediate jeopardy on 1/8/19 at 5:14 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 12/18/18. The immediate jeopardy continued through 1/9/19 and was removed on 1/10/19. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); 42 CFR 483.12(b)(1)?(4), Develop/Implement Abuse/Neglect, etc. Policies (F607, Scope/Severity: J); 42 CFR 483.12(c)(2)?(4) Alleged Violations-Investigate/Prevent/Correct (F610, Scope/Severity: J); 42 C.F.R. 483.21(b)(3)(i), Professional Standards (F658, Scope/Severity: J); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: J). Additionally, Substandard Quality of Care was identified at: F600, Freedom from Abuse, Neglect and Exploitation F607, Develop/Implement Abuse/Neglect, etc. Policies F610, Alleged Violations-Investigate/Prevent/Correct A Credible Allegation of Compliance was received on 1/10/19. Based on observations, record reviews, interviews and review of the facility's policies and staff training as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 1/10/19. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of staff treatment of [REDACTED]. Observation and interviews were conducted with staff and residents to ensure they demonstrated knowledge of facility Policies and Procedures governing identifying and reporting Abuse, Neglect and Exploitation of residents. The Immediate Jeopardy is outlined as follows: 1. The facility's failure to protect R#121 from abuse were related to lack of a complete investigative procedures of the multiple attempts to insert an indwelling urinary catheter for R#121. During the initial tour of the facility on 1/7/19 the surveyor conducted a family interview and was informed that on 12/18/18 a urinary catheter insertion was attempted at least nine times on R#121. Interviews with staff revealed that during the failed attempts R#121 was screaming spank them . The nurse replied to the resident, I will spank you. The facility did not conduct a full investigation when this incident of alleged abuse was reported to the Director of Nursing (DON) and Administrator by Resident (R) #121's family member and three Certified Nurse Aides (CNA) who were present in the room with R#121 when the incident occurred. The alleged perpetrator, Licensed Practical Nurse (LPN) II, continued to work at the facility until dismissed on 1/9/19. 2. On 1/9/19 the surveyor was made aware during staff interviews of R#55 receiving a forceful dis-impaction by the same nurse on 12/23/18. The nurse continued to digitally dis-impact the resident when he yelled out in pain Can we take a break, the nurse replied to R#55, We don't take breaks here. The alleged perpetrator refused to stop attempts to dis-impact stool from R#55's rectum when the resident yelled and told the nurse he needed a break because she was hurting him. The resident has a [DIAGNOSES REDACTED].#55 received digital stimulation by LPN II without a physician's orders [REDACTED]. The findings include: The facility's Abuse Prohibition policy dated (MONTH) (YEAR) indicated it is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse and misappropriation of patient property. Whenever a patient, family member, or anyone else makes a complaint on behalf of the patient that alleges abuse, corporal punishment, involuntary seclusion, neglect, mistreatment, misappropriation of patient property, or exploitation has occurred, the procedures listed in this policy will be adhered to. Under the section titled Identification of possible abuse, neglect, or exploitation indicates 'Once an injury or event is identified as suspicious and may constitute abuse, the center will follow the investigation procedures. 5. It will be the responsibility of any department head receiving the complaint of alleged abuse, corporate (sic) punishment, involuntary seclusion, neglect, mistreatment, misappropriation of patient property or exploitation to inform the Administrator or designee immediately The section titled Prevention B. indicated the Center will identify, correct and intervene in situations in which abuse, neglect and /or misappropriation of patient property is more likely to occur. This will include an analysis of: 3. The supervision of staff to identify in appropriate behaviors, such as using derogatory language, rough handling, ignoring patients while giving care, directing patients who need tilting assistance to urinate or defecate in their beds. 1. During an interview on 1/7/19 at 10:00 a.m. the family of R#121 revealed the family reported they had walked into the resident's room where they witnessed LPN II attempted at least six times to unsuccessfully insert a urinary catheter into R#121. The family added that LPN II did not stop even though the resident was screaming. The family reported the incident to the Director of Nursing (DON). Review of the facility's investigation dated 12/18/18 revealed documents that consisted of three CNA witness statements. Review of the witness documentation dated 12/18/18 from CNA FF indicated R#121 was agitated and screaming spank them, spank them, spank them! LPN II leaned down and told R#121 I'll spank you back. LPN II looked at R#121, and CNA FF and CNA HH we need to drug R#121 up because I can't deal with the screaming. R#121 is way too agitated, you won't be to hold R#121's legs open. CNA HH left the room, LPN II told me, you need to go and get someone to help hold R#121's hands while you hold R#121's legs. I don't have time for this, I have other things that I have to do. LPN II proceeded to try and insert the catheter into the clitoris (area above the urethral opening) and the vagina around eight times. Family walked into room and asked what was going on. I explained the situation and the family came over to help. LPN II put a hand up to R#121's family member and told them to step away, you're in my light. The family immediately was agitated with LPN II and came to my side to help calm R#121. LPN II attempted to insert the catheter at least seven more times. The family and I told CNA GG to go and get LPN EE. LPN EE came in and asked what was going on? LPN II replied it won't go into R#121's meatus. LPN EE immediately took over and easily inserted the catheter on the first try. Review of the witness documentation dated 12/18/18 from CNA GG indicated that CNA GG was asked by CNA FF to help both CNA FF and LPN II insert a new catheter for R#121 because the resident's old catheter was clogged. LPN II attempted to insert the catheter into the clitoris around eight times. The family entered the room and was wondering what was going on, CNA FF began to explain the catheter was clogged and it was being replaced. The family stepped over near the bed by LPN II, when LPN II put her hand up and told the family Stay away, you are in my light. LPN II continued to put the catheter into R#121's vagina at least six more times and I was told by both the family and CNA FF to go get LPN EE. LPN EE inserted the catheter. Review of the witness documentation dated 12/18/18 from CNA HH indicated that CNA FF and CNA HH were changing R#121, when they noticed the resident's catheter was clogged and all the urine was going into the brief. CNA FF went and told LPN II about the catheter and LPN II agreed it needed to be changed. R#121 had become very agitated and was yelling slap them, slap them. LPN responded I'll slap you back. LPN II also got a little tense and told CNA FF and me that we need to drug R#121 up before I do this. CNA HH told LPN II No and at this time, I was so mad at the situation I walked out of the room to calm down. The facility's investigation report failed to include statements from LPN EE, the family member, and additional residents taken care of by LPN II. In addition, the investigation did not include the determination or outcome of the investigation and what corrective actions were put in place to prevent a reoccurrence of this type of incident. Review of Nursing Notes dated from 12/1/18 to 1/7/19 failed to reveal any documentation of the incident involving R#121. Review of the Physician's Notes dated from 12/1/18 to 1/7/19 failed to reveal any medical documentation of assessing the resident after incident. An interview was conducted with the Administrator and DON in the Administrative office outer room on 1/7/19 at 3:30 p.m. informed the Administrator and DON of R#121's family allegation of abuse concerning #121's urinary catheter and LPN II. The DON and Administrator stated they both were aware of the catheter incident with LPN II They investigated it but did not find it to be abuse, it was a personality conflict. Both the DON and Administrator stated the family never told them it was abuse. The Administrator stated they will begin another investigation related to abuse and report to state as such. Interview was conducted with LPN JJ, Unit Manager for Units 1A and 1B, on 1/7/19 at 4:39 p.m. at the Unit 1B nursing station. LPN JJ was questioned what she recalled about the incident with R#121 and LPN II? LPN JJ stated, The family came out of R#121's room upset about LPN II trying to insert the urinary catheter while the resident was yelling. The family told me not to let LPN II go back into resident's room. LPN JJ was asked what she did next? LPN JJ stated, I told the DON. LPN JJ was questioned what else did LPN JJ do after informing the DON? LPN JJ stated the DON instructed me to remove LPN II from R#121's care and assign LPN II to another resident. LPN JJ was asked if LPN II was working on the same unit after their assignment was changed? LPN JJ stated, Yes, the only change was R#121's nurse assignment. 2. During an interview conducted with CNA GG on 1/9/19 at 9:25 a.m. in Unit 1B nursing station, CNA GG stated, About a month ago, she was in R#55's room holding him on his side so LPN II could dis-impact the resident. During the procedure, R#55 told LPN II I need a break. LPN II told R#55, we don't take breaks, I have other residents to take care of. CNA GG stated after LPN II was done, I went to LPN EE and let her know what had happened. LPN EE and I both wrote statements of what happened. During an interview with the Administrator on 1/9/19 at 10:30 a.m. the Administrator was asked if he was aware of the incident with R#55 related to the painful removal of stool from the resident's rectum? The Administrator stated, No I was not aware of that incident, but I will speak with the DON. The Administrator was asked if there was any documentation of an investigation being conducted? The Administrator stated, I will have to get with the DON on that. The facility was unable to provide investigative documentation of 12/23/18 incident. Review of the Nurses Notes dated 12/23/18 at 1:25 p.m. indicated Resident complained of constipation this a.m. (morning) States hasn't had a bowel movement in a week. Large fecal impaction cleared manually. Review of physician progress notes [REDACTED]. Interview was conducted with R#55 at the resident's bedside on 1/9/19 at 10:15 a.m. R#55 was asked if he recalled the incident on 12/23/18, R#55 stated, yes, he did recall that incident, the nurse was very rough with me. R#55 was asked why he had yelled and asked the nurse for a break? R#55 stated, because she was hurting me. When questioned if he could recall who the nurse was, R#55 stated no I don't recall her name. Interview on 1/9/19 at 4:15 p.m. with the DON revealed when asked who collects and investigates the complaints and grievances? The DON stated, I do, the Social Service Director and the Administrator. The DON was questioned concerning the incidents involving R#121 and R#55? The DON stated, I wasn't aware of R#55's incident until today and R#121 I perceived it to be a customer service issue. The DON was asked why she wasn't aware of R#55's situation until today, when LPN EE and CNA GG left written statements on her desk? The DON stated, I was told it was on my desk, but I never received the statements.

Based on interview and review of facility investigations, it was determined the facility failed to thoroughly investigate the 12/18/18 incident where R#121 was subjected to a painful urinary catheter insertion and verbal threats. The facility failed to develop preventive measures in place to ensure no other vulnerable residents experience abuse from the same nurse. This failure resulted in the 12/23/18 incident in which R#55 was subject painful removal of stool by the same nurse. The sample size was 57. This deficient practice created the potential that abuse would go unrecognized, not addressed, and perpetuate a culture in which abuse could occur. On 1/8/19, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and the Regional Nurse Consultant and Regional Nurse Consultant were informed of the immediate jeopardy on 1/8/19 at 5:14 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 12/18/18. The immediate jeopardy continued through 1/9/19 and was removed on 1/10/19. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); 42 CFR 483.12(b)(1)?(4), Develop/Implement Abuse/Neglect, etc. Policies (F607, Scope/Severity: J); 42 CFR 483.12(c)(2)?(4) Alleged Violations-Investigate/Prevent/Correct (F610, Scope/Severity: J); 42 C.F.R. 483.21(b)(3)(i), Professional Standards (F658, Scope/Severity: J); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: J). Additionally, Substandard Quality of Care was identified at: F600, Freedom from Abuse, Neglect and Exploitation F607, Develop/Implement Abuse/Neglect, etc. Policies F610, Alleged Violations-Investigate/Prevent/Correct A Credible Allegation of Compliance was received on 1/10/19. Based on observations, record reviews, interviews and review of the facility's policies and staff training as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 1/10/19. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of staff treatment of [REDACTED]. Observation and interviews were conducted with staff and residents to ensure they demonstrated knowledge of facility Policies and Procedures governing identifying and reporting Abuse, Neglect and Exploitation of residents. The Immediate Jeopardy is outlined as follows: 1. The facility's failure to protect R#121 from abuse were related to lack of a complete investigative procedures of the multiple attempts to insert an indwelling urinary catheter for R#121. During the initial tour of the facility on 1/7/19 the surveyor conducted a family interview and was informed that on 12/18/18 a urinary catheter insertion was attempted at least nine times on R#121. Interviews with staff revealed that during the failed attempts R#121 was screaming spank them . The nurse replied to the resident, I will spank you. The facility did not conduct a full investigation when this incident of alleged abuse was reported to the Director of Nursing (DON) and Administrator by Resident (R) #121's family member and three Certified Nurse Aides (CNA) who were present in the room with R#121 when the incident occurred. The alleged perpetrator, Licensed Practical Nurse (LPN) II, continued to work at the facility until dismissed on 1/9/19. 2. On 1/9/19 the surveyor was made aware during staff interviews of R#55 receiving a forceful dis-impaction by the same nurse on 12/23/18. The nurse continued to digitally dis-impact the resident when he yelled out in pain Can we take a break, the nurse replied to R#55, We don't take breaks here. The alleged perpetrator refused to stop attempts to dis-impact stool from R#55's rectum when the resident yelled and told the nurse he needed a break because she was hurting him. The resident has a [DIAGNOSES REDACTED].#55 received digital stimulation by LPN II without a physician's orders [REDACTED]. The findings include: 1. An interview was conducted with R#121's family on 1/7/19 at 10:00 a.m. during the initial resident pool selection. The family expressed concerns related to LPN II that is currently employed by the facility. The family stated they had reported an incident that occurred on 12/18/18 to the Director of Nursing (DON) involving LPN II attempting at least six times to insert a urinary catheter into the resident while the resident was screaming. They requested the nurse no longer take care of R#121. Although this occurred, LPN II continues to work at the facility on the same unit. Interview with the DON and Administrator on 1/7/19 at 3:30 p.m. revealed when asked if they were aware of the allegation from R#121's family? They both stated, Yes, they were aware of it. They were asked if it had been investigated and if there was any documentation of the investigation? The DON stated she had investigated it and the Administrator and the DON agreed they thought it was a personality conflict between the family and the nurse. But that they were unable provide complete documentation of the investigation. The facility was only able to provide three CNAs' witnesses statements, no other documentation of the investigation. The DON was questioned if there was any further documentation? The DON stated, No, this was all they had. Interview on 1/8/19 at 1:30 p.m. with the DON revealed when asked what type of investigation did the facility conduct following the incident with R#121 and LPN II? The DON stated, I took statements from the CNAs present, and spoke with LPN II and provided counseling for the nurse. The DON was questioned if the facility had interviewed any other staff or residents concerning care they received from LPN II and why after reading the CNA's written statement and speaking with the family did the facility not report the incident or initiate an investigation? The DON stated, No I didn't interview anyone else because after speaking with LPN II, I did not feel the incident was abuse but a customer service issue. The DON was asked for the counseling provided to LPN II but was only able to provide the nurse's orientation training from (MONTH) (YEAR). A review of the facility's staffing schedule for 12/1/18 through 1/7/19 indicated LPN II had continued to work on both nursing units that R#121 and R#55 were located. Although LPN II was no longer assigned to R#121 after the incident was reported, LPN II continued to care for R#55 after the 12/23/18 incident had occurred until the nurse was suspended on 1/7/19. Review of the facility reported incidents since the last annual survey in 2/2018 and the incident/grievance log from 8/2018 through 1/7/18 was conducted and there were no reports that included R#121 or R#121's family. 2. During an interview with CNA GG on 1/9/19 at 9:25 a.m. at the Unit 1B nursing station it was revealed that LPN II was involved in an incident with R#55. While LPN II was manually removing stool from R#55's rectum it became too painful and the resident asked to take a break. LPN II responded We don't take breaks . and proceeded with the procedure. CNA GG immediately reported the incident to the LPN EE CNA GG and LPN EE stated during interviews on 1/9/19 at 9:25 a.m. and 9:45 a.m., respectively, that they had written a statement regarding the incident as it occurred and placed it on the DON's office desk. LPN EE did not report the incident to the Unit Manager (UM), the UM was not available due to the holidays and the nurse did not recall if she had called the DON. An interview with the DON on 1/9/18 at 4:15 p.m. revealed when asked if there was any written statements from the staff concerning R#55's incident with LPN II, the DON stated, No, I wasn't aware of the situation until today. The DON was asked what should the staff do if they need to report an incident such as R#55s? The DON stated, The staff are to notify their Charge Nurse or Unit Manager. If unavailable, they are to notify either the DON or Administrator. The DON was asked what happens next? The DON stated, the facility would start an investigation to see if it was abuse or not. The staff member involved would be suspended during the investigation. A review of the facility's reportable incidents since last survey in 2/2018 and the incident/grievance log failed to indicate R#55's incident had been investigated.

Based on interview, record review, and review of the Georgia Practical Nurses Practice Act, it was determined the facility failed to ensure professional standards of care were maintained for two residents (R) (R#121 and R#55) from a sampled 57 residents. Specifically, nursing staff were not following the standard of care related to urinary catheter insertion for R#121 and the treatment for [REDACTED]. On 1/8/19, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and the Regional Nurse Consultant and Regional Nurse Consultant were informed of the immediate jeopardy on 1/8/19 at 5:14 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 12/18/18. The immediate jeopardy continued through 1/9/19 and was removed on 1/10/19. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); 42 CFR 483.12(b)(1)?(4), Develop/Implement Abuse/Neglect, etc. Policies (F607, Scope/Severity: J); 42 CFR 483.12(c)(2)?(4) Alleged Violations-Investigate/Prevent/Correct (F610, Scope/Severity: J); 42 C.F.R. 483.21(b)(3)(i), Professional Standards (F658, Scope/Severity: J); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: J). Additionally, Substandard Quality of Care was identified at: F600, Freedom from Abuse, Neglect and Exploitation F607, Develop/Implement Abuse/Neglect, etc. Policies F610, Alleged Violations-Investigate/Prevent/Correct A Credible Allegation of Compliance was received on 1/10/19. Based on observations, record reviews, interviews and review of the facility's policies and staff training as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 1/10/19. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of staff treatment of [REDACTED]. Observation and interviews were conducted with staff and residents to ensure they demonstrated knowledge of facility Policies and Procedures governing identifying and reporting Abuse, Neglect and Exploitation of residents. The Immediate Jeopardy is outlined as follows: 1. The facility's failure to protect R#121 from abuse were related to lack of a complete investigative procedures of the multiple attempts to insert an indwelling urinary catheter for R#121. During the initial tour of the facility on 1/7/19 the surveyor conducted a family interview and was informed that on 12/18/18 a urinary catheter insertion was attempted at least nine times on R#121. Interviews with staff revealed that during the failed attempts R#121 was screaming spank them . The nurse replied to the resident, I will spank you. The facility did not conduct a full investigation when this incident of alleged abuse was reported to the Director of Nursing (DON) and Administrator by Resident (R) #121's family member and three Certified Nurse Aides (CNA) who were present in the room with R#121 when the incident occurred. The alleged perpetrator, Licensed Practical Nurse (LPN) II, continued to work at the facility until dismissed on 1/9/19. 2. On 1/9/19 the surveyor was made aware during staff interviews of R#55 receiving a forceful dis-impaction by the same nurse on 12/23/18. The nurse continued to digitally dis-impact the resident when he yelled out in pain Can we take a break, the nurse replied to R#55, We don't take breaks here. The alleged perpetrator refused to stop attempts to dis-impact stool from R#55's rectum when the resident yelled and told the nurse he needed a break because she was hurting him. The resident has a [DIAGNOSES REDACTED].#55 received digital stimulation by LPN II without a physician's orders [REDACTED]. The findings include: Review of the Georgia Practical Nurses Practice Act with a copyright date of 2013 documents the following: The practice of licensed practical nursing means the provision of care for compensation, under the supervision of a physician [MEDICATION NAME] medicine, a dentist [MEDICATION NAME] dentistry, a podiatrist [MEDICATION NAME] podiatry, or a registered nurse [MEDICATION NAME] nursing in accordance with applicable provisions of law. Such care shall relate to the maintenance of health and prevention of illness through acts authorized by the board, which shall include, but not be limited to, the following: A. Participating in the assessment, planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately trained and consistent with board rules and regulations B. Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or other health care facilities in areas of practice including, but not limited to: coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpatient services, home health care, or other such areas of practice . C. Performing comfort and safety measures . D. Administering treatments and medication . 1. An interview on 1/7/19 at 10:00 a.m., with R#121's family revealed approximately the week before last while walking down the hall R#121 could be heard screaming bloody murder. When the family member entered R#121's room she witnessed LPN II attempting at least six times to insert a urinary catheter into R#121, while the resident was still screaming. The family also stated they requested the nurse to stop since the resident was so agitated. However, LPN II told the family member to leave the room and continued to insert the urinary catheter. The family member further stated the incident was reported to the Social Worker (SW) and the Director of Nursing (DON). A review of the resident's electronic record revealed R#121 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was assessed to be severely cognitively impaired with limited range of motion of the lower extremities and required the use of an indwelling urinary catheter. Review of the facility's investigation dated 12/18/18 revealed three witness statements from the Certified Nursing Assistants (CNAs) present during the incident with R#121. Review of CNA FF's signed statement dated 12/18/18 indicated that R#121 was agitated and screaming spank them, spank them, spank them! LPN II leaned down and told R#121 I'll spank you back. LPN II looked at R#121, and CNA FF and CNA HH We need to drug R#121 up because I can't deal with the screaming. R#121 is way too agitated, you won't be able to hold R#121's legs open. CNA HH left the room, LPN II told me, you need to go and get someone to help hold R#121's hands while you hold R#121's legs. I don't have time for this, I have other things that I have to do. LPN II proceeded to try and insert the catheter into the clitoris (located above the urethral opening) and the vagina around eight times. LPN II attempted to insert the catheter at least seven more times. (sic) Review of CNA GG's signed statement dated 12/18/18 indicated that CNA GG was asked by CNA FF to help both CNA FF and LPN II insert a new catheter for R#121 because the resident's old catheter was clogged. LPN II attempted to insert the catheter into the clitoris around eight times. LPN II continued to put the catheter into R#121's vagina at least six more times and I was told by both the family and CNA FF to go get LPN EE. LPN EE inserted the catheter.(sic) Review of CNA HH's hand written statement, dated and signed on 12/18/18 indicated that R#121 had become very agitated and was yelling slap them, slap them. LPN responded I'll slap you back. LPN II also got a little tense and told CNA FF and me that We need to drug R#121 up before I do this. CNA HH told LPN II No and CNA FF told LPN II that she could hold resident's legs open for LPN II to insert the catheter. Interview was conducted with LPN EE on 1/7/19 at 4:20 p.m. in the Unit 1A nursing station. LPN EE was questioned on what type of orientation or training does the nursing staff receive upon hire? LPN EE stated that the nursing staff receives two weeks of nursing orientation and must complete a skills competency list with their preceptor. All other training is conducted with the education coordinator. LPN EE was asked if they she knew who had conducted the orientation for LPN II? LPN EE stated that she had done the orientation/competency training. LPN EE was asked if there had ever been any concerns prior to the incident with R#121? LPN EE stated, No, there were no issues prior to that incident. LPN EE asked if she had checked LPN II off on the urinary catheter insertion? LPN EE stated, Yes and LPN II did it without any problems. LPN EE did not indicate that she spoke to LPN II regarding the incident, although LPN EE had conducted LPN II's orientation and competency check off. LPN II was interviewed by telephone on 1/8/19 at 5:29 p.m. LPN II was asked what had happened on 12/18/18 during the re-insertion of R#121's urinary catheter? LPN II said the catheter needed to be changed because it was occluded and there was a white milky substance in it. LPN II stated she had attempted two to three times to insert the catheter but stopped after the third attempt. LPN II was asked if R#121 was agitated or upset? LPN II stated the resident was laughing and saying, spank you, spank you, so I replied, I'll spank you back. The nurse was asked if the family was present during the procedure and if so were they concerned? LPN II stated, Yes, the family was there, but didn't seem to be upset or concerned. LPN II was asked what should have happened when the nurse could not get the urinary catheter inserted? LPN II stated, I should have asked for assistance. An Interview on 1/9/19 at 9:07 a.m. with CNA FF revealed when questioned if she recalled the incident with R#121 and LPN II? CNA FF stated LPN II was struggling to get the urinary catheter inserted when R#121's family walked into the room. When the family stated, let me help, LPN II put her hand up and told the family they needed to back up. At one-time LPN II stated, we need to drug R#121 up because she is too agitated. I felt I needed to stay in R#121's room or LPN II would hurt her. A telephone interview on 1/10/18 at 11:25 a.m. with the facility's Medical Director (MD) revealed if the catheter is difficult to place then we would send the resident next door to the hospital. The MD also stated, Even if proficient, if you realize you can't place the catheter, don't continue, ask for help; the nurse should use good decision making. 2. Record review for R#55 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission MDS dated [DATE] revealed the resident had intact cognition and required extensive assistance of two persons for activities of daily living, toileting, and mobility. Review of the Physicians Orders' dated 11/8/18 revealed the resident was to receive Senna (laxative) 8.6 milligrams (mg) one tablet twice a day as needed for constipation; [MEDICATION NAME] (laxative) [MEDICATION NAME] coated 5 mg delayed release one tablet daily by mouth for constipation. Additional review of the physician orders [REDACTED].>A review of R#55's clinical record revealed, LPN II's Nurse Note dated 12/23/18 at 1:25 p.m. resident complained of constipation this a.m. (morning) States hasn't had a bowel movement in a week. Large fecal impaction cleared manually. Large bowel movement later. Resident states feel better. An interview with CNA GG on 1/9/19 at 9:25 a.m. revealed about a month ago, I was in R#55's room holding him on his side so LPN II could dis-impact the resident. LPN II just walked up to the side of the R#55's bed, put a glove on and some lubrication and started to remove the stool from the resident's rectum. During the procedure, R#55 told LPN II I need a break. LPN II told R#55, We don't take breaks, I have other residents to take care of. Interview with LPN EE on 1/9/19 at 9:45 a.m. revealed that CNA GG came to me and told me that LPN II had refused to stop the dis-impaction when the resident had yelled in pain that he needed a break, but that LPN II didn't stop, saying to the resident we don't take breaks. I immediately went into resident's room and did an assessment. There were no injuries. LPN EE stated, We do not perform dis-impactions at this facility. I would try other interventions such as medications, suppositories and rectal massage but not dis-impaction. If none of that worked, I would contact the Physician. An attempt was made to contact LPN II by telephone for an interview on 1/10/19 at 10:00 a.m. and at 11:30 a.m. related to R#55's incident. There was no answer and the voice mail was full. An interview was conducted with R#55 at the resident's bedside on 1/9/19 at 10:15 a.m. R#55 was asked if he recalled LPN II and initially he stated, No. R#55 was than questioned if he has a problem with constipation and ever needed any help to have a bowel movement? R#55 stated Yes, I do have constipation and sometimes I ask for help. R#55 was questioned if he recalled an incident before Christmas where he yelled at a nurse helping him to stop, he needed a break? The resident stated, Yes, he recalled that incident, the nurse was very rough with me. R#55 was asked why he had yelled and asked the nurse for a break? R#55 stated, because she was hurting me. An interview with the DON on 1/9/18 at 4:15 p.m. revealed dis-impaction would require a doctor's order. The DON stated, The facility does not provide training for dis-impaction, this is not a typical procedure that we do. I am not aware of staff doing dis-impaction. The DON further revealed, There is no policy, because we don't do dis-impactions. The DON was questioned who is responsible for training the staff and are they qualified to conduct training? The training is conducted by the most proficient nurse based on documentation and observations. LPN II was oriented by LPN EE in November. There were no concerns expressed prior to the (MONTH) incident. Staff Development Coordinator (SDC) gets involved with on-going education. During a telephone interview on 1/10/19 at 11:25 a.m. with the facility's MD revealed, The nurses should not attempt a dis-impaction unless they communicate with the Physician. Dis-impaction should not be a first choice, they should have orders for stool softener/laxative. The MD also stated the rectal exam is a low risk, in general with dis-impaction could develop a tear. The MD further stated, I don't recall anyone asking me about dis-impaction. I recently added a new medication for R#55, he had a problem with constipation in the past. Dis-impaction is not something I would encourage and is not commonly done. A Review of LPN II 's employment records revealed the LPN was hired 11/13/18 and her training included the following: - Patients (sic) Rights: Abuse Reporting on 11/13/18 - Catheter Insertion for Males and Females on 11/19/18 The facility was unable to provide documentation of further performance training for LPN II. Cross reference to F600 The facility implemented the following actions to remove the Immediate Jeopardy: 1. Patient assessment performed by DON on 1/8/19 to determine if any abnormalities in anatomy exist that would make it difficult to insert catheter per procedural guidelines. 5 of 151 residents have catheters and the ADON conducted patient assessments on the 5 of with catheters. 2. On 1/8/19 Patient #121's plan of care was reviewed by DON and updated to reflect that if patient becomes agitated during a procedure that the procedure is to be discontinued and re-approached at a later time to decrease the risk for increasing the patient's anxiety. On 1/9/19, 24/25 (96%) LPN's and 10/11 (90%) RN's received this education from the education coordinator. In total 34/36 (94%) Licensed nurses were educated. 3. Education was provided to six of six licensed nurses on 7-7 am shift regarding the following subjects on 1/8/19 by Education Coordinator: a. Importance of following professional standards when providing care to patients. b. Procedure for insertion of Foley catheter including assessment of anatomy to determine abnormalities prior to initiation of procedure. c. Identifying signs and symptoms of patient anxiety during care. d. Recognizing need to stop procedures or care if a patient refuses or shows signs and symptoms of pain or anxiety. 4. Nurse in questions related to R#121 and R#55 regarding professional services was suspended on 1/7/19 pending outcomes of the investigation. 5. Termination of charge nurse in question related to patient R#121 and R#55 was initiated on 1/9/19. Systemic Changes 1. Education began on 1/7/19 and competed on 1/9/19 provided on professional services and standards related to catheter insertion and digital evacuation of hard stool. 24/25 (96%) LPN's and 10/11 (90%) RN's received this education. In total 34/36 licensed nurses received this education. 2. Professional competencies began on 1/7/19 by the DON, ADON and education coordinator, on professional services and standards related to catheter insertion. 24/25 (96%) LPN's and 10/11 (90%) RN's received this education. In total 34/36 licensed nurses received this education. 3, Remedial education to be provided to licensed nurses as opportunities for improvement are identified by education coordinator starting on 1/9/19. 4. All finding will be addressed through the center's QAPI process on a monthly bases under the directions of the Administrator. The State Survey Agency (SSA) validated the Allegation of Compliance (A[NAME]) Jeopardy Removal as follows: 1. Review of the facility A[NAME] documentation verified on 1/8/19 the DON and ADON performed assessments on five of five residents that had catheters including R#121 to assess any abnormalities that persist that would impede catheter insertion. The survey team had already assessed these residents during the initial pool process. Training on the professional standards related to catheter insertion and evacuation of hard stool was reviewed by in-service roster and interviews with Registered Nurse (RN) DD, LPN EE, LPN JJ, LPN LL, LPN MM and LPN NN on 1/10/19 between 2:00 p.m. and 4:00 p.m. 2. Review of the facility A[NAME] documentation for When a patient becomes agitated during a procedure, the procedure is to be discontinued and re-approached later to decrease the risk of increasing the patient's anxiety. This training was provided to LPNs and RNs by the Education Coordinator on 1/8/19. This was verified by R#121's care plan and interviews with staff nurses, LPN EE, LPN JJ, RN DD, LPN LL, LPN MM, and LPN NN currently providing resident care on 1/10/19 between 2:00 p.m. and 4:00 p.m., and by the training roster signed by all licensed staff. 3. Review of the facility A[NAME] documentation related to the systemic changes indicated the facility, specifically the DON, ADON, and Education Coordinator began educating licensed staff (Registered Nurses and Licensed Practical Nurse) beginning 1/7/19 through 1/9/19 on the following subjects: a. Importance of following professional standards when providing care to patients b. Procedure for insertion of Foley catheter including assessment of anatomy to determine abnormalities prior to initiation of procedure c. Identifying signs and symptoms of patient anxiety during care d. Recognizing need to stop procedures or care if a patient refuses or shows signs and symptoms of pain. This education was validated through staff education rosters dated 1/7/19 through 1/9/19 indicating the attendance by staff for training. Interviews were conducted on 1/10/19 from 2:00 p.m. to 4:00 p.m. by surveyors with RN DD, LPN EE, LPN JJ, LPN LL, and LPN NN verifying the training provided by the facility through verbal demonstration of the Foley catheter procedures, abnormalities in residents anatomy, identifying patient anxiety during care and what to do to ease resident's anxiety, and to stop if resident refuses treatments or is exhibiting signs of pain. 4. LPN II in relation to R#121 and R#55 regarding professional services was suspended pending investigation on 1/7/19. This was verified through review of staff schedule for 1/7/19 through 1/11/19 and observations of staffing during the survey process from 1/7/19 through 1/10/19. 5. LPN II was terminated by the Administrator on 1/9/19 as verified through observations and staffing schedules for 1/9/19 through 1/10/19 and interview with the DON on 1/9/19 at 4:15 p.m. in the conference room. Systemic Changes: 1. Review of the facility's A[NAME] indicated beginning 1/7/19 through 1/9/19 staff nurses were educated on professional services and standards related to catheter insertion and digital evacuation of hard stool. On 1/10/19 from 2:00 p.m. to 4:00 p.m. surveyors interviewed nursing staff (LPN EE, LPN JJ, RN DD, LPN LL, LPN MM and LPN NN) concerning their training related to catheter insertion and digital evacuation of hard stool. The nursing staff confirmed that the staff does not conduct digital evacuation of hard stool, they would contact the physician first and request assistance when having difficulty with inserting an indwelling catheter. 2. Review of the facility's A[NAME] indicated professional competencies were conducted starting on 1/7/19 by the DON, ADON and Education Coordinator. Interviews were conducted during the A[NAME] verification process on 1/10/19 from 2:00 p.m. to 4:00 p.m. with the following nurses: LPN EE, LPN JJ, RN DD, LPN LL, LPN MM, and LPN NN. The nursing staff was asked to verbally explain the process for urinary catheter procedures related to insertion, identifying correct anatomy and when to request assistance. 3. Review of the facility's A[NAME] indicated remedial education was to be provided to licensed staff as opportunities for improvement starting on 1/9/19. Interviews were conducted on 1/10/19 between 2:00 p.m. and 4:00 p.m. with LPN EE, LPN JJ and LPN NN concerning identifying and reporting abuse 4. Review of the facility's A[NAME] indicated all findings will be addressed through the center's QAPI process monthly under the direction of the Administer. This was validated through review of the ad hoc QAPI meeting documentation on 1/8/19 revealed a Performance Improvement Project was developed and presented during the QAPI meeting for identifying, addressing and investigation of abuse. An interview was conducted on 1/10/19 at 1:23 p.m. with the Administrator in the Administrator's office. The Administrator stated, The systematic analysis and actions were discussed during the ad hoc QAPI meeting. The QAPI Committee recognizes that any change that is made has the potential to have broader impact than intended. QA Event (Just do it) reports will be reviewed by QAPI Committee to ensure this tool is used for QA events in absence of system/process problems. The QA Event tool (Just Do it form) should not be used in place of the Performance Improvement Plans (PIPs).

Based on record review and interviews it was determined that Administration failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to ensure each resident attained or maintained the highest possible level of physical, mental and psychological well-being. The Administration failed to conduct a thorough investigation of an employee's verbal threats and physical abusive actions for Resident (R) #121 on 12/12/18 while attempting to insert an indwelling urinary catheter and for disregarding R #55's complaints of pain during a rectal dis-impaction to remove stool on 12/23/18. The facility census was 151 residents. On 1/8/19, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and the Regional Nurse Consultant and Regional Nurse Consultant were informed of the immediate jeopardy on 1/8/19 at 5:14 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 12/18/18. The immediate jeopardy continued through 1/9/19 and was removed on 1/10/19. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); 42 CFR 483.12(b)(1)?(4), Develop/Implement Abuse/Neglect, etc. Policies (F607, Scope/Severity: J); 42 CFR 483.12(c)(2)?(4) Alleged Violations-Investigate/Prevent/Correct (F610, Scope/Severity: J); 42 C.F.R. 483.21(b)(3)(i), Professional Standards (F658, Scope/Severity: J); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: J). Additionally, Substandard Quality of Care was identified at: F600, Freedom from Abuse, Neglect and Exploitation F607, Develop/Implement Abuse/Neglect, etc. Policies F610, Alleged Violations-Investigate/Prevent/Correct A Credible Allegation of Compliance was received on 1/10/19. Based on observations, record reviews, interviews and review of the facility's policies and staff training as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 1/10/19. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of staff treatment of [REDACTED]. Observation and interviews were conducted with staff and residents to ensure they demonstrated knowledge of facility Policies and Procedures governing identifying and reporting Abuse, Neglect and Exploitation of residents. The Immediate Jeopardy is outlined as follows: 1. The facility's failure to protect R#121 from abuse were related to lack of a complete investigative procedures of the multiple attempts to insert an indwelling urinary catheter for R#121. During the initial tour of the facility on 1/7/19 the surveyor conducted a family interview and was informed that on 12/18/18 a urinary catheter insertion was attempted at least nine times on R#121. Interviews with staff revealed that during the failed attempts R#121 was screaming spank them . The nurse replied to the resident, I will spank you. The facility did not conduct a full investigation when this incident of alleged abuse was reported to the Director of Nursing (DON) and Administrator by Resident (R) #121's family member and three Certified Nurse Aides (CNA) who were present in the room with R#121 when the incident occurred. The alleged perpetrator, Licensed Practical Nurse (LPN) II, continued to work at the facility until dismissed on 1/9/19. 2. On 1/9/19 the surveyor was made aware during staff interviews of R#55 receiving a forceful dis-impaction by the same nurse on 12/23/18. The nurse continued to digitally dis-impact the resident when he yelled out in pain Can we take a break, the nurse replied to R#55, We don't take breaks here. The alleged perpetrator refused to stop attempts to dis-impact stool from R#55's rectum when the resident yelled and told the nurse he needed a break because she was hurting him. The resident has a [DIAGNOSES REDACTED].#55 received digital stimulation by LPN II without a physician's orders [REDACTED]. The findings include: On 1/7/19 at 3:30 p.m. an interview was conducted with the Administrator and the DON in the Administrative office outer room. The Administrator and DON were made aware of an interview with family of R#121 and an incident that occurred on 12/18/18. They stated they had been made aware by the surveyor of a concern for abuse on 12/18/18. Both the Administrator and DON stated that they were aware of the incident and they had investigated but determined that abuse did not occur, rather it was a personality conflict. The Administrator stated that they would begin another investigation related to abuse and report to the appropriate authorities. Review of the investigation that was conducted on 12/18/18 revealed three statements written by the nursing aides who witnessed the abuse to R#121, however there were no statements from the family member or the nurses involved in the incident. The facility was unable to provide documentation that LPN II received any type of counseling or re-training following this incident. The Administrator stated that he did not personally investigate, the DON had taken the lead on the discussion, and it was believed that abuse had not occurred. During the investigation of the incident on 12/18/18 with R#121 an additional incident was identified for possible abuse involving R#55 and LPN II. This incident occurred on 12/23/18. Interview on 1/8/19 at 5:15 p.m. with the Administrator revealed that he was made aware of the allegation of abuse for R#121 but that he felt that the DON had conducted an investigation and determined that abuse had not occurred. The Administrator further stated that R#121 was known to scream and yell out as part of her behaviors. The Administrator was not able to state whether or not R#121's comprehensive care plan had been reviewed to determine if her behavior had been addressed as it pertained to changing out her Foley catheter when needed. A review of the Administrator's job description revealed, in part, the following documentation; Essential Regulatory Functions 7. Operates the Nursing Center in accordance with the established guidelines of the Organization and in compliance with federal, state and local regulations. 18. Assumes responsibility for and honors patients' rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to wage complaints. 19. Assumes responsibility for procedural guidelines relative to the prevention and reporting patient abuse. 20. Reviews, investigates and arbitrates patient complaints and grievances and makes available to supervisor written reports of action taken. 22. Maintains appropriate documentation in regard to accidents/incidents. 31. Ensures that all associates, patients, visitors and the general public follow established policies and procedures. Cross Refer F600 The facility implemented the following actions to remove the Immediate Jeopardy: The Regional Vice President was to provide education to the Administrator and DON on job description, roles, and responsibilities and duty to ensure the safety of all the residents. Also, the Regional Vice President was to provide education on the abuse, neglect, and exploitation policy and procedure to the Administrator and DON. The Administrator and DON were to be re-educate on their roles in the Quality Assurance Performance Improvement process. The State Survey Agency (SSA) validated the Allegation of Compliance (A[NAME]) Jeopardy Removal as follow: The AoC presented for validation documented that the Regional Vice President (RVP) would provide education to the Administrator and the DON on their job descriptions, roles and responsibilities and duties to ensure the safety of residents. Education was also provided on 1/8/19 at 10:00 p.m. on abuse, neglect and exploitation policy and procedures to the Administrator and DON. A performance evaluation review document was acknowledged and reviewed on 1/8/19 by the Administrator and the RVP as received. The Administrator job description was reviewed, signed and dated on 1/9/19 by the Administrator and the RVP. The facility document Job Description: Nursing Services. Director of Nursing was reviewed, signed and dated by the DON and RVP on 1/8/19. During the interview with the Administrator and the RVP conducted on 1/10/19 at 2:53 p.m. in the Administrators office the RVP confirmed that he had reviewed with the Administrator and the DON their job descriptions and job expectations. Review of the facility's AoC revealed the RVP provided education to the Administrator and the DON on 1/8/19 regarding their roles and responsibilities of the QAPI process. This education was verified by interview with the Administrator and the RVP on 1/10/19 at 2:53 p.m. during a meeting in the Administrator's office.

Based on observation, clinical record review, facility staff interview, hospital ED Nursing Record review, hospital ED Discharge Instructions review, and facility Follow-Up Report review, the facility failed to ensure resident supervision for elopement/wandering behavior, in accordance with the Care Plan which specified WanderGuard bracelet use to address elopement/wandering behavior, by failing to ensure that the WanderGuard system provided protection which included a set of double doors located in one (1) first floor corridor which was accessible to Unit B and Unit C residents, and which exited the nursing facility into an adjoining hospital facility. The failure of the facility to ensure WanderGuard alarm protection on the double doors contained within this unsecured corridor allowed this corridor to serve as an unsecured route of exit for one (1) resident (#1) who eloped through this corridor, and as a potential unsecured route of exit for four (4) additional residents (#5, #11, #12, and #14), whose Care Plans specified the use of WanderGuard bracelets to address known elopement/wandering behavior, on the total survey sample of fourteen (14) residents. Resident #1 subsequently accessed this unsecured corridor on 02/09/2014 without the knowledge of facility staff, exited the facility through the corridor, and eloped through the adjoining hospital. Resident #1 traveled along a street for approximately one-half mile, fell on to the pavement, was taken to the hospital Emergency Department (ED), and was found to have facial abrasions, a nasal laceration requiring sutures, a nasal fracture, and a fractured right knee cap. This resulted in a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of the immediate jeopardy on February 18, 2014 at 9:30 a.m. The non-compliance related to the immediate jeopardy was identified to have existed on February 9, 2014 (the date Resident #1 eloped from the facility via the unlocked, unalarmed, and unsecured doors located within a corridor which lead from the nursing facility to an adjoining hospital), continued through February 18, 2014, and was removed on February 19, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 18, 2014. During this survey, it was determined that Resident #1, who had a history of [REDACTED]. In addition to Resident #1, Resident #s 5, 11, 12, and 14, who all had cognitive impairment and whose Care Plans all specified the use of WanderGuard bracelets for known elopement/wandering behavior, also resided on Unit B or Unit C, and all had direct access to these unlocked, unalarmed corridor doors which lead directly to the hospital. During an interview conducted on 02/14/2014 at 11:50 a.m., the Administrator acknowledged that the set of unlocked corridor doors located in the corridor leading from the nursing facility into the hospital did not have a WanderGuard alarm. An allegation of jeopardy removal was received on February 19, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 19, 2014, and the facility remained out of compliance at a lower scope and severity of "E" while the facility completed a process which involved the retraining, via staff in-service, of available nursing staff related to procedural revisions made to ensure adequate supervision for residents at risk of wandering/elopement, but continued to provide in-service training to staff who were initially unavailable for training, as they reported to work. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of residents requiring supervision related to the risk of wandering/elopement. Observations were made to assess staffs' performance of care and supervision of these residents. Findings include: During a tour of the facility's first floor conducted on 02/14/2014 at 12:30 p.m., observations were made in first floor Unit B and Unit C. Observation during this tour revealed that the facility utilized a WanderGuard alert system to allow for the supervision of residents at risk for elopement/wandering. A WanderGuard alarm was observed on the nursing facility's main entrance/exit doors located at the front of the facility, and a WanderGuard alarm was observed on doors located at the terminal end of the Unit C front corridor which opened into a corridor of the adjoining hospital facility. However, observation of Unit B revealed a corridor which turned off the end of the B Hall of Unit B and lead into the adjoining hospital facility. This corridor which connected the nursing facility and the hospital was noted to contain a set of double doors which did not have a WanderGuard alarm. These doors were not locked, and opened upon pressing a wall-mounted button. This corridor containing these unalarmed, unlocked doors lead from the nursing facility to the adjoining hospital, continued through the hospital and exited through the hospital's main front entrance/exit doors. During this observation, it was noted that the nursing facility's Unit B and Unit C adjoined, and that residents of both units could travel between units, thus allowing residents of both units to have access to this corridor which exited from Unit B and which contained these unalarmed, unlocked double doors leading into the adjoining hospital. During an interview conducted on 02/14/2014 at 11:50 a.m., the Administrator acknowledged that the double doors located in the corridor leading off of Unit B had no WanderGuard alarm and were not locked. 1. Resident #1's Minimum Data Set (MDS) Assessment of 02/06/2014, for an admission of 01/30/2014, documented diagnoses, in Section I - Active Diagnoses, which included [MEDICAL CONDITION] Fibrillation, [MEDICAL CONDITION] Disorder, and Non-Alzheimer's Dementia, and Section C - Cognitive Patterns indicated severe cognitive impairment, with a Brief Interview for Mental Status (BIMS) Summary Score of six (06). Section E - Behavior documented that Resident #1 had exhibited wandering behavior 1 to 3 days during the look-back period. Resident #1's Nursing Admission Care Plan, dated 01/30/2014, identified that the resident was at risk for elopement, and was also at risk for falls. This Nursing Admission Care Plan identified an Approach which specified the use of a WanderGuard alarm to address Resident #1's risk for elopement, with the indicated Goal being that the resident would remain free of injuries and falls. A Nurse's Notes (NN) entry of 02/09/2014 for the 7:00 a.m.-7:00 p.m. shift documented that at around 3:45 p.m., Resident #1 had been seated in the Day Room for an activity. However, a subsequent 02/09/2014, 5:00 p.m. NN documented that Resident #1 had been found at the side of a road by a previous neighbor and was being taken to the hospital. Resident #1's hospital ED (Emergency Department) Nursing Record of 02/09/2014 documented lacerations/abrasions to the face, nose, and forehead, and that the resident had been found by a previous neighbor in the highway outside of the resident's former home. Resident #1's ED Discharge Instructions form of 02/09/2014 documented [DIAGNOSES REDACTED]. A 02/14/2014 facility Follow-Up Report (FR) documented that at 3:45 p.m. on 02/09/2014, Resident #1, who resided on first floor Unit B, had left the facility's Day Room sometime after 4:00 p.m. and eloped, almost reaching his/her former home located 0.83 mile from the nursing facility. This FR documented that the facility believed Resident #1 could have eloped through a set of double doors located in a corridor which lead to the adjoining hospital. As indicated in the 02/14/2014, 12:30 p.m. tour observation referenced above, the corridor which lead off the B Hall of facility Unit B, to which Resident #1 had direct access, contained unlocked double doors which had no WanderGuard alarm, were not locked, and continued into the adjoining hospital facility, passed through the hospital, and exited through the hospital's main entrance/exit doors. During an interview conducted on 02/14/2014 at 11:50 a.m., the Administrator acknowledged these corridor doors off of the Unit B corridor were not locked and did not have a WanderGuard alarm. The Administrator stated that it was thought that on 02/09/2014, Resident #1 walked down the B Hall corridor, passed through the unalarmed double doors, entered into the hospital and eloped through the hospital's front main entrance/exit doors. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard bracelets, and despite Resident #1 having severe cognitive impairment and a known history of wandering behavior, thereby requiring the use of a WanderGuard bracelet as specified by the Nursing Admission Care Plan, the facility failed to ensure that the unlocked double doors located in the corridor leading from the Unit B hall where Resident #1 resided were equipped with a WanderGuard alarm, to thus ensure WanderGuard bracelet supervision as specified by the Care Plan. Resident #1 then exited the nursing facility through the unalarmed, unlocked corridor double doors and then exited the hospital through the front entrance/exit doors and eloped. Resident #1 then traveled approximately one-half (1/2) mile, fell and sustained facial abrasions, a nasal laceration requiring sutures, a nasal fracture, and a fractured right knee cap. Cross refer to F323, example 1, for more information regarding Resident #1. 2. Resident #12's MDS of 11/11/2013 documented diagnoses, in Section I - Active Diagnoses, which included Hypertension and Dementia, and Section C - Cognitive Patterns documented a BIMS Summary Score of seven (7), indicating severe cognitive impairment. Review of Resident #12's Care Plan revealed that the resident resided on Unit B of the facility. An entry on this Care Plan, indicated as a Problem/Need and originally dated 12/31/2013, identified Resident #12 to have wandering behavior. Approaches listed on Resident #12's Care Plan to address this wandering behavior included the use of a WanderGuard bracelet to be applied at all times, and to redirect the resident as indicated. The Goal for these Approaches identified on Resident #12's Care Plan included that the resident would not leave the facility unescorted. However, as indicated in the 02/14/2014, 12:30 p.m. tour observation referenced above, the corridor leading to the adjacent hospital facility, and located at the end of the B Hall of Unit B where Resident #12 resided and to which Resident #12 had direct access, contained double doors which were unlocked and not equipped with a WanderGuard alarm. This corridor continued into the hospital facility and exited through the hospital's main front entrance/exit. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard bracelets, despite Resident #12, who resided on Unit B, having Dementia and severe cognitive impairment and having been assessed to have a history of wandering behavior, and despite the resident's Care Plan specifying the use of a WanderGuard bracelet and that staff redirect the resident as indicated, the facility failed to ensure that double doors located in the corridor which exited Unit B and lead directly into the adjoining hospital were WanderGuard alarm equipped. By failing to ensure WanderGuard alarm placement on the unlocked double doors contained within this corridor leading from the nursing facility to the hospital, and which served as a direct route of egress from the nursing facility, the facility failed to ensure that the WanderGuard bracelet utilized by Resident #12, as specified by the Care Plan, would allow redirection of the resident as indicated, also as specified by the Care Plan, by alerting staff to wandering/elopement attempts through this unsecured corridor. This presented a wandering risk for Resident #12. Cross refer to F323, example 2, for more information regarding Resident #12. 3. Resident #14's MDS of 01/06/2014 documented diagnoses, in Section I - Active Diagnoses, which included [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Dementia, [MEDICAL CONDITION] Disorder, and a [MEDICAL CONDITION], and Section C - Cognitive Patterns documented severe cognitive impairment, with a BIMS Summary Score of ninety-nine (99). Resident #14's Care Plan identified that the resident resided on Unit C. The Care Plan also identified, as a Problem/Need originally dated 04/18/2013, that Resident #14 was at risk for elopement from the facility. The Care Plan referenced Approaches to address Resident #14's elopement risk which include the use of a WanderGuard bracelet at all times, and for staff to provide redirection as indicated. However, as indicated in the 02/14/2014, 12:30 p.m. tour observation referenced above, Resident #14, who wore a WanderGuard bracelet for elopement-risk and resided on Unit C, had direct access to Unit B, where observation revealed the corridor which lead off of Unit B and contained the double doors which were not locked or equipped with a WanderGuard alarm, and lead to the hospital facility that adjoined the nursing facility, exiting through the hospital's main front entrance/exit. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard bracelets, despite Resident #14 (who resided on Unit C and had direct access to Unit B) having Dementia and severe cognitive impairment, despite the resident having been assessed to be at risk for elopement, and despite the resident's Care Plan specifying the use of a WanderGuard bracelet for this elopement-risk and that staff redirect the resident as indicated, the facility failed to ensure WanderGuard alarm placement on the unlocked double doors located in the corridor which exited Unit B, lead directly into the adjoining hospital, and allowed nursing facility egress. By failing to ensure WanderGuard alarm placement on these unlocked double doors, the facility failed to ensure that the WanderGuard bracelet utilized by Resident #14, as specified by the Care Plan, would allow redirection as indicated, also as specified by the Care Plan, by alerting staff to elopement attempts through this unsecured corridor. This presented an elopement risk for Resident #14. Cross refer to F323, example 3, for more information regarding Resident #14. 4. Resident #5's MDS of 11/19/2014 documented diagnoses, in Section I - Active Diagnoses, of [MEDICAL CONDITION], Heart Failure, Hypertension, [MEDICAL CONDITION], Diabetes Mellitus, Arthritis, a history of [MEDICAL CONDITION], and Dementia. Section C - Cognitive Patterns documented that Resident #5 had moderate cognitive impairment, with a BIMS Summary Score of twelve (12). The Care Plan of Resident #5 identified that he/she resided on facility Unit B. Resident #5's Care Plan also identified, as a Problem/Need originally dated 11/20/2013, that the resident had the potential for elopement related to both episodes of confusion with wandering and a history of wandering. This Care Plan identified Approaches to address Resident #5's elopement-risk which included the use of a WanderGuard at all times, and also staff redirection as indicated. However, as indicated in the 02/14/2014, 12:30 p.m. tour observation referenced above, the double doors located within the corridor which lead off of Unit B, where Resident #5 resided, were unlocked and were not equipped with a WanderGuard alarm. This corridor within which these unlocked, unalarmed double doors were located was accessible by Resident #5, lead into the adjoining hospital facility, and exited through the hospital's main front entrance/exit. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard bracelets, despite Resident #5, who resided on Unit B, having Dementia and cognitive impairment and having been assessed to have the potential for elopement due to confusion and a history of wandering behavior, and despite the resident's Care Plan specifying the use of a WanderGuard bracelet and that staff redirect the resident as indicated, the facility failed to ensure that double doors located in the corridor which exited Unit B and lead directly into the adjoining hospital were WanderGuard alarm-equipped. By failing to ensure WanderGuard alarm placement on the unlocked double doors within this corridor which served as a direct route of egress from the nursing facility, the facility failed to ensure that the WanderGuard bracelet utilized by Resident #5, as specified by the Care Plan, would allow redirection of the resident as indicated, also as specified by the Care Plan, by alerting staff to wandering/elopement attempts through this unsecured corridor. This presented an elopement risk for Resident #5. Cross refer to F323, example 4, for more information regarding Resident #5. 5. Resident #11's MDS assessment of 01/06/2014 documented in Section I - Active [DIAGNOSES REDACTED]. The Care Plan of Resident #11 identified that the resident resided on facility Unit C. The Care Plan also identified, as a Problem/Need originally dated 07/16/2013, that Resident #11 had the potential for wandering behavior, with a history of wandering in the hallways. Care Plan Approaches to address Resident #11's risk for wandering included the use of a WanderGuard bracelet at all times and for staff to redirect the resident as indicated. However, as indicated in the 02/14/2014, 12:30 p.m. tour observation referenced above, Resident #11, who utilized a WanderGuard bracelet and resided on Unit C, had access to the corridor which exited off of Unit B, contained the double doors which were unlocked and were not equipped with a WanderGuard alarm, and which lead from the nursing facility to the adjoining hospital and exited through the hospital's main front entrance/exit. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard bracelets, despite Resident #11 (who resided on Unit C and had direct access to Unit B) having Dementia/severe cognitive impairment and having been assessed with [REDACTED]. Unit B, lead directly into the adjoining hospital, and allowed nursing facility egress. By failing to ensure WanderGuard alarm placement on these unlocked doors, the facility failed to ensure that the WanderGuard bracelet utilized by Resident #11, as specified by the Care Plan, would allow redirection as indicated, also as specified by the Care Plan, by alerting staff to resident wandering in this unsecured corridor. This represented a wandering risk for Resident #11. Cross refer to F323, example #5, for more information regarding Resident #11. The immediate jeopardy was determined to have been removed on February 19, 2014, at which time the facility had presented and implemented a credible allegation of jeopardy removal with the following interventions: A. On February 9, 2014, after learning of Resident #1's elopement, the facility conducted a full resident audit to assure the presence of all residents. B. On February 9, 2014, all doors exiting the nursing facility were checked to ensure the proper working order of the WanderGuard alarm system. All existing WanderGuard alarms were functioning properly. C. On February 9, 2014, a procedure was put into place by which a facility employee was placed at the doorway, located in the corridor leading from the nursing facility to the hospital, which was not equipped with a WanderGuard alarm. A scheduled was developed reflecting specific employees who were assigned to be in place at the unalarmed doorway, at specific times and continuously around the clock, until a WanderGuard alarm was installed on the doorway. D. On February 9, 2014, chart audits for all current facility residents were conducted to ensure that all residents who demonstrated a potential for elopement had been accurately identified by the facility. During these chart audits, no new residents were identified to have the potential for elopement. E. On February 9, 2014, Care Plan reviews were conducted for residents assessed to be at risk for elopement to ensure that a comprehensive approach to address this risk was in place. During these Care Plan reviews, no problems were identified. F. On February 9, 2014, in addition to daily WanderGuard bracelet checks completed by the Activities Director which were in place prior to Resident #1's elopement, the facility implemented audits of the door alarms through the preventative maintenance program. The door alarms would be checked weekly, on each Tuesday, by the Maintenance Director, and these door alarm checks would be documented via computer data entry. The door alarm test would include a check of the power indicator light to ensure proper function, and also a check for battery condition. A sensor button was to be used to test each door alarm, with the alarm to sound when within six feet of an alarmed doorway. If a door alarm did not initially sound, the test was to be repeated with a different sensor button. Any deviation from full working order found during these weekly door alarm checks would be reported to the Administrator for immediate correction. The Administrator or DON would monitor the results of these weekly door alarm audits, conducted by the Maintenance Director, by reviewing the computer data entered as a result of the door alarm checks weekly for four (4) weeks, then monthly for three (3) months, then quarterly thereafter. The results of these supervisory audits will be submitted to the Quality Assessment/Performance Improvement (QA/PI) Committee for their review. G. On February 9, 2014, the facility contacted the Medical Director to inform him of the elopement of Resident #1. Additionally, a meeting which consisted of some members of the QA/PI Committee, including the Administrator, DON, and Director of Maintenance, was held to review the elopement event and the actions which had been taken by the facility, and to identify any additional actions that were needed. H. On February 15, 2014, the corridor doorway, which lead from the nursing facility to the hospital and which had previously lacked a WanderGuard alarm, was equipped with a WanderGuard alarm. I. On February 18, 2014, the facility continued to provide staff in-service training to facility staff, including licensed nurses, CNAs, and maintenance/housekeeping staff. This in-service training served to both reinforce current facility protocols involving the routine monitoring of residents having WanderGuard bracelet devices and also to provide staff training on newly-implemented protocols related to the facility's WanderGuard alarm system. As of February 18, 2014, 116 of the facility's total 118 employees had received this in-service training. The two (2) remaining staff members, who were on Family and Medical Leave Act leave at the time this in-service training was provided, will received the training upon their return to work. J. On February 18, 2014, the QA/PI Committee met to review the elopement event involving Resident #1, to review the actions taken by the facility as of that date, and to review the monitoring systems put into place as a result of the elopement. The QA/PI Committee will review the results of WanderGuard bracelet monitoring and door alarm audits weekly for four (4) weeks, then monthly for three (3) months, then quarterly thereafter to ensure ongoing compliance with the systemic measures implemented to correct the identified issue and prevent recurrence. The information will be analyzed by the QA/PI Committee, and subsequent plans of correction will be developed and implemented as needed. This will be an ongoing process. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on February 19, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. On February 9, 2014, the facility implemented a weekly audit of WanderGuard door alarms to be accomplished through the preventative maintenance program by the Maintenance Director. These weekly WanderGuard door alarm audits would check for the proper function of all facility WanderGuard door alarms, and were to be documented via computer data entry. However, these weekly WanderGuard door alarm audits had been initiated only on February 9, 2014, and had occurred only twice prior to the February 20, 2014 exit date of this complaint survey. Therefore, ongoing staff compliance with this newly implemented procedure involving routine, scheduled WanderGuard door alarm monitoring could not be entirely assessed at the time of survey completion, and will thus need future evaluation. Additionally, by February 18, 2014, the facility had completed in-service training for 116 of its 118 facility employees, to include licensed nurses, CNAs, and maintenance/housekeeping staff, regarding both existing and newly-implemented protocols involving the monitoring of residents with WanderGuard bracelets and the WanderGuard alarm system. However, two (2) remaining staff members, who were on leave and had been unavailable for training, will need to receive this training upon returning to work, and this training will thus need future evaluation. Additionally, the QA/PI Committee was to include the review the results of WanderGuard bracelet monitoring and door alarm audits in future meetings, but the Committee had met on On February 18, 2014, only two (2) days prior to the February 20, 2014 exit date of this complaint survey, to begin this process. Thus, the QA/PI Committee's ongoing process of facility procedural oversight could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to the "E" level.

Based on observation, clinical record review, EMS Prehospital Care Report Summary review, hospital Record of Admission report review, hospital ER Triage Record review, hospital ED Nursing Record review, nursing facility Follow-Up Report review, Weather.com report review, MapQuest.com report review, hospital staff interview, and nursing facility staff interview, the facility failed to ensure that the WanderGuard alarm system, utilized by the facility to alert staff of attempts by residents having wandering/elopement behavior to exit the facility, included alarm coverage for a set of unlocked double doors contained in one (1) first floor corridor which was accessible to Unit B and Unit C residents, and which exited the nursing facility into the adjoining hospital facility. The facility's failure to ensure WanderGuard alarm protection on these unlocked doors located in this corridor leading from the nursing facility into the hospital thus allowed this corridor to serve as a route of elopement for one (1) resident (#1) who utilized a WanderGuard bracelet for wandering/exit-seeking behavior and eloped through these unlocked/unalarmed doors, and as a potential route of elopement for four (4) additional residents (#5, #11, #12, and #14) on the survey sample with known elopement/wandering behavior, all of whom utilized WanderGuard bracelets and had access to this unsecured nursing home/hospital corridor, on the total survey sample of fourteen (14) residents. Resident #1 accessed this unsecured corridor on 02/09/2014, exited the nursing facility through this corridor via these unalarmed and unlocked doors, and eloped through the adjoining hospital. Resident #1 then traveled along a street for a distance of approximately one-half mile, fell hitting his/her head on the pavement, was taken to the hospital Emergency Department (ED), and was found to have sustained facial abrasions, a nasal laceration requiring sutures, a nasal fracture, and a fractured right knee cap. This resulted in a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of the immediate jeopardy on February 18, 2014 at 9:30 a.m. The non-compliance related to the immediate jeopardy was identified to have existed on February 9, 2014 (the date Resident #1 eloped from the facility via the set of unlocked, unalarmed, and unsecured doors located within the corridor which lead from the nursing facility to the adjoining hospital) continued through February 18, 2014, and was removed on February 19, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 18, 2014. During this survey, it was determined that the facility failed to ensure supervision of Resident #1, who had a history of [REDACTED]. On 02/09/2014, Resident #1 eloped from the facility, traveled a distance of approximately one-half mile, and sustained a fall resulting in facial abrasions, a nasal laceration requiring sutures, a nasal fracture, and a fractured right knee cap. On 02/05/2014, prior to this elopement incident of 02/09/2014, Resident #1 had been transferred to Unit B located on the nursing facility's first floor after having been admitted to Unit E located on the second floor upon original facility admission. However, a Unit B corridor directly connected with, and lead into, a corridor of the hospital which adjoined the nursing facility, and double doors within this corridor were not equipped with a WanderGuard alarm and were not locked. During an interview with the Administrator conducted on 02/14/2014 at 11:50 a.m., when questioned about Resident #1's 02/09/2014 nursing facility elopement, the Administrator acknowledged that Resident #1's Unit B room had been located in close proximity to the unlocked corridor doors which were located in the corridor leading into the hospital and which did not have a WanderGuard alarm. The Administrator stated it was thought that Resident #1 had passed through the unalarmed corridor double doors into the hospital and exited through the front main entrance/exit doors of the hospital. In addition to Resident #1, four (4) more sampled residents (#5, #11, #12, and #14) who had cognitive impairment and utilized WanderGuard bracelets for known elopement/wandering/exit-seeking behavior, also resided either on Unit B or Unit C, both of which allowed direct access to this set of unlocked, unalarmed corridor doors which lead into the hospital. An allegation of jeopardy removal was received on February 19, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 19, 2014, and the facility remained out of compliance at a lower scope and severity of "E" while the facility completed a process which involved the retraining, via staff in-service, of available nursing staff related to procedural revisions made to ensure adequate supervision for residents at risk of wandering/elopement, but continued to provide in-service training to staff who were initially unavailable for training, as they reported to work. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of residents requiring supervision related to the risk of wandering/elopement. Observations were made to assess staffs' performance of care and supervision of these residents. Findings include: 1. Record review for Resident #1 revealed a 5-day PPS Minimum Data Set (MDS) Assessment having an Assessment Reference Date of 02/06/2014 which documented a facility Entry Date of 01/30/2014. Section I - Active [DIAGNOSES REDACTED]. Section C - Cognitive Patterns documented that Resident #1 had a Brief Interview for Mental Status (BIMS) Summary Score of 06, indicating that the resident had severe impairment in cognition. Section G - Functional Status indicated that Resident #1 was independent with walking, and Section E - Behavior documented that the resident had exhibited wandering behavior 1 to 3 days during the look-back period, and that this wandering placed the resident at significant risk of getting to a potentially dangerous place (e.g., outside of the facility). Review of Resident #1's admission physician's orders [REDACTED]. A Physician's Interim Orders form dated 01/31/2014 specified that Resident #1 was to wear a WanderGuard bracelet at all times. The 01/30/2014 admission physician's orders [REDACTED].#1 was admitted to a room on Unit E (one of the facility's second floor units utilized for the placement of residents at risk for elopement). However, a Nurse's Notes (NN) entry of 02/05/2014 at 4:40 p.m. documented that Resident #1 had been transferred to Unit B (a first floor, ground-level unit) per the family's request. A NN entry of 02/06/2014 of the 7:00 a.m.-7:00 p.m. shift for Resident #1 documented that the resident was alert but with confusion, and that the resident had been pacing in the hall and going into other residents' rooms. This NN also documented that Resident #1 had approached the C Hall doors twice that shift, and that staff had to redirect the resident. A NN entry of 02/07/2014 of the 7:00 p.m.-7:00 a.m. shift for Resident #1 documented that the resident had been walking up and down the hall, and a twenty-four hour summary assessment sheet of 02/07/2014 for Resident #1 documented that the resident had exhibited wandering behavior on both the day and night shifts. A NN entry of 02/08/2014 of the 7:00 a.m.-7:00 p.m. shift for Resident #1 documented that the resident remained confused, was looking to go home, and stating that someone was "coming to get her." This NN also documented that Resident #1's family would visit, but that the resident would wander after the family left. A twenty-four hour shift summary assessment of 02/08/2014 for Resident #1 documented that the resident had exhibited wandering behavior on the day shift of that date. A NN entry of 02/09/2014 of the 7:00 a.m.-7:00 p.m. shift for Resident #1 documented that the resident continued to show confusion and was following staff around from room-to-room. This NN documented that Resident #1 was walking up and down the hallways, and that staff would redirect him/her as he/she got to the end of the hallways. This NN also documented that Resident #1 had stated "Which way is the way out? I need to get home." The NN documented that at around 3:45 p.m. on 02/09/2014, Resident #1 had been given drawing material and Crayons by Licensed Practical Nurse (LPN) "AA" and seated in the Day Room for an activity, and that moments later, a certified nursing assistant was noted assisting Resident #1 with the activity while seated at the table in the Day Room. However, a NN entry of 02/09/2014, timed at 5:00 p.m., for Resident #1 documented that the nurse received a telephone call from a family member of Resident #1 to inform the nurse that the resident had been found at the roadside, and in close proximity to a local lake, by a previous neighbor, who had noted injuries and called Emergency Medical Service (EMS) 911. The family member informed the nurse that Resident #1 was being taken to the hospital emergency room . In this NN, the nurse referenced the resident's use of a WanderGuard bracelet and indicated that it was unknown how the resident had eloped from the building. A NN entry of 02/09/2014, timed at 5:10 p.m., for Resident #1 documented that the nurse copied the necessary paperwork from the resident's nursing facility medical record and walked the paperwork over to the hospital (which was located adjacent to the nursing home and connected to the nursing home via a shared corridor). The nurse documented in this NN that once she arrived in the hospital ER, she was informed by an Emergency Medical Technician that he had cut a WanderGuard bracelet off of Resident #1. The EMS Prehospital Care Report Summary for Resident #1 documented that on 02/09/2014 at 4:40 p.m., EMS had received a telephone call regarding Resident #1. This EMS Report Summary documented that EMS staff responded and found Resident #1 to have walked from the nursing home to her prior private home and to have fallen face-first to the roadway. This EMS Summary documented a hematoma to Resident #1's forehead and a contusion with laceration to the nose, and further documented the resident's hospital transport. Review of the hospital Record of Admission for Resident #1 revealed a hospital admission date of [DATE], with an Admitting [DIAGNOSES REDACTED]. The ER Triage Record for Resident #1 documented, in the Assessment section, a Chief Complaint of the resident having fallen onto pavement and having hit his/her face and forehead approximately thirty (30) minutes prior to hospital arrival. The hospital ED Nursing Record (EDNR) for Resident #1 contained an entry, dated 02/09/2014 and timed at 5:10 p.m., which documented the resident's hospital ED nursing assessment. This EDNR entry documented that Resident #1 stated he/she had fallen and hit his/her face. The EDNR entry also documented that lacerations and abrasions were noted to Resident #1's face, bridge of the nose, and forehead. The EDNR entry further documented that Resident #1 had been found by a previous next-door neighbor, who had found the resident in the highway and on the ground outside of the resident's former home (the place of dwelling prior to nursing home admission). A subsequent EDNR entry for Resident #1, dated 02/09/2014 and timed at 8:20 p.m., documented that Resident #1 had been discharged to home from the hospital with family members. The ED Discharge Instructions form for Resident #1 documented an ED discharge date of [DATE], and documented ED [DIAGNOSES REDACTED]. During an interview with hospital ED Registered Nurse (RN) "CC" conducted on 02/18/2014 at 1:15 p.m., RN "CC" stated that he was working in the hospital's ED on the evening of 02/09/2014 when Resident #1 was brought to the ED for treatment of [REDACTED].#1 was wearing a long-sleeve shirt, jogging pants, and shoes when he/she presented at the hospital ED for treatment. Review of Weather.com revealed that the exterior environmental temperature for the Commerce, Georgia area, in which the nursing facility was located, registered at 59 degrees Fahrenheit on 02/09/2014 at 4:55 p.m., the date and approximate time of Resident #1's elopement from the facility. A facility Follow-Up Report (FR) dated 02/14/2014 referenced Resident #1 and documented the facility's investigation into Resident #1's 02/09/2014 elopement. This facility FR documented, in the Background section, that after Resident #1's original facility admission to Unit E (on the facility's second floor) where residents considered to be at risk for elopement were housed, the resident was moved from Unit E to Unit B (on the facility's first floor) on 02/05/2014 at the request of the resident's family. The Review of Initial Report section of this FR documented that on 02/09/2014 at 5:00 p.m., the facility received a telephone call from a family member informing facility staff that Resident #1 had left the facility. Further review of the FR revealed, in the Details of Investigation/Chronology of Events section, that at 3:45 p.m. on 02/09/2014, Resident #1 had been placed in the Day Room for an activity by LPN "AA", and that Certified Nursing Assistant (CNA) "BB" had assisted Resident #1 in the Day Room from 4:00 p.m. until 4:05 p.m. CNA "BB" then left Resident #1 to assist other residents in preparing for dinner. This FR documented that sometime after 4:00 p.m. on 02/09/2014, Resident #1 left the Day Room and headed toward his/her former home. The FR documented that Resident#1 almost reached his/her former home, located 0.83 mile from the nursing facility, but sustained a fall prior to arriving. This FR documented that at 5:00 p.m., the facility received a telephone call from the family of Resident #1 informing facility staff of the resident's elopement and hospital transfer, and that upon Resident #1's arrival at the hospital after the elopement and fall, the resident was treated for [REDACTED]. This FR documented that later in the evening of 02/09/2014 at 8:20 p.m., Resident #1 left the hospital in the company of a family member and went home, not returning to the nursing facility. The Summary/Conclusion section of the FR, which chronicled the facility's investigation into Resident #1's elopement and fall with injuries on 02/09/2014 as referenced above, documented the facility had concluded that it was unknown how Resident #1 was able to elope from the facility undetected. This section of the FR further documented that it was believed that Resident #1 could have eloped through the set of double doors located in a corridor which went past the facility's kitchen and eventually lead to the adjoining hospital's main entrance/exit. During an observation conducted on 02/14/2014 at 12:30 p.m., accompanied by the facility's Administrator, a tour of the entire facility was conducted, to include the former Unit B room where Resident #1 had resided prior to the 02/09/2014 elopement. Resident #1's former room was observed to be at the end of the B Hall of Unit B. Approximately ten (10) feet from Resident #1's former room, and at the end of the B Hall of Unit B, a corridor turned to the right. After the right turn, this corridor extended a distance of approximately twenty (20) feet, at which point a set of double doors was encountered. These double doors were observed to be unalarmed, and were observed to open after activation via a wall-mounted button located on an adjacent wall and in close proximity to the double doors. These doors were not locked, and opened when the wall-mounted button was pressed. Upon passing through this set of unlocked double doors, the corridor continued for a distance of approximately twenty (20) feet, then turned right and continued for a distance of approximately another eighty (80) feet, passing through the adjoining hospital facility and exiting through the hospital's main entrance/exit doors, which were unlocked, unalarmed, and located at the front of the hospital. Upon exit through the hospital's front main entrance/exit doors, the hospital's front parking lot was located directly in front of the entrance/exit doors. The hospital parking lot then adjoined a two lane street which ran in front of the hospital and nursing facility buildings. During an interview with the Administrator conducted on 02/14/2014 at 11:50 a.m., the Administrator stated that Resident #1's former home, where the resident had resided prior to nursing facility admission, was located on the street which was adjacent to the hospital parking lot, at a distance of 0.83 mile (Source: MapQuest.com) from the nursing facility/hospital. The Administrator further stated that it was on this street, and in close proximity to Resident #1's former home, that Resident #1 was found to have fallen and sustained injuries after having eloped from the nursing facility on 02/09/2014. During the 02/14/2014, 12:30 p.m. nursing facility tour referenced above, observations made of the facility's first floor units (both of Unit B where Resident #1 had resided and Unit C) revealed a WanderGuard alarm on the entrance/exit doors located at the nursing facility's main entrance at the front of the facility. Additionally, observation in Unit C's front corridor revealed WanderGuard-alarmed doors located at the terminal end of Unit C's front corridor which opened into a corridor of the adjoining hospital facility. However, as referenced above, the double doors which were located in the corridor leading off of Unit B and continuing into the adjoining hospital facility, and through which Resident #1 exited Unit B and eloped on 02/09/2014, did not have a WanderGuard alarm and were not locked. During this observation, it was noted that Unit B was contiguous to Unit C, allowing residents of both Unit B and Unit C to move freely between units, and thus allowing residents of both units access to the Unit B corridor, ultimately leading to the hospital, in which the unlocked double doors were not equipped with a WanderGuard alarm. During the 02/14/2014, 11:50 a.m. interview with the Administrator referenced above, the Administrator was questioned regarding Resident #1's 02/09/2014 nursing facility elopement. During this interview, the Administrator stated that Resident #1's room, located on the B Hall of Unit B, was located in close proximity to the set of corridor doors which were not locked, which did not have a WanderGuard alarm, and which were located in the corridor leading past the kitchen area and then into the hospital. The Administrator stated that on 02/09/2014 at approximately 4:00 p.m., Resident #1 had been observed by staff while participating in an activity in the Day Room. The Administrator stated that it was thought that Resident #1 left the Day Room shortly after 4:00 p.m. to return to his/her room, but then continued to walk down the B Hall corridor, passed through the unalarmed corridor double doors, entered into the hospital corridor, and exited the hospital through the hospital's front main entrance/exit doors. The Administrator stated it was thought that Resident #1, upon exiting the hospital, walked across the front parking lot, went to the street in front of the hospital, made a left onto the street, walked approximately one-half (1/2) mile, and was found by a former neighbor to be lying face down in a ditch by the street. The Administrator acknowledged that Resident #1's prior home was located approximately 0.83 mile from the nursing facility/hospital on the street where he/she was found to have fallen after the 02/09/2014 elopement from the nursing facility. The Administrator further stated that after Resident #1's elopement, all facility doors having WanderGuard alarms were checked and were found to be functioning properly, but acknowledged that the corridor doors through which it was though Resident #1 had passed (and then eloped through the hospital's main entrance/exit) did not have a WanderGuard alarm. During an interview with the DON conducted on 02/14/2014 at 12:48 p.m., the DON stated that on 02/09/2014, after Resident #1 eloped from the facility, the Maintenance Supervisor had tested all existing WanderGuard-alarmed exit doors and had found them to be working properly. However, the DON stated that Resident #1's former room was located close to the end of the B Unit corridor and close to the set of unalarmed corridor doors at the end of the corridor. The DON stated that, based on the Maintenance Supervisor's finding that all existing WanderGuard-alarmed doors were functioning correctly on 02/09/2014, the facility determined that Resident #1 had walked down the Unit B corridor upon which his/her room was located, but then the unalarmed corridor doors allowed the resident to continue walking down the corridor out of the nursing facility and to exit out the front doors of the hospital. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard bracelets, despite Resident #1 having severe cognitive impairment and a known history wandering behavior requiring the use of a WanderGuard bracelet, despite Resident #1 being observed on multiple occasions to continue exhibiting both wandering behavior and exit-seeking behavior, the facility transferred Resident #1 on 02/05/2014 from Unit E (a second floor unit for which the exit was WanderGuard alarm protected) to Unit B (a first floor unit which allowed access to a set of unsecured, unlocked corridor doors which did not have a WanderGuard alarm and which lead to the hospital.) Resident #1 then exited through the unalarmed, unlocked corridor double doors while wearing a WanderGuard bracelet but without the knowledge of nursing facility staff, gained access to the hospital corridor, exited the hospital through the hospital's front entrance/exit doors, and eloped from the facility. The facility thus failed to ensure supervision of Resident #1 related to his/her risk for elopement/wandering, via the use of the WanderGuard bracelet as ordered by the physician, by failing to ensure the placement of a WanderGuard alarm on the unlocked corridor doors contained within the corridor which exited off of Unit B where Resident #1 resided, allowing the resident to exit through these doors undetected by staff and to elope. After Resident #1 eloped, he/she then traveled approximately one-half (1/2) mile toward his/her former home, fell , and sustained facial abrasions, a nasal laceration requiring sutures, a nasal fracture, and a fractured right knee cap. In addition to Resident #1 referenced above, four (4) additional sampled residents (#5, #11, #12, and #14) utilized WanderGuard bracelets for elopement and/or wandering behaviors and resided on either Unit B or Unit C of the facility's first floor. As documented in the 02/14/2014, 12:30 p.m. observation of Unit B and Unit C referenced above, these units were contiguous, therefore allowing Residents #5, #11, #12, and #14 to move freely between these units. However, as also documented in the 02/14/2014, 12:30 p.m. Unit B and Unit C observation referenced above, the unlocked double doors located in the facility corridor which lead off of Unit B, into the adjoining hospital facility, and ultimately allowing exit through the hospital's main front entrance/exit doors, were neither locked nor WanderGuard alarm-equipped. This placed Residents #5, #11, #12, and #14 (who all had wandering and/or elopement behaviors requiring WanderGuard bracelet use and who all had access to these unlocked/unalarmed corridor doors) at risk for elopement, as evidenced by the following: 2. Record review for Resident #12 revealed a Quarterly MDS having an Assessment Referenced Date of 11/11/2013 which documented in Section I - Active [DIAGNOSES REDACTED]. Section C - Cognitive Patterns of this MDS documented that Resident #12 had a BIMS Summary Score of 7, indicating that the resident had severe cognitive impairment. Section G - Functional Status documented that Resident #12 utilized a walker and wheelchair as mobility devices, and Section J - Health Conditions documented that the resident had a history of [REDACTED]. An Interdisciplinary Progress Notes (IPN) entry of 02/14/14 at 2:00 p.m. for Resident #12 documented that the resident was rolling himself/herself in the wheelchair, going to the C Hall and "trying to go home." However, the 02/14/2014, 12:30 p.m. observation referenced above revealed that, even though Resident #12 resided on Unit B and required a WanderGuard bracelet, the resident had access to the double doors, which were neither locked nor WanderGuard alarm protected, located within the corridor exiting Unit B and then exiting through the adjoining hospital's main front entrance/exit doors. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard bracelets, despite Resident #12 (who resided on Unit B) having severe cognitive impairment, despite the resident having been assessed to have a history of wandering behavior and continuing to exhibit exit-seeking behavior thereby requiring the use of a WanderGuard bracelet, and despite the resident being ambulatory via wheelchair and walker, the facility failed to ensure that the WanderGuard system, intended to prevent resident elopement, included a WanderGuard alarm on the unlocked double doors in the nursing facility corridor which exited Unit B (upon which Resident #12 resided) and lead into an unsecured corridor in the hospital. The facility thus failed to ensure adequate supervision, via the WanderGuard bracelet, for Resident #12, who was at risk for wandering/elopement and who required the use of the WanderGuard bracelet for this risk. 3. Record review for Resident #14 revealed a Quarterly MDS assessment having an Assessment Reference Date of 01/06/2014 which documented in Section I - Active [DIAGNOSES REDACTED]. Section C - Cognitive Patterns documented that Resident #14 had a BIMS Summary Score of 99, indicating that the resident had severe cognitive impairment, and documented that the resident had both short-term and long-term memory problems. Section G - Functional Status documented that Resident #14 required only supervision/limited assistance with locomotion, and that the resident utilized a wheelchair as a mobility device. Resident #14's Care Plan identified the resident to be at risk for elopement, and specified the use of a WanderGuard bracelet. An Interdisciplinary Progress Notes (IPN) entry of 02/08/2014 at 11:00 a.m. for Resident #14 documented that the resident resided on Unit C (located on the facility's first floor and adjacent to Unit B), and that the resident was noted to be following other residents into their rooms, requiring redirection. A later IPN of 02/08/2014 at 3:00 p.m. documented that Resident #14 continued going into other residents' rooms, and that Resident #14 was following a resident down the hallway. An IPN of 02/13/2014 at 2:30 p.m. for Resident #14 documented that Resident #14 had again gone into another resident's room. However, the 02/14/2014, 12:30 p.m. observation referenced above revealed that, even though Resident #14 required the use of a WanderGuard bracelet for a risk of elopement and resided on Unit C, the resident also had access to Unit B and thus had access to the double doors, which were neither locked nor WanderGuard alarm protected, located within the corridor which exited Unit B and then exited the adjoining hospital's main front entrance/exit doors. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard bracelets, despite Resident #14 (who resided on Unit C) having severe cognitive impairment and having been assessed to be at risk for elopement requiring the use of a WanderGuard bracelet, and despite the resident being ambulatory via a wheelchair and continuing to exhibit wandering behavior, the facility failed to ensure that the WanderGuard alert system, intended to prevent resident elopement, included the placement of a WanderGuard alarm on the set of unlocked double doors in the nursing facility corridor which exited Unit B (to which Resident #14 had access) and lead into a corridor in the hospital adjacent to the nursing facility. The facility thus failed to ensure adequate supervision, via the WanderGuard bracelet, for Resident #14 who was at risk for elopement and who required the use of the WanderGuard bracelet for this risk. 4. Record review for Resident #5 revealed an Annual MDS assessment having an Assessment Reference Date of 11/19/2014 which documented in Section I - Active [DIAGNOSES REDACTED]. Section C - Cognitive Patterns of this MDS documented that Resident #5 had a BIMS Summary Score of 12, indicating that the resident had moderate cognitive impairment. Section G - Functional Status documented that Resident #5 utilized a walker and a wheelchair as mobility devices, and required the limited assistance with walking in the room and in the corridor of his/her unit, but was totally dependent on staff for locomotion off of the unit. Resident #5's Care Plan identified that the resident had the potential for elopement, and that the resident required the use of a WanderGuard bracelet. Further record review for Resident #5 revealed a NN entry of 11/17/2013 for the 7:00 a.m.-7:00 p.m. shift which documented that the resident resided on Unit B, and documented that the resident propelled himself/herself utilizing a wheelchair. However, the 02/14/2014, 12:30 p.m. observation referenced above revealed that, even though Resident #5 resided on Unit B and required a WanderGuard bracelet for the risk of elopement, the resident had access to the double doors which were not locked or WanderGuard alarm equipped, and were located in the corridor which exited Unit B and then exited through the hospital's front entrance/exit. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard bracelets, despite Resident #5 (who resided on Unit B) having cognitive impairment and having been assessed to be at risk for elopement and requiring the use of a WanderGuard bracelet, the facility failed to ensure that the WanderGuard alert system, intended to prevent resident elopement, included a WanderGuard alarm on the unlocked double doors in the corridor which exited Unit B and lead into a corridor in the hospital adjacent to the nursing f

Based on observation, record review, and staff interview, the facility failed to ensure oversight by, and the involvement of, the Quality Assessment/Performance Improvement (QA/PI) Committee in the formulation and implementation of a corrective action plan developed in response to resident elopement. This corrective action plan was developed regarding the elopement of one (1) resident (#1) who resided on Unit B, had wandering/elopement behavior, and utilized a WanderGuard bracelet, of five (5) sampled Unit B and Unit C residents (#1, #5, #11, #12, and #14) with known elopement/wandering behavior who utilized WanderGuard bracelets, on the total survey sample of fourteen (14) residents. Resident #1, who utilized a WanderGuard bracelet to address wandering behavior and resided on Unit B, eloped through unlocked double doors which had no WanderGuard alarm and which were located in a corridor leading from facility Unit B into the adjoining hospital. Facility administrative staff developed a corrective action plan in response to Resident #1's elopement to address this failure of the WanderGuard alert system to protect Resident #1, and the additional residents of Units B and C who were at risk for elopement/wandering, from eloping through these unlocked and unalarmed corridor doors. However, this corrective action plan was developed and implemented prior to QA/PI Committee review, analysis and evaluation. This resulted in a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on February 18, 2014 at 9:30 a.m. The non-compliance related to the immediate jeopardy was identified to have existed on February 9, 2014 (the date Resident #1 eloped from the facility via the set of unlocked, unalarmed, and unsecured doors located within the corridor which lead from the nursing facility to the adjoining hospital) continued through February 18, 2014, and was removed on February 19, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 18, 2014. During an interview with the Administrator conducted on 02/14/2014 at 11:50 a.m., the Administrator acknowledged Resident #1's 02/09/2014 nursing facility elopement, and that a plan of action had been developed by facility management staff in response to the resident's elopement. However, the Administrator further acknowledged that at the time of this 02/14/2014 interview, the QA/PI Committee had not met to review and analyze this plan of action which had been developed by facility management staff. An allegation of jeopardy removal was received on February 19, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 19, 2014, and the facility remained out of compliance at a lower scope and severity of "E" while the facility completed a process which involved the retraining, via staff in-service, of available nursing staff related to procedural revisions made to ensure adequate supervision for residents at risk of wandering/elopement, but continued to provide in-service training to staff who were initially unavailable for training, as they reported to work. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of residents requiring supervision related to the risk of wandering/elopement. Observations were made to assess staffs' performance of care and supervision of these residents. Findings include: Cross refer to F323. Based on observation, clinical record review, and staff interview, the facility failed to ensure that the WanderGuard alarm system included alarm coverage for unlocked double doors located in a first floor corridor which was accessible to residents having elopement/wandering behavior of Unit B and Unit C and which exited the nursing facility into the adjoining hospital. The failure allowed this unlocked and unsecured corridor to serve as a route of elopement, or potential route of elopement, for five (5) residents who utilized WanderGuard bracelets for elopement/wandering behavior (#1, #5, #11, #12, and #14), on the survey sample of fourteen (14) residents. Resident #1 exited the nursing facility through this corridor on 02/09/2014, eloped through the adjoining hospital, traveled along a street for a distance of approximately one-half mile, then fell , was transferred to the hospital, and had sustained facial abrasions, a nasal laceration requiring sutures, a nasal fracture, and a fractured right knee cap. An interview was conducted with the Administrator and DON on 02/20/2014 at 11:30 a.m. related to the facility's QA/PI Committee. During this interview, the Administrator was questioned regarding the QA/PI Committee's involvement in the oversight and evaluation of the facility's system for monitoring residents at risk for elopement/wandering, and of the Committee's involvement in the formulation of corrective actions which were developed and implemented as a result of Resident #1's 02/09/2014 elopement. The Administrator presented a written response to the questions posed during this 02/20/2014, 11:30 a.m. interview. In this written response, the Administrator documented that, prior to the elopement incident of 02/09/2014 involving Resident #1, the WanderGuard system had not been presented to the QA/PI Committee as it had not been identified as an issue that needed to be addressed. The Administrator documented that on the night of 02/09/2014, after Resident #1 eloped, the Administrator, DON, and Director of Maintenance met and developed a corrective action plan. However, the Administrator documented that there had been no meeting of the QA/PI Committee related to the 02/09/2014 elopement of Resident #1 until 02/18/2014, and acknowledged that it was not until that date (some nine (9) days after the incident involving Resident #1's elopement and injury) that the QA/PI Committee had conducted an analysis of the elopement of Resident #1, and had reviewed and evaluated the corrective actions, which included procedural changes and staff in-service training, which had been developed and put into place by the Administrator, DON, and Director of Maintenance. No evidence was presented by the facility to indicate that the QA/PI Committee had been involved in the formulation of the corrective action plan, developed and put into place by management staff as a result of the 02/09/2014 elopement of Resident #1, to evaluate the effectiveness of the corrective actions in assuring the supervision of residents at risk for elopement. Instead, this corrective action plan was developed and implemented in the absence of input by the QA/PI Committee, and without oversight by the Committee, prior to plan implementation. By the time the QA/PI Committee met on 02/18/2014 to review the plan of action, originally developed on 02/09/2014 by facility management staff and which involved procedural modifications related to the facility's WanderGuard alert system, 116 of the facility's 118 employees (as documented in the facility's credible allegation of jeopardy removal) had already received inservice training regarding these procedural changes. The immediate jeopardy was determined to have been removed on February 19, 2014, at which time the facility had presented and implemented a credible allegation of jeopardy removal with the following interventions: A. On February 9, 2014, after learning of Resident #1's elopement, the facility conducted a full resident audit to assure the presence of all residents. B. On February 9, 2014, all doors exiting the nursing facility were checked to ensure the proper working order of the WanderGuard alarm system. All existing WanderGuard alarms were functioning properly. C. On February 9, 2014, a procedure was put into place by which a facility employee was placed at the doorway, located in the corridor leading from the nursing facility to the hospital, which was not equipped with a WanderGuard alarm. A scheduled was developed reflecting specific employees who were assigned to be in place at the unalarmed doorway, at specific times and continuously around the clock, until a WanderGuard alarm was installed on the doorway. D. On February 9, 2014, chart audits for all current facility residents were conducted to ensure that all residents who demonstrated a potential for elopement had been accurately identified by the facility. During these chart audits, no new residents were identified to have the potential for elopement. E. On February 9, 2014, Care Plan reviews were conducted for residents assessed to be at risk for elopement to ensure that a comprehensive approach to address this risk was in place. During these Care Plan reviews, no problems were identified. F. On February 9, 2014, in addition to daily WanderGuard bracelet checks completed by the Activities Director which were in place prior to Resident #1's elopement, the facility implemented audits of the door alarms through the preventative maintenance program. The door alarms would be checked weekly, on each Tuesday, by the Maintenance Director, and these door alarm checks would be documented via computer data entry. The door alarm test would include a check of the power indicator light to ensure proper function, and also a check for battery condition. A sensor button was to be used to test each door alarm, with the alarm to sound when within six feet of an alarmed doorway. If a door alarm did not initially sound, the test was to be repeated with a different sensor button. Any deviation from full working order found during these weekly door alarm checks would be reported to the Administrator for immediate correction. The Administrator or DON would monitor the results of these weekly door alarm audits, conducted by the Maintenance Director, by reviewing the computer data entered as a result of the door alarm checks weekly for four (4) weeks, then monthly for three (3) months, then quarterly thereafter. The results of these supervisory audits will be submitted to the Quality Assessment/Performance Improvement (QA/PI) Committee for their review. G. On February 9, 2014, the facility contacted the Medical Director to inform him of the elopement of Resident #1. Additionally, a meeting which consisted of some members of the QA/PI Committee, including the Administrator, DON, and Director of Maintenance, was held to review the elopement event and the actions which had been taken by the facility, and to identify any additional actions that were needed. H. On February 15, 2014, the corridor doorway, which lead from the nursing facility to the hospital and which had previously lacked a WanderGuard alarm, was equipped with a WanderGuard alarm. I. On February 18, 2014, the facility continued to provide staff in-service training to facility staff, including licensed nurses, CNAs, and maintenance/housekeeping staff. This in-service training served to both reinforce current facility protocols involving the routine monitoring of residents having WanderGuard bracelet devices and also to provide staff training on newly-implemented protocols related to the facility's WanderGuard alarm system. As of February 18, 2014, 116 of the facility's total 118 employees had received this in-service training. The two (2) remaining staff members, who were on Family and Medical Leave Act leave at the time this in-service training was provided, will received the training upon their return to work. J. On February 18, 2014, the QA/PI Committee met to review the elopement event involving Resident #1, to review the actions taken by the facility as of that date, and to review the monitoring systems put into place as a result of the elopement. The QA/PI Committee will review the results of WanderGuard bracelet monitoring and door alarm audits weekly for four (4) weeks, then monthly for three (3) months, then quarterly thereafter to ensure ongoing compliance with the systemic measures implemented to correct the identified issue and prevent recurrence. The information will be analyzed by the QA/PI Committee, and subsequent plans of correction will be developed and implemented as needed. This will be an ongoing process. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on February 19, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. On February 9, 2014, the facility implemented a weekly audit of WanderGuard door alarms to be accomplished through the preventative maintenance program by the Maintenance Director. These weekly WanderGuard door alarm audits would check for the proper function of all facility WanderGuard door alarms, and were to be documented via computer data entry. However, these weekly WanderGuard door alarm audits had been initiated only on February 9, 2014, and had occurred only twice prior to the February 20, 2014 exit date of this complaint survey. Therefore, ongoing staff compliance with this newly implemented procedure involving routine, scheduled WanderGuard door alarm monitoring could not be entirely assessed at the time of survey completion, and will thus need future evaluation. Additionally, by February 18, 2014, the facility had completed in-service training for 116 of its 118 facility employees, to include licensed nurses, CNAs, and maintenance/housekeeping staff, regarding both existing and newly-implemented protocols involving the monitoring of residents with WanderGuard bracelets and the WanderGuard alarm system. However, two (2) remaining staff members, who were on leave and had been unavailable for training, will need to receive this training upon returning to work, and this training will thus need future evaluation. Additionally, the QA/PI Committee was to include the review the results of WanderGuard bracelet monitoring and door alarm audits in future meetings, but the Committee had met on On February 18, 2014, only two (2) days prior to the February 20, 2014 exit date of this complaint survey, to begin this process. Thus, the QA/PI Committee's ongoing process of facility procedural oversight could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to the "E" level.

Based on observation, clinical record review, staff interview, hospital ER Triage Record review, and facility Follow-Up Report review, the facility failed to prevent neglect by failing to ensure that the WanderGuard system, utilized by facility staff for the supervision of residents at risk for elopement/wandering behavior on the first floor Units B and C, provided alarm coverage which included a set of unlocked doors located in a first floor corridor which was accessible to Unit B and Unit C residents, and which exited the nursing facility into the adjoining hospital. This failure resulted in neglect by allowing the elopement of one (1) Unit B resident (#1), who was at risk for wandering/elopement and who utilized a WanderGuard bracelet, on the total survey sample of fourteen (14) residents. Resident #1, while wearing a WanderGuard bracelet, was able to access this unsecured first-floor corridor on 02/09/2014, pass through the unalarmed corridor doors, exit the nursing facility through this corridor, enter the adjoining hospital and elope. Resident #1 then fell and hit his/her head on pavement, was taken to the hospital emergency room and found to have facial abrasions, a nasal laceration requiring sutures, a nasal fracture, and a fractured right knee cap. This resulted in a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of the immediate jeopardy on February 18, 2014 at 9:30 a.m. The non-compliance related to the immediate jeopardy was identified to have existed on February 9, 2014 (the date Resident #1 eloped from the facility via a set of unlocked, unalarmed, and unsecured doors located within a corridor which lead from the nursing facility to the adjoining hospital), continued through February 18, 2014, and was removed on February 19, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 18, 2014. During an interview with the Administrator conducted on 02/14/2014 at 11:50 a.m., the Administrator acknowledged Resident #1's nursing facility elopement on 02/09/2014. The Administrator acknowledged that the unlocked corridor doors located in the corridor leading from the nursing facility to the hospital did not have a WanderGuard alarm, and it was thought that Resident #1 had gone through the unalarmed corridor doors, entered the hospital and exited through the front main entrance/exit doors of the hospital. An allegation of jeopardy removal was received on February 19, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 19, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the facility completed a process which involved the retraining, via staff in-service, of available nursing staff related to procedural revisions made to ensure adequate supervision for residents at risk of wandering/elopement, but continued to provide in-service training to staff who were initially unavailable for training, as they reported to work. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of residents requiring supervision related to the risk of elopement/wandering. Observations were made to assess staffs' performance of care and supervision of these residents. Findings include: Resident #1's Minimum Data Set assessment of 02/06/2014 documented [DIAGNOSES REDACTED]. Section C - Cognitive Patterns recorded a Brief Interview for Mental Status score of six (06), indicating severe cognitive impairment. Section E - Behavior documented that Resident #1 had exhibited wandering behavior, and a 01/31/2014 Physician's Interim Orders form specified a WanderGuard bracelet at all times. A Nurse's Notes (NN) entry of 02/09/2014 for the 7:00 a.m.-7:00 p.m. shift documented that Resident #1 was walking up and down the hallways requiring staff redirection, and that the resident had stated "Which way is the way out? I need to get home." The NN documented that at around 3:45 p.m. on 02/09/2014, Resident #1 had been at an activity in the Day Room being assisted by a certified nursing assistant. However, a 02/09/2014, 5:00 p.m. NN documented that a facility nurse received a telephone call from a family member to inform her that Resident #1 had been found with injuries at the roadside, and that Emergency Medical Service (EMS) 911 had been called for hospital transport. The 02/09/2014 hospital ER Triage Record documented that Resident #1 had fallen onto pavement and hit his/her face and forehead. The 02/09/2014 hospital ED Nursing Record (EDNR) documented lacerations/abrasions to Resident #1's face, nose, and forehead, and that the resident had been found by a former neighbor in the highway close to the resident's former home. Resident #1's 02/09/2014 ED Discharge Instructions form documented a laceration repair and injuries which included nasal and right knee patella fractures. A 02/14/2014 facility Follow-Up Report (FR) for Resident #1 documented that Resident #1 was originally admitted to Unit E, a second floor unit, but was moved to first floor Unit B on 02/05/2014 at family request. This FR documented that at 3:45 p.m. on 02/09/2014, Resident #1 was in the Day Room in an activity being assisted by Certified Nursing Assistant (CNA) "BB", who left Resident #1 in the Day Room around 4:05 p.m. This FR documented that Resident #1 then left the Day Room and eloped, sustaining a fall before reaching his/her former home located 0.83 mile from the facility. This FR documented Resident #1's hospital transfer after the elopement and fall, and documented treatment for [REDACTED]. During an observation of Unit B conducted on 02/14/2014 at 12:30 p.m. at the end of the B Hall of Unit B, a corridor turned to the right off of B Hall. Within this corridor which was directly accessible from Unit B, observation revealed a set of double doors which were not locked and did not have a WanderGuard alarm. The corridor within which these unalarmed double doors were located, and which originated at the end of the B Hall of nursing facility Unit B, continued into the hospital which adjoined the nursing facility, and terminated at the main entrance/exit doors located at the front of the hospital. A two lane street was observed to run in front of the hospital/nursing facility buildings. Interview with the Administrator conducted on 02/14/2014 at 11:50 a.m. revealed that Resident #1's former home, close to which the resident was found to have fallen after eloping on 02/09/2014, was located on this street which ran directly in front of the hospital/nursing home facilities. During an interview conducted on 02/14/2014 at 12:48 p.m., the DON stated that Resident #1's Unit B room had been located close to the set of unalarmed corridor doors. The DON stated that, based on investigation, the facility determined that on 02/09/2014, Resident #1 had walked down the corridor off of Unit B, passed through the unalarmed corridor doors, continued walking out of the nursing facility and exited out the front door of the hospital. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard alarm bracelets, and despite Resident #1 having severe cognitive impairment and a known history of wandering requiring a WanderGuard bracelet for supervision, the facility neglected Resident #1 by failing to provide supervision, per the resident's WanderGuard device, to address the resident's risk of elopement. Instead, the facility failed to ensure the placement of a WanderGuard alarm on the set of unlocked double doors located in the corridor leading from Unit B, where Resident #1 resided, and continuing into the hospital located adjacent to the nursing facility. This allowed Resident #1, who utilized a WanderGuard bracelet, to exit through these unalarmed, unlocked corridor double doors without the knowledge of nursing facility staff, to exit through the hospital's front entrance/exit doors and elope from the facility, then to gain access to a street where he/she subsequently fell and sustained facial abrasions, a nasal laceration requiring sutures, a nasal fracture, and a fractured right knee cap. The immediate jeopardy was determined to have been removed on February 19, 2014, at which time the facility had presented and implemented a credible allegation of jeopardy removal with the following interventions: A. On February 9, 2014, after learning of Resident #1's elopement, the facility conducted a full resident audit to assure the presence of all residents. B. On February 9, 2014, all doors exiting the nursing facility were checked to ensure the proper working order of the WanderGuard alarm system. All existing WanderGuard alarms were functioning properly. C. On February 9, 2014, a procedure was put into place by which a facility employee was placed at the doorway, located in the corridor leading from the nursing facility to the hospital, which was not equipped with a WanderGuard alarm. A scheduled was developed reflecting specific employees who were assigned to be in place at the unalarmed doorway, at specific times and continuously around the clock, until a WanderGuard alarm was installed on the doorway. D. On February 9, 2014, chart audits for all current facility residents were conducted to ensure that all residents who demonstrated a potential for elopement had been accurately identified by the facility. During these chart audits, no new residents were identified to have the potential for elopement. E. On February 9, 2014, Care Plan reviews were conducted for residents assessed to be at risk for elopement to ensure that a comprehensive approach to address this risk was in place. During these Care Plan reviews, no problems were identified. F. On February 9, 2014, in addition to daily WanderGuard bracelet checks completed by the Activities Director which were in place prior to Resident #1's elopement, the facility implemented audits of the door alarms through the preventative maintenance program. The door alarms would be checked weekly, on each Tuesday, by the Maintenance Director, and these door alarm checks would be documented via computer data entry. The door alarm test would include a check of the power indicator light to ensure proper function, and also a check for battery condition. A sensor button was to be used to test each door alarm, with the alarm to sound when within six feet of an alarmed doorway. If a door alarm did not initially sound, the test was to be repeated with a different sensor button. Any deviation from full working order found during these weekly door alarm checks would be reported to the Administrator for immediate correction. The Administrator or DON would monitor the results of these weekly door alarm audits, conducted by the Maintenance Director, by reviewing the computer data entered as a result of the door alarm checks weekly for four (4) weeks, then monthly for three (3) months, then quarterly thereafter. The results of these supervisory audits will be submitted to the Quality Assessment/Performance Improvement (QA/PI) Committee for their review. G. On February 9, 2014, the facility contacted the Medical Director to inform him of the elopement of Resident #1. Additionally, a meeting which consisted of some members of the QA/PI Committee, including the Administrator, DON, and Director of Maintenance, was held to review the elopement event and the actions which had been taken by the facility, and to identify any additional actions that were needed. H. On February 15, 2014, the corridor doorway, which lead from the nursing facility to the hospital and which had previously lacked a WanderGuard alarm, was equipped with a WanderGuard alarm. I. On February 18, 2014, the facility continued to provide staff in-service training to facility staff, including licensed nurses, CNAs, and maintenance/housekeeping staff. This in-service training served to both reinforce current facility protocols involving the routine monitoring of residents having WanderGuard bracelet devices and also to provide staff training on newly-implemented protocols related to the facility's WanderGuard alarm system. As of February 18, 2014, 116 of the facility's total 118 employees had received this in-service training. The two (2) remaining staff members, who were on Family and Medical Leave Act leave at the time this in-service training was provided, will received the training upon their return to work. J. On February 18, 2014, the QA/PI Committee met to review the elopement event involving Resident #1, to review the actions taken by the facility as of that date, and to review the monitoring systems put into place as a result of the elopement. The QA/PI Committee will review the results of WanderGuard bracelet monitoring and door alarm audits weekly for four (4) weeks, then monthly for three (3) months, then quarterly thereafter to ensure ongoing compliance with the systemic measures implemented to correct the identified issue and prevent recurrence. The information will be analyzed by the QA/PI Committee, and subsequent plans of correction will be developed and implemented as needed. This will be an ongoing process. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on February 19, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. On February 9, 2014, the facility implemented a weekly audit of WanderGuard door alarms to be accomplished through the preventative maintenance program by the Maintenance Director. These weekly WanderGuard door alarm audits would check for the proper function of all facility WanderGuard door alarms, and were to be documented via computer data entry. However, these weekly WanderGuard door alarm audits had been initiated only on February 9, 2014, and had occurred only twice prior to the February 20, 2014 exit date of this complaint survey. Therefore, ongoing staff compliance with this newly implemented procedure involving routine, scheduled WanderGuard door alarm monitoring could not be entirely assessed at the time of survey completion, and will thus need future evaluation. Additionally, by February 18, 2014, the facility had completed in-service training for 116 of its 118 facility employees, to include licensed nurses, CNAs, and maintenance/housekeeping staff, regarding both existing and newly-implemented protocols involving the monitoring of residents with WanderGuard bracelets and the WanderGuard alarm system. However, two (2) remaining staff members, who were on leave and had been unavailable for training, will need to receive this training upon returning to work, and this training will thus need future evaluation. Additionally, the QA/PI Committee was to include the review the results of WanderGuard bracelet monitoring and door alarm audits in future meetings, but the Committee had met on On February 18, 2014, only two (2) days prior to the February 20, 2014 exit date of this complaint survey, to begin this process. Thus, the QA/PI Committee's ongoing process of facility procedural oversight could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to the "D" level.