Every finding on record at Our Lady of Wisdom Community Care Center

Based on observation, interviews, and record reviews, the facility failed to ensure a resident's aspiration precautions were maintained in order to prevent the possibility of choking during a meal for 1 (Resident #3) of 2 sampled residents observed for meal safety precautions. Findings:Review of the facility's Licensed Staff job description, dated 07/01/2015 with a revision date of 12/03/2019, revealed, in part, a key responsibility of the licensed practical nurse (LPN) was to review the resident's care plans, assure the plans were followed, and ensure the highest degree of quality care was maintained at all times. Further review revealed the LPN supervised the meal service for each resident on the unit. Review of Resident #3's medical record revealed, in part, Resident #3 was admitted to the facility on [DATE] with diagnoses which included left sided hemiplegia (muscle weakness on one side of the body) and hemiparesis (partial paralysis affecting only one side of the body), dysphagia (trouble swallowing), dementia, and cognitive communication deficit. Review of Resident #3's admission Minimum Data Set with an Assessment Reference Date of 06/30/2026 revealed in part, a Brief Interview for Mental Status summary score of 5, which indicated Resident #3 was significantly cognitively impaired. Further review revealed Resident #3's swallowing status indicated Resident #3 was at risk for coughing or choking during meals. Further review revealed Resident #3 required a mechanically altered diet. Review of Resident #3's Speech Evaluation dated 06/25/2026 revealed, in part, Resident #3's overall swallow function was at risk for potential aspiration, and swallow precautions should be reinforced to reduce Resident #3's risk for aspiration. Further review revealed speech therapy recommended to use small bites, alternate bites and sips, and to feed Resident #3 at a slow rate. Review of Resident #3's care plan, with a start date of 07/02/2026, and a target date of 10/14/2026, revealed, in part, Resident #3 had a swallowing problem and was at risk for choking related to dysphagia. Further review revealed the following approaches during meal intake:-Alternate small bites and sips;-Do not use straws;-Instruct Resident #3 to eat slowly; and,-Instruct Resident #3 to chew each bite thoroughly. Observation on 07/30/2026 at 12:07PM of S4LPN feeding Resident #3 in the dining room revealed S4LPN fed Resident #3 with an overfilled spoon of food, and food was observed falling from the spoon on Resident #3 as Resident #3 was eating. Further observation revealed S4LPN continued to feed overfilled spoon portions to Resident #3 without offering fluids, until Resident #3 had consumed approximately 50 percent of the meal. Further observation revealed Resident #3 coughed twice then S4LPN opened a can of cola, placed a straw inside the can, and assisted Resident #3 to drink from the straw. Further observation revealed Resident #3 coughed again, and then proceeded to drink the can of cola from the straw. Further observation revealed S4LPN continued to feed Resident #3 overfilled spoonfuls of food, not providing liquids between bites, and allowed Resident #3 to drink from a straw for the remaining portion of the meal. In an interview on 07/30/2026 at 12:20PM, S3Speech Therapist (ST) indicated Resident #3 was on aspiration precautions due to cognitive decline. S3ST further indicated Resident #3 required small bites of food and should not have been given overfilled spoonfuls of food. S3ST further indicated Resident #3 should have alternated bites and sips of liquids at a slow feeding rate and frequent breaks. In an interview on 07/30/2026 at 12:45PM, S2Director of Nursing was informed of the above mentioned observation and could not offer any explanation as to why S4LPN did not adhere to Resident #3's aspiration precautions. In an interview on 07/30/2026 at 1:00PM, S1Administrator was informed of the above mentioned observation and could not offer any explanation as to why S4LPN did not adhere to Resident #3's aspiration precautions.

Based on observations, interviews, and record reviews, the facility failed to ensure: 1. Kitchen A was maintained in a clean and sanitary manner; 2. The sanitization of dishware and three-compartment sinks were monitored and recorded; and, 3. Food temperatures were monitored and accurately recorded for Kitchen A, Mini-Kitchen X, Mini-Kitchen Y, and Mini-Kitchen Z. This deficient practice was identified for 4 (Kitchen A, Mini-Kitchen X, Mini-Kitchen Y, Mini-Kitchen Z) of 4 kitchens observed for food safety requirements. Findings: Review of the facility's Food Service Manager's job description, with a revision date of 07/01/2015 revealed, in part, the food service manager was responsible for the overall management and operation of the department, including budget control, personnel management, food production, sanitation, equipment operation and related clinical work in accordance with the established policies, procedures and standards of the corporation. 1.Review of the Dietary Services Staff's job description, with a revision date of 07/01/2015 revealed, in part, the dietary area must keep the dietary area in a clean and sanitary condition. Observation on 06/15/2026 at 8:35AM revealed: - A liquid substance on the counter top behind the juice dispenser and coffee machine;- A large dark brown dry substance on the counter next to the coffee maker;- A liquid substance on the floor behind the steamer;- A sticky build-up of dirt and grime on the kitchen floors;- A dried brown substance on the commercial size mixer; and, - A sticky greasy build-up and dust on the stainless steel counter top near the food preparation area. Observation on 06/17/2026 at 10:00AM revealed: - A liquid substance on the counter top behind the juice dispenser and coffee machine;- A sticky build-up of dirt and grime on the kitchen floors;- A dried brown substance on the commercial size mixer; and, - A sticky greasy build-up and dust on the stainless steel counter top near the food preparation area. In an interview on 06/17/2026 at 10:02AM S4Dietary Manager, indicated the kitchen was not kept in a clean and sanitary manner. S4Dietary Manager further indicated there was no cleaning schedule initiated to keep the kitchen clean and sanitary. 2.Review of the facility's dishwashing machine and the three-compartment sink temperature and sanitization logs revealed the logs were incomplete on 06/04/2026, 06/07/2026, 06/10/2026, 06/13/2026, and 06/14/2026. In an interview on 06/17/2026 at 9:50AM, S4Dietary Manager indicated the dishwashing machine and the three-compartment sink temperature and sanitation were not monitored and recorded as required, and it should have been. 3. Review of the facility's Food Preparation and Service policy, with a revision date of 04/2019 revealed, in part, food and nutrition service employees should prepare and serve food in a manner that complies with safe food handling practices. In an interview on 06/15/2026 at 8:48AM, S4Dietary Manager indicated all food temperatures should be checked and recorded for all foods prepared in the kitchen, and should be re-checked and recorded when delivered to each mini-kitchen before being served to residents. Review of the food temperature logs from 06/01/2026 to 06/15/2026 at 9:10AM revealed, in part, the temperature logs were incomplete. Further observation revealed on: -06/02/2026 there were no documented food temperatures for dinner for Mini-Kitchen Y;-06/04/2026 there were no documented food temperatures for lunch for the Kitchen A;-06/06/2026 there were no documented food temperatures for dinner for Mini-Kitchen Y;-06/07/2026 there were no documented food temperatures for breakfast for the Kitchen A; and,-06/07/2026 there were no documented food temperatures for dinner for Mini-Kitchen Y. Surveyor requested copies of the incomplete food temperature logs on 06/15/2026 at 9:15AM. Surveyor requested copies of the incomplete food temperature logs on 06/15/2026 at 9:25AM. Observation on 06/15/2026 at 10:40AM revealed the food temperature logs were left in the conference room for the surveyor. Further review of the food temperature logs revealed the food temperatures that were reviewed as incomplete earlier were now documented as completed. Observation on 06/15/2026 at 12:00PM in Mini-Kitchen Z revealed, in part, lunch was served to residents in the dining area. Review of Mini-Kitchen Z food temperature logs on 06/15/2026 at 12:00PM revealed there were no lunch food temperatures recorded for 06/15/2026. In an interview on 06/15/2026 at 12:07PM S5Dietary Aide, indicated the food temperatures were not checked and recorded before being served to residents, and it should have been. Review of the Mini-Kitchen X food temperature logs on 06/15/2026 at 12:15PM revealed there were no lunch food temperatures recorded for 06/15/2026. In an interview on 06/15/2026 at 12:16PM S6Dietary Aide, indicated the food temperatures were not checked and recorded before being served to residents, and it should have been. Surveyor requested copies of food temperature logs for Mini-Kitchen Z and Mini-Kitchen X on 06/15/2026 at 2:00PM. Review of food temperature logs presented by S4Dietary Manager on 06/15/2026 at 2:10PM for Mini-Kitchen Z and Mini-Kitchen X revealed the logs had documented temperatures that were reviewed as incomplete earlier. In an interview on 06/17/2026 at 9:50AM, S4Dietary Manager indicated the food temperature logs submitted to the surveyor on 06/15/2026 were falsely documented and further indicated the food temperatures were not checked and documented prior to being served to residents on 06/02/2026, 06/04/2026, 06/06/2026, 06/07/2026, and 06/15/2026.

Based on observations, interviews and record review, the facility failed to ensure staff performed hand hygiene while passing ice to residents for 1 (S3Certified Nursing Assistant [CNA]) of 1 CNAs observed passing ice to residents. Findings:Review of the facility's Handwashing/Hand Hygiene Policy and Procedure, revised August 2015 revealed, in part, the use of alcohol based hand rub containing at least 62% alcohol; or, alternatively soap (antimicrobial or non-antimicrobial) and water after contact with objects in the immediate vicinity of a resident and after removing gloves. Observation on 06/15/2026 at 9:25AM, revealed S3CNA exited Room A with gloves on. Further observation revealed S3CNA then entered Room B with the same gloves on that she exited Room A with, dumped water from the water pitcher in the bathroom sink, placed ice in the water pitcher, wiped the table down with sanitizing wipes, and exited the room with the same pair of gloves on without performing hand hygiene. Observation on 06/15/2026 at 9:29AM, revealed S3CNA entered Room C with the same above-mentioned pair of gloves on used in Room A and Room B. S3CNA then delivered ice in the water pitcher and sanitized the bedside table. S3CNA then removed her gloves and disposed of the gloves in the garbage can in Room C before S3CNA exited Room C without performing hand hygiene. In an interview on 06/15/2026 at 9:37AM, S3CNA indicated she should have sanitized or washed her hands after glove removal, and should not have used the same pair of gloves after handling items and passing ice in one resident room before entering another resident room. In an interview on 06/16/2026 at 3:18PM, when asked to explain the process of passing ice, S2Director of Nursing (DON) indicated hands should be washer or sanitized first, gloves should then be put on, scoop ice into the pitcher, and then gloves should be removed before exiting the room. S2DON further indicated hands should be washed or sanitized between residents.

Based on interviews and record reviews, the facility failed to ensure medications were administered timely for 1 (Resident #3) of 4 (Resident #3, Resident #13, Resident #45, Resident #51) sampled residents interviewed for medication administration. Findings: Review of the facility's Medication Administration policy, revised April 2019, revealed, in part, medications are administered in accordance with the prescribers orders; and within 1 hour of the prescribed time, unless otherwise specified. Further review revealed the individual administering the medication records the date and time the medication was administered. Review of Resident #3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/08/2025 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #3 was cognitively intact. Review of Resident #3's clinical record revealed, in part, a diagnoses of insomnia (insomnia is difficulty falling asleep or staying asleep). Review of Resident #3's June 2025 Physician Orders revealed, in part, Doxepin HCl (a medication used to treat insomnia) 10 milligram (mg) capsule take 3 capsules by mouth at bedtime. Review of Resident #3's June 2025 electronic Medication Administration Record (eMAR) revealed, in part, Resident #3's Doxepin HCl was scheduled for administration at 8:00PM. Review of Resident #3's Care Plan, with a target date of 07/01/2025, revealed Resident #3 was on sedative / hypnotic therapy due to insomnia with a documented intervention to administer medications as ordered by the physician. In an interview on 06/24/2025 at 10:00AM, Resident #3 indicated she often does not get her sleeping pill on time and reported her sleeping pill was often not administered until 10:30PM. Review of Resident #3's medication administration audit report dated 06/01/2025 through 06/24/2025, with a run date of 06/24/2025 at 1:42PM Central Standard Time, presented to the surveyor by S2Director of Nursing (DON) revealed, in part, the following: 06/05/2025: Doxepin HCL 30mg was administered at 12:13AM; 06/06/2025: Doxepin HCL 30mg was administered at 9:47PM; 06/09/2025: Doxepin HCL 30mg was administered at 9:36PM; 06/13/2025: Doxepin HCL 30mg was administered at 9:45PM; 06/14/2025: Doxepin HCL 30mg was administered at 2:32AM; 06/15/2025: Doxepin HCL 30mg was administered at 10:39PM; 06/18/2025: Doxepin HCL 30mg was administered at 4:53AM; 06/21/2025: Doxepin HCL 30mg was administered at 9:26PM; 06/22/2025: Doxepin HCL 30mg was administered at 11:22PM; and, 06/23/2025: Doxepin HCL 30mg was administered at 10:38PM. In an interview on 06/24/2025 at 2:50PM, S2DON confirmed the above documented administration times for Resident #3's Doxepin HCl 30mg revealed the medication was administered to Resident #3 more than 1 hour after the scheduled time of 8:00PM, and should not have been.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's pressure ulcer treatment plan was carried out in accordance with the resident's care plan and physician's orders for 1 (Resident #332) of 2 (Resident #87, Resident #332) sampled residents investigated for pressure ulcers. Findings: Review of Resident #332's clinical record revealed, in part, Resident #332 was admitted to the facility on [DATE]. Review of Resident #332's physician order dated 06/18/2025 revealed, in part, an order for bilateral heel protectors while in bed. Review of Resident #332's Minimum Data Set with an Assessment Reference Date of 06/07/2025 revealed, in part, Resident #332 had a Brief Interview for Mental Status score of 13, which indicated Resident #332 was cognitively intact. Further review revealed Resident #332 was dependent on staff for lower body foot wear. Review of Resident #332's care plan created on 06/05/2025, revealed, in part, Resident #332 had a deep tissue injury to the bilateral heels and staff was to apply bilateral heel protectors while in bed. Review of Resident #332's electronic Medication Administration Record for June 2025 revealed, in part, no documented evidence heel protectors were applied to Resident #332's bilateral heels while in bed. Record review revealed there was no documented evidence, and the facility did not present any documented evidence, heel protectors were applied to Resident #332's bilateral heels while in bed as ordered. Observation on 06/23/2025 at 10:34AM revealed Resident #332 was lying in bed and bilateral heel protectors were not applied. Observation on 06/24/2025 at 9:40AM revealed, Resident #332 was lying in bed and bilateral heel protectors were not applied. Further observation revealed Resident #332's bilateral heel protectors were on a shelf in Resident #332's room. In an interview on 06/24/2025 at 9:42AM, Resident #332 indicated staff had not applied his bilateral heel protectors. Observation on 06/24/2025 at 1:40PM revealed Resident #332 lying in bed and bilateral heel protectors were not applied. Further observation revealed Resident #332's bilateral heel protectors were on a shelf on in Resident #332's room. In an interview on 06/25/2025 at 9:31AM, Resident #332 indicated the facility staff had not been putting his heel protectors on. In an interview on 06/24/2025 at 1:26PM, S2Director of Nursing (DON) indicated Resident #332 should have had bilateral heel protectors on as ordered.

Based on observations and interviews, the facility failed to maintain a clean and sanitary environment for 1 (Hall B Mini Pantry) of 3 (Hall A Mini Pantry, Hall B Mini Pantry, Hall C Mini Pantry) of 3 Mini Pantries observed. Findings: Review of the 2022 Food Code United States Food and Drug Administration revealed, in part, heating and air conditioning system vents that are not properly designed and located may be difficult to clean and result in the contamination of food, food preparation surfaces, equipment, or utensils by dust or other accumulated soil from the exhaust vents. Observation of the Hall B Mini Pantry 9:40AM revealed, in part, a portable electric fan with an accumulation of a light gray unknown substance on the fan's grill. In an interview on 06/23/2025 at 9:45AM, S4Food Safety Manager confirmed there was an accumulation of a light gray unknown substance on the portable electric fan's grill in the Hall B Mini Pantry. S4Food Safety Manager further indicated the portable electric fan in the Hall B Mini Pantry should have been kept in a clean and sanitary manner. In an interview on 06/25/2025 at 10:00AM, S1Administrator indicated the portable electric fan in the Hall B Mini Pantry should have been kept in a clean and sanitary manner.

Based on observations, interviews and record reviews, the facility failed to ensure a resident was treated with dignity when staff did not provide incontinence care to a resident as requested prior to meal service. This deficient practice was identified for 2 (Resident #3, Resident #4) of 4 (Resident #1, Resident #2, Resident #3, Resident #4) sampled residents reviewed for resident rights. Findings: Review of the facility's Resident Rights policy statement, revised on 10/2016, revealed, in part, employees should treat residents with respect and dignity. Further review revealed federal and state laws guaranteed certain basic rights to all residents of this facility. Observation on 04/09/2025 at 11:40AM of the Hall z nurse's station revealed, in part, the call light monitor was alarming for Resident #3 and Resident #4 rooms. Further observation revealed at 11:41AM S3Licensed Practical Nurse (LPN) made an announcement on the facility speaker system that staff assistance was needed for Resident #3 and Resident #4 rooms. Further observation of the call system monitor revealed at 11:42AM, Resident #3's call light was no longer alarming, and Resident #4's call light remained activated. Resident #3 Review of Resident #3's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/14/2025 revealed, in part, Resident #3 had a Brief Interview for Mental Status (BIMS) of 15 which indicated Resident #3's cognition was intact. Further review revealed Resident #3 was dependent for transfers and toileting, and was incontinent (loss of bladder or bowel control) of both bladder and bowel. Review of Resident #3's care plan revealed, in part, Resident #3 had a self-care deficit related to mobility impairment and weakness and required total assistance with toileting. Further review revealed Resident #3 was incontinent of bowel and staff was to check Resident #3 for incontinence as needed and provide incontinence care after each incontinent episode. Observation on 04/09/2025 at 11:42AM revealed Resident #3's call light above the doorway of his room was not activated. Further observation revealed he was sitting in his wheelchair in his room with his wife present. In an interview on 04/09/2025 at 11:42AM, Resident #3 indicated the call light had been activated because Resident #3 wanted to be changed before lunch was served. In an interview on 04/09/2025 at 11:43AM Resident #3's wife indicated that a staff member had entered the room, turned off the call light, and stated she would get Resident #3 some help and did not provide incontience care. Observation on 04/09/2025 at 1:21PM revealed S9Certified Nursing Assistnat (CNA) entered multiple resident rooms to remove lunch meal trays. Further observation revealed S9CNA entered Resident #3's room, removed the lunch trays, and did not provide incontinence care. In an interview on 04/09/2025 at 1:40PM, S6MDS Clinical Coordinator indicated she had entered Resident #3's room to address the call light before lunch. S6MDS Clinical Coordinator further indicated Resident #3 had asked to be changed and she then notified Resident #3's nurse and S9CNA per Resident #3's request. In an interview on 04/09/2025 at 1:41PM S9CNA indicated she had been notified by S6MDS Clinical Coordinator of Resident #3's request for personal care, but was informed of the request after the lunch trays had already been passed out to all the residents. S9CNA further indicated incontinence care was not provided to residents during meal service. Resident #4 Review of Resident #4's Admission MDS with an ARD of 01/23/2025 revealed Resident #4 had a BIMS Score of 13 which indicated Resident #4's cognition was intact, and Resident #4 required substantial/maximum assistance with toilet hygiene. Review of Resident #4's care plan revealed, in part, Resident #4 had a self-care deficit related to limited mobility and was total dependent on staff for toilet use. Further review revealed Resident #4 was incontinent of bowel and bladder and staff was to check Resident #4 for incontinence as needed and provide incontinence care after each incontinent episode. Observation on 04/09/2025 at 11:57AM, S8CNA approached Resident #4 who was sitting outside his room in his wheelchair. Resident #4 stated to S8CNA that he still needed to be changed and S8CNA responded with, I am about to push you to the table. Further observation revealed S8CNA pushed Resident #4 to a dining table next to other residents waiting for lunch meal to be served. Observation on 04/09/2025 at 12:15PM revealed Resident #4 was sitting at Hall z dining table with multiple residents eating lunch without receiving incontinence care. In an interview on 04/09/2025 at 1:14PM, Resident #4 indicated he needed his adult brief to be changed and he had asked the CNA to provide incontinence care to him right before he was brought to lunch, as he preferred not to go to lunch without being changed. Resident #4 further indicated that the CNA did not change his adult brief at that time. In an interview on 04/09/2025 at 1:50PM, S6MDS Clinical Coordinator indicated she had entered Resident #4's room before lunch to answer an activated call light. S6MDS Clinical Coordinator further indicated Resident #4 had asked for his adult brief to be changed and she then notified Resident #4's nurse and S8CNA of Resident #4's request. In an interview on 04/09/2025 at 2:15PM, S2Interim Director of Nursing (DON) indicated staff normally did not provide incontinence care to residents during meal times due to infection control concerns. In an interview on 04/09/2025 at 3:33PM, S8CNA acknowledged she heard Resident #4 state he was still waiting to be changed when she was pushing him to Hall z dining room, but did not address him or respond to his needs at that time because he caught me off guard there was too much going on. S8CNA indicated residents were rounded on every 2 hours and CNAs don't typically change residents during meal time. When asked if she would want to sit in stool or urine for 2 or more hours, S8CNA shook her head no in response. In an interview on 04/09/2025 at 3:53PM, S1Administrator indicated he, himself, would not want to sit in stool or urine for 2 hours and/or eat a meal while he, himself, was sitting in stool or urine. S1Administrator indicated staff should have provided incontinence care to Resident #3 and Resident #4 regardless if it was during meal service.

Based on observation, interviews, and record reviews, the facility failed to ensure only licensed personnel administered medications for 1 (Resident #3) of 4 (Resident #1, Resident #2, Resident #3, Resident #4) sampled residents reviewed for nursing services. Findings: Review of the facility's Administering Medications policy revised on 04/2019 revealed, in part, only persons licensed or permitted by the state to prepare, administer and document the administration of medication may do so. Observation on 04/08/2025 at 11:06AM with S10Certified Nursing Assistant (CNA) present revealed an unmarked cup with no identifying information on it was filled to three-quarters capacity which contained a clear ointment located on the shelf inside a cabinet on Hall z. In an interview on 04/08/2025 at 11:10AM, S11CNA indicated she placed the above mentioned medication cup of ointment in the cabinet on Hall z after she obtained the ointment from S4LPN. S11CNA indicated she had applied the ointment in the past to Resident #3's chest, abdomen, and groin. In an interview on 04/08/2025 at 11:23PM, S4Licensed Practical Nurse (LPN) indicated he gave S11CNA Resident #3's ointment so she could apply the ointment topically to Resident #3's dry and itching skin. S4LPN identified the above mentioned ointment was Mometasone Furoate Ointment 0.1% (a steroid cream used to treat skin conditions) and confirmed the ointment was medicated. S4LPN further indicated the facility allowed CNAs to apply medicated ointments. Review of Resident #3's April 2025 Physician Orders revealed, in part, Resident #3 had an order dated 11/15/2023 for Mometasone Furoate External Ointment 0.1% apply topically one time a day for psoriasis (a skin condition that causes dry and itchy skin). In an interview on 04/08/2025 at 12:30PM, S2Interim Director of Nursing (DON) indicated it was not the facility's standard of practice to allow CNAs to apply medicated ointments to residents. In an interview on 04/08/2025 at 12:35PM, S5Minimum Data Set Clinical Coordinator stated CNAs were absolutely not allowed to apply medicated ointments to residents. In an interview on 04/08/2025 at 3:53PM, S1Administrator indicated S4LPN should not have given S11CNA Resident #3's medicated ointment to apply.

Based on observations, interviews and record reviews the facility failed to provide timely incontinence care for 2 (Resident #3, Resident #4) of 4 (Resident #1, Resident #2, Resident #3, Resident #4) sampled residents reviewed for incontinence. Findings: Review of the facility's Resident Rights policy statement, revised on 10/2016, revealed, in part, employees should treat residents with respect and dignity. Further review revealed federal and state laws guaranteed certain basic rights to all residents of this facility. Observation on 04/09/2025 at 11:40AM of the Hall z nurse's station revealed, in part, the call light monitor was alarming for Resident #3 and Resident #4 rooms. Further observation revealed at 11:41AM S3Licensed Practical Nurse (LPN) made an announcement on the facility speaker system that staff assistance was needed for Resident #3 and Resident #4 rooms. Further observation of the call system monitor revealed at 11:42AM, Resident #3's call light was no longer alarming, and Resident #4's call light remained activated. Resident#3 Review of Resident #3's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/14/2025 revealed, in part, Resident #3 had a Brief Interview for Mental Status (BIMS) of 15 which indicated Resident #3's cognition was intact. Further review revealed Resident #3 was dependent for transfers and toileting, and was incontinent (loss of bladder or bowel control) of both bladder and bowel. Review of Resident #3's care plan revealed, in part, Resident #3 had a self-care deficit related to mobility impairment, weakness and required total assistance with toileting. Further review revealed Resident #3 was incontinent of bowel and staff was to check Resident #3 for incontinence as needed and provide incontinence care after each incontinent episode. Observation on 04/09/2025 at 11:42AM revealed Resident #3's call light above the doorway of his room was not activated. Further observation revealed he was sitting in his wheelchair in his room with his wife present. In an interview on 04/09/2025 at 11:42AM, Resident #3 indicated the call light had been activated because Resident #3 wanted to be changed before lunch was served. In an interview on 04/09/2025 at 11:43AM, Resident #3's wife indicated that a staff member had entered the room, turned off the call light, and stated she would get Resident #3 some help. Resident #3's wife stated because Resident #3 required a total lift for transfers in and out of bed, the staff often took a long time to change Resident #3 after incontinent episodes. In an interview on 04/09/2025 at 12:09PM, Resident #3 indicated he had not been changed since he activated the call light at 11:40AM and he had a bowel movement. In an interview on 04/09/2025 at 12:35PM, Resident #3 indicated he had not been changed since he activated the call light at 11:40AM. Observation on 04/09/2025 at 1:21PM revealed S9 Certified Nursing Assistant (CNA) entered multiple resident rooms to remove lunch meal trays. Further observation revealed S9CNA entered Resident #3's room, removed the lunch trays, and did not provide incontinence care. In an interview on 04/09/2025 at 1:40PM, S6MDS Clinical Coordinator indicated she had entered Resident #3's room to address the call light before lunch. S6MDS Clinical Coordinator further indicated Resident #3 had asked to be changed and she then notified Resident #3's nurse and S9CNA per Resident #3's request. In an interview on 04/09/2025 at 1:41PM S9CNA indicated she had been notified by S6MDS Clinical Coordinator of Resident #3's request for personal care, but was informed of the request after the lunch trays had already been passed out to all the residents. S9CNA further indicated incontinence care was not provided to residents during meal service. Observation on 04/09/2025 at 1:50PM revealed Resident #3 was provided incontinence care by S9CNA. Further observation revealed Resident #3 had a bowel movement in his adult brief. Resident #4 Review of Resident #4's Admission MDS with an ARD of 01/23/2025, revealed Resident #4 had a BIMS Score of 13 which indicated that Resident #4's cognition was intact and Resident #4 required substantial/maximal assistance from staff with toilet hygiene. Review of Resident #4's care plan revealed, in part, Resident #4 had a self-care deficit related to limited mobility and was total dependent on staff for toilet use. Further review revealed Resident #4 was incontinent of bowel and bladder and staff was to check Resident #4 for incontinence as needed and provide incontinence care after each incontinent episode. Observation on 04/09/2025 at 11:57AM revealed S8CNA approached Resident #4 who was sitting outside his room in his wheelchair. Resident #4 stated to S8CNA that he still needed to be changed and S8CNA responded with I am about to push you to the table. Further observation revealed S8CNA pushed resident to a dining table next to other residents waiting for lunch meal to be served. Observation on 4/09/2025 at 12:15PM revealed Resident #4 sitting at Hall z dining table with multiple residents eating lunch. In an interview on 04/09/2025 at 1:14PM, Resident #4 indicated he needed his brief to be changed and he had asked the CNA to change his brief right before he was brought to lunch, as he preferred not to go to lunch without being changed. Resident #4 further indicated the CNA did not change his brief at that time and stated they (CNAs) will change me when they get around to it, I have just learned to live with it. Observation on 04/09/2025 at 1:38PM revealed Resident #4 activated his call light and the light came on above the doorway to his room. Observation on 04/09/2025 at 1:41PM revealed S8CNA entered Resident #4's room and Resident #4 asked S8CNA to change him. Further observation revealed S8CNA told Resident #4 that she had to go get help and left the room. In an interview on 04/09/2025 at 1:50PM, S6MDS Clinical Coordinator indicated she had entered Resident #4's room before lunch to answer an activated call light. S6MDS Clinical Coordinator further indicated Resident #4 had asked for his adult brief to be changed and she then notified Resident #4's nurse and S8CNA of Resident #4's request. Observation on 04/09/2025 of Hall z revealed Resident #4 was within Surveyor's eyesight from 11:40AM - 2:25PM and was not provided incontinence care until 2:10pm. In an interview on 04/09/2025 at 2:15PM, S2Interim Director of Nursing (DON) indicated staff normally did not provide incontinence care to residents during meal times due to infection control concerns. In an interview on 04/09/2025 at 3:33PM, S8CNA acknowledged she heard Resident #4 state he was still waiting to be changed when she was pushing him to Hall z dining room, but did not address him or respond to his needs at that time because he caught me off guard there was too much going on. S8CNA indicated residents were rounded on every 2 hours and CNAs don't typically change residents during meal. When asked if she would want to sit in stool or urine for 2 or more hours, S8CNA shook her head no in response. In an interview on 04/09/2025 at 3:53PM, S1Administrator indicated he, himself, would not want to sit in stool or urine for 2 hours and/or eat a meal while he, himself, was sitting in stool or urine. S1Administrator indicated staff should have provided incontinence care to Resident #3 and Resident #4 regardless if it was during meal service.

Based on observations, interviews, and record reviews, the facility failed to ensure medicated ointments and/or lotions were stored in a locked compartment and only accessible to authorized personnel for 2 random observations made 1 of 2 days while onsite. Findings: Review of the facility's Medication Storage policy and procedure revised on 11/2020 revealed, in part, drugs and biologicals used in the facility are stored in locked compartments and only persons authorized to prepare and administer medications have access to locked medications. Observation on 04/08/2025 at 10:27AM revealed a bottle of Ammonium Lactate Lotion 12% (a medicated lotion used to treat skin conditions) was found sitting on a shelf, inside of an unlocked supply cabinet on Hall y, that was accessible to residents, visitors and unauthorized personnel. Further observation revealed parts of the prescription label had been removed and there was no identifiable resident specific information or prescription number. In an interview on 04/08/2025 at 10:28AM, S7MDS Clinical Coordinator indicated she could not say why the bottle of Ammonium Lactate Lotion 12% was placed in the unlocked supply cabinet on Hall y. Observation on 04/08/2025 at 11:06AM with S10Certified Nursing Assistant (CNA) present revealed a medication cup 3/4 filled with a clear ointment located on the shelf inside an unlocked cabinet on Hall z. Further observation revealed there was no identifying information on the medication cup containing the clear ointment. In an interview on 04/08/2025 at 11:06AM, S10CNA indicated she did not know why the medication cup containing ointment was placed into the supply cabinet on Hall z. S10CNA further indicated the medication cup containing ointment should not have been placed inside the unlocked and unattended supply cabinet on Hall z. In an interview on 04/08/2025 at 11:10AM, S11CNA indicated she placed the medication cup of ointment in the cabinet on Hall z. S11CNA further indicated she placed the ointment in the cabinet because she wasn't able to apply the ointment to the resident at the time and she thought the unlocked cabinet on Hall z was a safe place to store the ointment. In an interview on 04/08/2025 at 11:23PM, S4Licensed Practical Nurse (LPN) indicated he gave S11CNA Resident #3's ointment to be applied topically. S4LPN indicated the ointment was Mometasone Furoate Ointment 0.1% (a steroid cream used to treat skin conditions) and confirmed the ointment was medicated. Review of Resident #3's April 2025 Physician Orders revealed, in part, Resident #3 had an order dated 11/15/2023 for Mometasone Furoate External Ointment 0.1% apply topically one time a day for psoriasis (a skin condition that causes dry and itchy skin). In an interview on 04/09/2025 at 3:53PM, S1Administrator indicated the medicated ointment and lotion mentioned above should have been in a locked compartment and should not have been stored in a supply cabinet on the halls

Based on observation, interviews, and record review the facility failed to ensure a staff member removed gloves and used proper hand hygiene when performing incontinent care for 1(Resident #R1) of 2 (Resident #R1, Resident #2 observed for incontinent care. Findings: Review of the facility's Infection Control policy and procedure, dated 2001 and revised on 10/2018, revealed, in part, the objectives of our infection control policies and practices were to: prevent, detect, investigate, and control infections in the facility. Observation on 02/18/2025 at 11:45AM revealed S2Certified Nurse Assistant (CNA) unfastened Resident #R1's adult brief while wearing gloves, but did not remove those gloves and S2CNA did not use proper hand hygiene before obtaining a clean wipe to clean Resident #R1's buttock. In an interview on 02/18/2025 at 11:55AM, S2CNA acknowledged she should have removed her dirty gloves and performed hand hygiene before using a clean cleansing wipe to perform incontinent care to Resident #R1. In an interview on 02/18/2025 at 12:00PM, S1Director of Nursing (DON) acknowledged S2CNA should have removed her dirty gloves, performed hand hygiene and applied clean gloves.

Based on record reviews, observations, and interviews, the facility failed to: 1. Ensure food was not expired and stored in a sanitary manner. 2. Ensure a carton of nutritional supplement was stored per manufacturer's guidelines and was not available for consumption. Findings: 1. Observation on [DATE] at 9:42 a.m. of storage pantry revealed, in part, the following: two 27-ounce (oz.) packages of refried beans with an expiration date of [DATE]; a one-gallon container of taco sauce with an expiration date of [DATE]; one 24 oz. container of bread crumbs with an expiration date of [DATE]; and one-gallon container of red enchilada sauce with an expiration date of [DATE]. In an interview on [DATE] at 9:42 a.m., S7Food Service Manager confirmed the two packages of refried beans; breadcrumbs, enchilada sauce, and taco sauce were all expired. Observation on [DATE] at 9:45 a.m., revealed an opened undated one-gallon container of blue cheese dressing. Further observation revealed the rim and the outside of the blue cheese-dressing container had an unidentified creamy substance with an unidentified green fuzzy substance. Observation also revealed an undated open box of small pastries which was not labeled. In an interview [DATE] at 9:45 a.m., S7Food Service Manager confirmed the presence of the unidentified substance and confirmed it was not stored in a sanitary manner. S7Food Service Manager further confirmed there should not have been expired food on the shelves. S7Food Service Manager also confirmed the box of pastries should have been properly dated and labeled. In an interview on [DATE] at 9:50 a.m., S1Administrator confirmed there should not have been any expired food in the kitchen area. 2. In an interview on [DATE] at 12:21 p.m., S5Licensed Practical Nurse (LPN) indicated the Med Pass 2.0 nutritional supplement was already opened on Medication cart X when she arrived for her shift today at 7:00 a.m. S5LPN further indicated she was unaware of the time the Med Pass 2.0 nutritional supplement on medication cart X was opened. Observation on [DATE] at 12:53 p.m. revealed an opened unrefrigerated carton of Med Pass 2.0 nutritional supplement on medication cart X. Further observation revealed the carton had an opened date of [DATE] but did not indicate a time the carton was opened. Review of Med Pass 2.0 nutritional supplement's directions revealed, in part, the product should be used within 4 hours of opening if not refrigerated. In an interview on [DATE] at 12:53 p.m., S5LPN confirmed the Med Pass 2.0 nutritional supplement on medication cart X had not been refrigerated. In an interview on [DATE] at 1:47 p.m., S2Director of Nursing (DON) confirmed the carton of Med Pass 2.0 nutritional supplement on medication cart X should have been labeled with a date and time the supplement was opened. S2DON further indicated the nursing staff should ensure the Med Pass 2.0 nutritional supplement was discarded 4 hours after being opened if not refrigerated. S2DON confirmed the opened and unrefrigerated Med Pass 2.0 nutritional supplement should not have been on medication cart X and available for use. 49753

Based on record review and interview the facility failed to ensure the Resident's right to formulate an advanced directive was properly reflected in the Resident's medical record for 1 (Resident #335) of 28 (Resident #5, Resident #15, Resident #20, Resident #27, Resident #32, Resident #35, Resident 37, Resident #40, Resident #41, Resident #46, Resident #49, Resident #58, Resident #59, Resident #63, Resident #82, Resident #83, Resident #88, Resident #89, Resident #93, Resident #94, Resident #95, Resident #102, Resident #103,Resident #104, Resident #205, Resident #255, Resident #355) sampled residents reviewed for advanced directives. Findings: Review of Resident #355's EMR (electronic medical record) revealed Resident #355 was admitted to the facility on [DATE]. Review of Resident #355's [DATE] Physician's Orders revealed, in part, a copy of a signed order in the medical record dated [DATE] for Cardio Pulmonary Resuscitation (CPR). Review of Resident #355's [DATE] Physician's Orders in the Electronic Medical Record (EMR) revealed, in part, an order dated [DATE] for Do Not Resuscitate (DNR). In an interview on [DATE] at 10:57 a.m., S3MDS Nurse confirmed there was an order dated [DATE] for Resident #355 to be Full Code in the physical chart, while there was an order dated [DATE] in the EMR for Resident #355 to be DNR. S3MDS further indicated there should not be a discrepancy in Resident #355's code status orders. In an interview on [DATE] at 11:47 a.m., S2Director of Nursing (DON) agreed there should not have been a discrepancy in Resident #355's code status orders.

Based on record reviews, observations and interviews, the facility failed to ensure a resident's percutaneous endoscopic gastrostomy (PEG) tube (a tube that goes directly into the stomach to receive nutrition) feeding pole was in safe operating condition for 1 (Resident #46) of 3 (Resident #15, Resident #37, and Resident #46) sampled residents reviewed for environment. Findings: Review of Resident #46's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/28/2024 revealed, in part, Resident #46 was dependent on staff for all Activities of Daily Living (ADL's) and received all nutrition per PEG tube. Observation on 06/24/2024 at 09:50 a.m., revealed Resident #46 was in bed and Resident #46's PEG tube was attached to the feeding pump and pole which held a bag of formula and a bag of water. Further review revealed the PEG tube feeding pole, the feeding pump, and the bags of formula and water leaned to the side and swayed back and forth when touched. In an interview on 06/25/2024 at 11:11 a.m., S10CNA indicated broken equipment should be placed out of service. Observation on 06/25/2024 at 12:15 p.m. revealed Resident #46 was in bed and Resident #46's PEG tube was attached to the feeding pump and pole which held a bag of formula and a bag of water. Further review revealed the PEG tube feeding pole, the feeding pump, and the bags of formula and water leaned to the side and swayed back and forth when touched. Observation on 06/26/2024 at 10:45 a.m. revealed Resident #46 was in bed and Resident #46's PEG tube was attached to the feeding pump and pole which held a bag of formula and a bag of water. Further review revealed the tube feeding pole, the feeding pump, and the bags of formula and water leaned to the side and swayed back and forth when touched. Observation on 06/27/2024 at 1:45 p.m. revealed Resident #46 was in bed and Resident #46's PEG tube was attached to the feeding pump and pole which held a bag of formula and a bag of water. Further review revealed the tube feeding pole, the feeding pump, and the bags of formula and water leaned to the side at an angle and swayed back and forth when touched. In an interview on 06/27/2024 at 2:40 p.m., S2Director of Nursing (DON) confirmed Resident #46's PEG tube feeding pole leaned to the side significantly and should not have been leaning. S2DON further indicated the nursing staff should have removed Resident #46's PEG tube feeding pole. S2DON further indicated Resident # 46's PEG tube feeding pole was unstable and had the potential to fall over.

Based on record reviews and interviews, the facility failed to maintain an accurate count of the disposition of controlled medications for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for pharmaceutical services. Findings: Review of the facility's Controlled Substance policy and procedure with a revised date of 10/06/2023 revealed, in part, when a resident's medication was not given the medication shall be destroyed and may not be returned to the container. The destruction of the medication shall be witnessed by 2 nurses and identified on the resident's individual narcotic record. Further review revealed the Director of Nursing (DON) services shall investigate any discrepancies in narcotic reconciliation to determine the cause. Review of Resident #1's Medication Administration Record (MAR) for May 2024 revealed, in part, Resident #1 had an order for Norco (Hydrocodone -Acetaminophen) 5-325 milligrams (mg) (a medication used to treat pain) give one tablet by mouth every 8 hours for pain. Review of Resident #1's Individual Resident Controlled Substance Record dated 04/19/2024 for Hydrocodone-Acetaminophen 5-325 mg revealed, in part, on 04/24/2024 at 8:00 p.m. the amount of tablets on hand was 42, the amount of tablets administered was 1, and the amount of tablets remaining was 40. Further review revealed on 05/16/2024 S1DON documented the disposition of remaining doses; the quantity of doses transferred to a federally approved waste receptacle was 0. In an interview on 05/22/2024 at 3:02 p.m., S1DON confirmed Resident #1's Individual Resident Controlled Substance Record for Hydrocodone-Acetaminophen 5-325mg tablets had a discrepancy for the quantity of tablets administered to Resident #1 on 04/24/2024. S1DON indicated one Hydrocodone-Acetaminophen 5-325mg tablet was wasted by the nurse but was not documented on Resident #1's Individual Resident Controlled Substance Record and it should have been.

Based on observation, interview and record review, the facility failed to ensure the Infection Preventionist established and maintained an effective infection prevention and control program to prevent the transmission of COVID-19 infections in the facility by: 1.)failing to ensure staff quarantined and tested a resident (Resident #3) upon symptom onset of COVID-19; 2.)failing to ensure staff quarantined a resident ( Resident #27) who tested positive for Covid-19;and 3.)failing to ensure staff used personal protective equipment (PPE) with COVID-19 positive residents (Resident #3 and Resident #27). This deficient practice resulted in an Immediate Jeopardy situation on 05/28/2023 at 11:30 a.m. when Resident #3 who displayed symptoms of COVID-19 and was not quarantined or tested by the facility. The Immediate Jeopardy situation continued for the following: On 05/31/2023 at 11:46 a.m., when Resident #27 tested positive for COVID-19 and was not placed on quarantine until 1:17p.m. On 05/31/2023 at 12:43 p.m. S23Agency Certified Nursing Assistant (CNA) entered Resident #27's, a symptomatic COVID-19 positive resident's room without a gown, gloves, or face shield in place. On 05/31/2023 at 1:02 p.m. S24Housekeeper entered Resident #27's room to deliver a clothing item without a gown, gloves, or face shield in place and then entered the housekeeping closet to stock her housekeeping cart. On 5/31/2023 at 1:33 p.m. S4LPN exited Resident #3's, a symptomatic COVID-19 positive resident, room with a contaminated yellow gown in her hands and entered Hall Y Dayroom. Resident #59 and Resident #74 tested positive for COVID-19 on 06/04/2023. As of 06/06/2023, there were 4 active resident COVID-19 cases in the facility. S1Administrator was notified of the Immediate Jeopardy on 06/01/2023 at 4:48 p.m. The Immediate Jeopardy was removed on 06/04/2023 at 4:03 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit, which included: 1. Resident #3 was placed on isolation precautions on 05/30/2023 and Resident #27 was placed on isolation precautions on 05/31/2023. This was completed on 05/31/2023. 2. The other 86 residents residing in the facility had the potential to be affected. In order to keep the current resident population free from contracting COVID-19, S2Director of Nursing (DON) and S3Assistant Director of Nursing/Infection Preventionist (ADON/IP) were educated on 06/02/2023 regarding Infection Control policies and procedures and Infection Surveillance policies by the consultant nurse. This was completed on 06/02/2023. On 05/31/2023 S2DON, S3ADON/IP and Nursing Administration conducted broad based testing of all residents and onsite staff. Resident #27 tested positive for COVID-19 and was placed on isolation precautions on 5/31/2023. Broad based testing was repeated on 06/02/2023 with all tests being negative. Broad based testing conducted by S2DON, S3ADON/IP, and Nursing Administration would continue every 3 days until test results were negative for a two week period. This began on 05/31/2023 and would end once all negative tests were obtained for two weeks. 3. In order to keep the current resident population free from contracting COVID-19, S2DON and S3ADON/IP were educated on 06/02/2023 regarding Infection Control policies and procedures and Infection Surveillance policies by the consultant nurse. This was completed on 06/02/2023. On 05/31/2023 S2DON, S3ADON/IP, and Nursing Administration conducted broad based testing of all residents and onsite staff. Resident #27 tested positive for COVID-19 and was placed on isolation precautions on 5/31/2023. Broad based testing was repeated on 06/02/2023 with all tests negative. Broad based testing conducted by S2DON, Infection negative for two week period. This began on 05/31/2023 and would end once all negative tests are obtained for two weeks. Responsible Employee: S3ADON/IP was responsible for ensuring that Infection Control policies and procedures and Infection Surveillance policies were implemented, and that staff were inserviced and monitored for adherence to the policies and procedures that prevented the transmission of COVID-19. S2DON would provide oversight of S3ADON/IP to ensure compliance of the Infection Prevention and Control Program. 4. S2DON and/or Designee would conduct 10 random interview audits of staff from both shifts that ensured knowledge of COVTD-19 symptoms 3 times a week for 4 weeks, then 2 times a week for 4 weeks, then as deemed necessary by the QAPI Committee. This began on 06/03/2023 and will end on 07/29/2023. S2DON and/or Designee would conduct 10 random visual audits that ensured the proper use of transmission-based precautions including the use of personal protective equipment (PPE) with COVID-19 positive residents in accordance with CDC guidelines 3 times a week for 4 weeks, then 2 times a week for 4 weeks, then as deemed necessary by the QAPI Committee. This began on 06/03/2023 and will end on 07/29/2023. S2DON would conduct documentation audits of broad based testing on 10 random residents 3 times per week for 4 weeks, then 2 times per week for weeks, then as deemed necessary by the QAPI Committee. This began on 06/03/2023 and will end on 07/29/2023. Results of audits and surveillance would be reviewed weekly by the QAPI Committee, and any identified issues would be addressed with re-education, plan modification and progressive discipline. This was completed on 06/03/2023. This deficient practice had the potential to cause serious injury, harm, or death for the remaining 86 non-positive COVID-19 residents residing in the facility who were at risk for contracting COVID-19. Findings: Cross reference F880. In an interview on 05/31/2023 at 2:36 p.m., S3ADON/IP stated COVID-19 testing was currently being completed on all residents in the facility and would not be completed again until 06/03/2023.S3ADON/IP further stated she had not interviewed Resident #3 and she was unaware of when her COVID-19 symptoms began. In an interview on 05/31/2023 at 3:57 p.m., S3ADON/IP stated personal protective equipment(PPE) and COVID-19 isolation signage should be placed on a COVID-19 positive resident's door immediately and all staff should be made aware. S3ADON/IP further stated staff should wear a face shield, gown, N95 mask, and gloves prior to entering a COVID-19 isolation room and all PPE should be removed prior to exiting a COVID-19 isolation room. S3ADON/IP further stated PPE and COVID-19 isolation signage should be placed on a COVID-19 positive resident's door immediately and all staff should be made aware. S3ADON/IP further stated she had not read the updated infection control guidelines issues on 05/11/2023 and she was unaware of any of the new regulations. In an interview on 06/01/2023 at 11:46 a.m., S2DON stated staff should never enter a COVID-19 positive Resident's room without PPE in place and should never exit a COVID-19 positive residents room with contaminated PPE on their person. S2DON further stated the observations reflected above puts the facility at risk for a facility wide COVID-19 outbreak. S2DON further stated Resident #27 should have been placed on COVID-19 precautions immediately following her positive COVID-19 test. In an interview on 06/06/2023 at 12:15 p.m., S2DON confirmed Resident #3 should have been tested for COVID-19 and placed in quarantine immediately upon the onset of COVID-19 symptoms. S2DON further stated if the facility had acted upon Resident #3's symptoms on 05/28/2023 when they began, the facility could have implemented precautions to prevent Resident #27, Resident #59, and Resident #74 from contracting COVID-19. In an interview on 06/02/2023 at 11:25 a.m., S2DON confirmed it was S3ADON/IP's responsibility to educate herself on the new regulations for infection control. S2DON further confirmed the infection control program was S3ADON/IP's responsibility. S2DON further stated the actions stated in the above interviews were S3ADON/IP's responsibility and S3ADON/IP should have ensured the proper infection control practices were implemented.

46683 Based on record review, observations, and interviews, the facility failed to provide supervision to prevent elopement for 2 (Resident #38 and Resident #71) of 4 (Resident #38, Resident #70, Resident #71, and Resident #83) sampled residents reviewed for elopement. This deficient practice resulted in an Immediate Jeopardy situation on 01/08/2023 at 4:40 p.m. when Resident #71, an unsupervised resident identified as an elopement risk, eloped from the facility and was found in the facility's parking lot by staff. The continued failure to provide adequate supervision resulted in the immediate jeopardy continuing on 02/16/2023 at 10:35 p.m. when Resident #38, who was identified as an elopement risk and had severe cognitive impairment, eloped from the facility and was found in the facility's parking lot by a security guard. S1Administrator was notified of the Immediate Jeopardy on 06/01/2023 at 4:48 p.m. The Immediate Jeopardy was removed on 06/03/2023 at 1:56 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit, which included: 1. On 06/01/2023 a designated employee was trained by S1Administrator and assigned to provide supervision for Resident #37 and Resident #71 to keep them free of elopement and Resident #37's and Resident #71's Plan of Care was updated by the Minimum Data Set (MDS) Assessment nurse to reflect supervision. Completion: 06/02/2023. 2. On 06/02/2023 an MDS/CCC: Risk of Elopement Wandering Review was completed by facility MDS Assessment nurses on all current residents to identify other residents that may be affected due to being at risk to elope. 10 residents were identified at risk for elopement and were assigned a designated employee trained by S1Administrator to provide visual supervision at all times to keep them free of elopement and their Plans of Care were updated by a MDS Assessment nurse to reflect supervision. Completion: 06/02/2023. On 06/02/2023 and 06/03/2023 Nursing Administration identified the 10 residents identified as a wandering risk by placing over bed signage of a W. Completion: 06/02/2023 On 06/02/2023 Nursing Administration was educated on completing MDS/CCC: Risk of Elopement Wandering Review with the admission, readmission, quarterly, significant change in condition and annual MDS by a consultant nurse. Completion: 06/02/2023. On 06/02/2023 the S1Administrator and Nursing Administration were educated on ensuring the 10 residents identified as at risk for elopement had adequate supervision with a designated employee trained by S1Administrator and assigned to provide supervision by consultant nurse. Completion: 06/02/2023. Beginning on 06/01/2023 and continuing on 06/02/2023 and 06/03/2023 all onsite staff and onsite contracted agency staff were received in-service training conducted by MDS Assessment Nurses and Nursing Administration in regards to residents at risk for wandering have been identified by a W posted on the wall above their bed and in an Elopement Binder accessible to all staff and contracted agency staff at each nurses station, which contained a document with each residents name and picture and a photo document kept was located at the receptionist desk, also easily accessible by all staff and contracted agency staff. Start Date: 06/01/2023 End Date: 07/01/2023. Moving forward, staff and contracted agency staff that have not been inn-serviced already, will receive in-service training as they are scheduled to work and also called in for training. Facility staff and contracted agency staff will not be allowed to work until the training will be completed. 100% compliance will be obtained by 07/01/2023. Start Date: 06/01/2023 End Date: 07/01/2023. On 06/02/2023 a Patient Wandering system designed to secure facility egresses to prevent residents at risk for eloping from exiting the facility was ordered and will be installed upon delivery. Once the Patient Wandering system is installed and staff are in-serviced on use of the system, the monitoring of residents at risk for elopement by the trained designated employee may be discontinued as advised by Quality Assurance and Process Improvement (QAPI) Committee. Start Date: 06/03/2023 End Date: 07/01/2023; 3. On 06/02/2023 Nursing Administration was educated on completing MDS/CCC: Risk of Elopement Wandering Review with the admission, readmission, quarterly, significant change in condition and annual MDS by consultant nurse. Completion: 06/02/2023. On 06/02/2023 S1Administrator and Nursing Administration were educated on ensuring residents identified as at risk for elopement had adequate supervision with a trained designated employee assigned to provide supervision by consultant nurse. Completion: 06/02/2023. Beginning on 06/01/2023 and continuing on 06/02/2023 and 06/03/2023 all onsite staff and onsite contracted agency staff were received in-service training conducted by MDS Assessment Nurses and Nursing Administration in regards to residents at risk for wandering have been identified by a W posted on the wall above their bed and in an Elopement Binder accessible to all staff and contracted agency staff at each nurses station which contains a document with each resident's name and picture and the photo document kept is located at the receptionist desk, also easily accessible by all staff and contracted agency staff. Start Date: 06/01/2023 End Date: 07/01/2023. Moving forward staff and contracted agency staff that have not been in-serviced already, will receive in-service training as they are scheduled to work and also called in for training. Facility staff and contracted agency staff will not be allowed to work until the training is completed. 100% compliance will be obtained by 07/01/2023. Start Date: 06/01/2023 End Date: 07/01/2023. On 06/02/2023 a Patient Wandering system designed to secure facility egresses to prevent identified residents at risk for elopement from exiting the facility was ordered and will be installed upon delivery. Once the Patient Wandering system is installed and staff are in-serviced on use of the system, the monitoring of residents at risk for elopement by trained designated employee may be discontinued as advised by QAPI Committee; 4. S1Administrator, S2Director of Nursing (DON) and/or Designee will conduct 5 random chart audits of residents who have been admitted , readmitted , had quarterly or annual MDS review, or significant change in condition for completion of MDS/CCC: Risk of Elopement Wandering Review. Administrator and/or Designee will conduct visual audits for the presence of trained designated employee supervising residents identified as at risk for elopement and documentation review audits for all residents identified as at risk for elopement. These audits will occur 3 times a week for 4 weeks, then 2 times a week for 4 weeks, then as deemed necessary by the QAPI Committee. Begin Date: 06/03/2023 End Date: 07/01/2023 Results of audits including tracking and trends will be reviewed weekly in QAPI meeting, and any identified issues will be addressed with re-education, plan modification and progressive discipline; and, 5. Completion Date: 06/03/2023. The deficient practice had the likelihood to cause serious harm to the remaining 8 residents identified as elopement risks by the facility. Findings: Review of the facility's Wandering Resident Policy and Procedure revealed, in part, it is the policy of the facility to identify residents who walk or wheel about unrestricted and are a threat to leave the facility unattended due to their confusion, the purpose is to ensure the resident's safety utilizing the least restrictive means necessary. Resident #71 Review of the facility's Incident Report entered on 01/08/2023 at 7:58pm revealed, in part, Resident #71 was found outside the facility's back door near the dumpster. Further review revealed staff on the unit were in another resident's room at the time Resident #71 had gotten outside. Review revealed Resident #71 had pushed the push release paddle, opened the door while in her wheelchair, and exited the facility. Further review revealed the door did not have an alarm. Review of Resident #71 medical record revealed Resident #71 admitted to the facility initially on 12/03/2020 with a readmitted [DATE] with a diagnosis of Dementia. Review of Resident #71's Quarterly Minimum Data Set (MDS) dated [DATE] revealed in part, Resident #71 had a BIMS (Brief Interview Mental Status) score of 5 indicating severe cognitive impairment. Further review revealed, Resident #71 used a wheelchair as her mobility device. Review of Resident #71 current Comprehensive Care plan revealed, in part, Resident #71 was care planned for being at risk for elopement related to wandering and attempting to leave the facility unsupervised with interventions that included alarms placed on exit doors, observe Resident #71's location every hour daily, and Monitor Resident #71's location every 2 hours on even hours. Review of Resident #71's current physician orders revealed, in part, an order with a start date of 02/17/2023 that read Resident #71 was an elopement risk and needed to be rounded on every 2 hours on the even hours. Review of Resident #71's Electronic Medication Administration Record (eMAR) for February 2023 revealed documentation for rounds completed on Resident #71 every 2 hours on even hours that started on 02/17/2023 at 7:00pm. Further review revealed no documentation on 02/17/2023 for the time of 7:00 p.m., on 02/19/2023 for the time of 7:00 p.m, on 02/23/2023 for the time of 7:00 p.m, and on 02/25/2023 for the time of 7:00 a.m. Review of Resident #71's March 2023 eMAR revealed, in part, an order that stated elopement risk: round on resident every 2 hours on even hours every day and night shift. Further review revealed it was documented from 03/01/2023 through 03/31/2023 on once each shift for the 8:00 a.m-8:00 p.m. shift and once each shift for the 8:00 p.m.-8:00 a.m. Review of Resident #71's April 2023 eMAR revealed, in part, an order that stated elopement risk: round on resident every 2 hours on even hours every day and night shift. Further review revealed it was documented from 04/01/2023 through 04/30/2023 on once each shift for the 8:00 a.m-8:00 p.m. shift and once each shift for the 8:00 p.m.-8:00 a.m. Review of Resident #71's May 2023 eMAR revealed, in part, an order that stated elopement risk: round on resident every 2 hours on even hours every day and night shift. Further review revealed it was documented 05/01/2023 through 05/31/2023 on once each shift for the 8:00 a.m-8:00 p.m. shift and once each shift for the 8:00 p.m.-8:00 a.m. Review of Resident #71's Documentation Survey Report Form for February 2023 revealed documentation for rounds completed on Resident #71 every 2 hours on odd hours that started on 02/17/2023 at 7:00 a.m. that were documented once a shift at 7:00 a.m. and 7:00 p.m. Further review revealed no documentation on 02/17/2023 for the time of 7:00 a.m., on 02/19/2023 for the time of 7:00 p.m, on 02/23/2023 for the time of 7:00 p.m, and on 02/25/2023 for the time of 7:00 a.m. Review of Resident #71's Documentation Survey Report Form for March 2023 revealed documentation for rounds completed on Resident #71 every 2 hours on odd hours were documented once a shift at 7:00 a.m. and 7:00 p.m. Further review revealed no documentation on 03/03/2023 for the time of 7:00 p.m., on 03/11/2023 for the time of 7:00 p.m., on 03/13/2023 for the time of 7:00 a.m. and 7:00 p.m., and on 03/21/2023 for the time of 7:00 p.m. Review of Resident #71's Documentation Survey Report Form for April 2023 revealed documentation for rounds completed on Resident #71 every 2 hours on odd hours were documented once a shift at 7:00 a.m. and 7:00 p.m. Further review revealed no documentation on 04/08/2023 for the time of 7:00 p.m. and on 04/28/2023 for the time of 7:00 p.m. Review of Resident #71's Documentation Survey Report Form for May 2023 revealed documentation for rounds completed on Resident #71 every 2 hours on odd hours were documented once a shift at 7:00 a.m. and 7:00 p.m. Further review revealed no documentation on 05/03/2023 for the time of 7:00 p.m., on 05/12/2023 for the time of 7:00 a.m. and 7:00 p.m., on 05/17/2023 for the time of 7:00 p.m., 05/19/2023 for the time of 7:00 p.m., 05/22/2023 for the time of 7:00 p.m., 05/26/2023 for the time of 7:00 p.m., 05/27/2023 for the time of 7:00 a.m., and on 05/31/2023 for the time of 7:00 p.m. Review of Resident #71's nurse's notes revealed a nurses note with a date of 01/08/2023 at 4:40pm which stated Resident #71 was found in the parking lot by a housekeeper. Review revealed Resident #71 stated she was looking for a bathroom. Further review revealed Resident#71's RP was notified at 4:10pm and expressed concerns about a door alarm being placed on the facility exit door. Review of Resident #71's nurse's notes revealed a nurses note with a date of 01/31/2023 at 9:55pm which stated Resident #71 attempted to wander off of the unit on occasions. Review of Resident #71's nurses notes revealed a nurse's note with a date of 03/10/2023 at 6:00pm which stated, a dietary worker was walking to the unit and stated your resident was almost out of the building, if I wasn't walking the hallway she would have been gone. Review of Resident #71's Wandering Risk Assessment completed on 11/01/2023 revealed, in part, Resident #71 was at low risk for wandering. Further review revealed the assessment documented Resident #71 as forgetful with a short attention span, with a diagnosis of vascular dementia, and attempted to exit the building. Review of Resident #71's Wandering Risk Assessment completed on 01/08/2023 revealed, in part, Resident #71 was at moderate risk for wandering. Further review revealed the assessment documented Resident #71 as disoriented and forgetful with short attention span. Review revealed Resident #71 had a diagnosis of early dementia, had a known history of wandering, wandered in the hallway, and attempted to exit the building Review of Resident #71's Wandering Risk Assessment completed on 01/31/2023 revealed, in part, Resident #71 was at low risk for wandering. Further review revealed the assessment documented Resident #71 as forgetful with a short attention span, with a diagnosis of vascular dementia, and attempted to exit the building. Review of Resident #71's Wandering Risk Assessment completed on 03/10/2023 revealed, in part, Resident #71 was at moderate risk for wandering. Review revealed the assessment documented Resident #71 as forgetful with a short attention span. Review revealed Resident #71 had a diagnosis of early dementia, had a known history of wandering, wandered in other rooms, the hallway, and restricted area, and attempted to exit the building. Further review revealed, Resident #71 was being transferred from her current unit to another unit and would receive a room change. Review of the facility's hourly rounding log for the time period of 03/13/2023 through 04/29/2023 revealed no documentation of hourly rounding for Resident #71 on 03/15/2023, 04/08/2023, and 04/24/2023. Observation on 05/31/2023 at 11:41 a.m. revealed, Resident #71 sitting in the recliner in Hall V's dayroom. Further observations revealed no staff present on Hall V at this time. In an interview on 05/30/2023 at 10:51 a.m., S38LPN stated Resident #71 used to wander off the unit frequently. S38LPN stated she had gotten out of the facility a few times. In an interview on 05/31/2023 at 11:41 a.m., S17CNA stated Resident #71 used her wheelchair to move around throughout the facility without difficulty. S17CNA further stated Resident #71 did not have any restrictions with supervision and she could attend events and move throughout the facility unsupervised. Observation on 05/31/2023 at 11:50 a.m. revealed, the exit door located on Hall V was disarmed and unlocked. Observation on 05/31/2023 at 5:13 p.m. revealed Resident #71 sitting in the dining room without staff supervision. In an interview on 05/31/2023 at 12:15 p.m. S37LPN stated Resident #71 was able to roll herself around in her wheelchair without any difficulty. S37LPN stated Resident #71 was a wander risk and had gotten off of Hall V a few times. S37LPN stated she frequently disappears and staff have to go find her. Observation on 06/01/2023 at 12:30 p.m. revealed the exit door located on Hall V disarmed and unlocked. Observation on 06/01/2023 at 2:35 p.m. revealed, a visitor exited the door on Hall V. Further observation revealed the door was disarmed and unlocked. Observation on 06/01/2023 at 4:14 p.m. revealed Hall U's exterior door with a red locking device that was in the off position. Resident #38 Review of the facility's Incident Report entered on 02/17/2023 at 1:07 p.m. revealed, in part, a description that stated: Resident #38 eloped from the facility and was found by a security guard in the front of the building on the sidewalk between the front entrance door and the facility parking lot. Further review revealed Resident #38 was placed on 15 minute visual observation. Review of the incident investigation revealed the front doors of the facility had been locked for the night, the side door of the lobby did not lock and opened with a panic bar. It does not have an alarm. It is believed that Resident #38 walked to the lobby and exited the building from the side door. Resident #38 was not able to say how she got out of the facility or where she was going. Resident #38 was found walking on sidewalk between the exit door and the front parking lot approximately 5 feet from the door. No staff inside the building saw Resident #38 exit from the side lobby door. Plans have are being made by the company that will purchase the facility to install a Wander Guard system and video surveillance cameras. The facility is now purchasing AngelSense devices for resident to wear which includes a geofencing feature that will alert staff if resident walks through exit door. This will be in use until the Wander Guard system is installed. Review of the facility's incident report dated 02/16/2023, revealed while completing medication pass, S42LPN was called to the desk phone through the facility's overhead page and was notified that a security officer was at the entrance door with Resident #38. S42LPN then went to the facility's main entrance to retrieve Resident #38. The security guard notified staff that Resident #38 was found walking in parking lot area near the facility entrance door. Review of Resident #38 medical record revealed Resident #38 admitted to the facility on [DATE] with a diagnosis of Dementia and anxiety. Review of Resident #38's current physician orders revealed, in part, an order with a start date of 03/30/2023 that read Resident #38 was an elopement risk and needed to be rounded on every 2 hours on the even hours. Review of Resident #38's Quarterly Minimum Data Set (MDS) dated [DATE] revealed in part, Resident #38 had a BIMS (Brief Interview Mental Status) score of 5 indicating severe cognitive impairment. Review revealed, Resident #38 used a wheelchair as her mobility device and had no wander/elopement alarm documented. Review of Resident #38 current Comprehensive Careplan with a date of 02/16/2023, revealed, in part, Resident #38 was care planned for being at risk for elopement related to wandering and attempting to leave the facility unsupervised with interventions that included alarms placed on exit doors, apply stop signs to exit doors, assist resident to and from activities and dining area daily, allow resident to wander on unit and in courtyard under supervision; redirect resident as needed. Further review revealed if Resident #38 had behaviors observed they should be documented in Resident #38's progress notes and Resident #38's Responsible Party and Medical Director should be notified. Review of Resident #38's Wandering Risk Assessment completed on 11/29/2022 revealed, in part, Resident #38 was at moderate risk for wandering. Review revealed the assessment documented Resident #38 as forgetful with a short attention span and does not understand her surroundings. Further review revealed Resident #38 was independent with mobility, had a diagnosis of early dementia, and had a known history of wandering. Review of Resident #38's Elopement Risk Assessment, dated 02/16/2023, revealed in part, resident, Resident #38 was cognitively impaired. Review revealed, Resident #38 ambulated independently, wandered aimlessly, and could not be found by staff for 15 minutes. Further review revealed Resident #38 was found in another resident's bathroom. Review of Resident #38's Wandering Risk Assessment completed on 02/17/2023 at 7:58 a.m. revealed, in part, Resident #38 was at high risk for wandering. Review revealed the assessment documented Resident #38 as disoriented with a short attention span and does not understand her surroundings. Review revealed Resident #38 was independent with mobility, had a diagnosis of early dementia, had a known history of wandering, wandered in the hallway, and had attempted to exit the building Review of Resident #38's Wandering Risk Assessment completed on 02/17/2023 at 11:04 a.m. revealed, in part, Resident #38 was at moderate risk for wandering. Review revealed the assessment documented Resident #38 as disoriented with a short attention span and does not understand her surroundings. Review revealed Resident #38 was independent with mobility, had a diagnosis of early dementia, had a known history of wandering, wandered in the hallway, and had attempted to exit the building Review of Resident #38's Wandering Risk Assessment completed on 02/28/2023 at 5:14 a.m. revealed, in part, Resident #38 was at high risk for wandering. Review revealed the assessment documented Resident #38 as disoriented with a short attention span and does not understand her surroundings. Review revealed Resident #38 was independent with mobility, had a diagnosis of early dementia, had a known history of wandering, wandered in the hallway, and had attempted to exit the building Review of Resident #38's Wandering Risk Assessment completed on 05/31/2023 at 9:04 a.m. revealed, in part, Resident #38 was at moderate risk for wandering. Review revealed the assessment documented Resident #38 as disoriented with a short attention span and does not understand her surroundings. Review revealed Resident #38 was independent with mobility, had a diagnosis of early dementia, had a known history of wandering, wandered in the hallway, and had attempted to exit the building. Review of Resident #38's February 2023 eMAR revealed, in part, an order that stated elopement risk: round on resident every 2 hours on even hours every day and night shift. Review revealed it was documented from 02/17/2023 through 02/28/2023 once each shift for the 7:00 a.m-7:00 p.m. shift and once each shift for the 7:00 p.m.-7:00 a.m. Further review revealed an additional order that stated observe for exit seeking behavior every hour beginning on 02/17/2023 at 8:00am hourly until 02/20/2023 at 9:00am. Review of Resident #38's March 2023 eMAR revealed, in part, an order that stated elopement risk: round on resident every 2 hours on even hours every day and night shift. Further review revealed it was documented from 03/01/2023 through 03/31/2023 on once each shift for the 7:00 a.m-7:00 p.m. shift and once each shift for the 7:00 p.m.-7:00 a.m. Review of Resident #38's April 2023 eMAR revealed, in part, an order that stated elopement risk: round on resident every 2 hours on even hours every day and night shift. Further review revealed it was documented from 04/01/2023 through 04/30/2023 on once each shift for the 7:00 a.m-7:00 p.m. shift and once each shift for the 7:00 p.m.-7:00 a.m. Review of Resident #38's May 2023 eMAR revealed, in part, an order that stated elopement risk: round on resident every 2 hours on even hours every day and night shift. Further review revealed it was documented 05/01/2023 through 05/31/2023 on once each shift for the 7:00 a.m-7:00 p.m. shift and once each shift for the 7:00 p.m.-7:00 a.m. Review of Resident #38's Documentation Survey Report Form for February 2023 revealed documentation for rounds completed on Resident #38 every 2 hours on odd hours that started on 02/17/2023 at 7:00 a.m. that were documented once a shift at 7:00 a.m. and 7:00 p.m. Review revealed no documentation on 02/17/2023 for the time of 7:00 a.m. and 7:00 p.m., on 02/24/2023 for the time of 7:00 p.m, on 02/27/2023 for the time of 7:00 a.m, and on 02/28/2023 for the time of 7:00 p.m. Further review revealed on 0/28/2023 at the time of 7:00 p.m. the facility documented the task was not applicable. Review of Resident #38's Documentation Survey Report Form for March 2023 revealed documentation for rounds completed on Resident #38 every 2 hours on odd hours that were documented once a shift at 7:00 a.m. and 7:00 p.m. Review revealed no documentation on 03/01/2023 for the time of 7:00 p.m., on 03/03/2023 for the time of 7:00 a.m, on 03/06/2023 for the time of 7:00 p.m, on 03/11/2023 for the time of 7:00 p.m., on 03/21/2023 for the time of 7:00 p.m., and on 03/30/2023 for the time of 7:00 p.m. Further review revealed on 03/17/2023 at the time of 7:00 p.m., 03/22/2023 at the time of 7:00 p.m., 03/24/2023 at the time of 7:00 p.m., 03/25/2023 at the time of 7:00 p.m. 03/29/2023 at the time of 7:00 p.m., and 03/31/2023 at the time of 7:00 p.m. the facility documented the task was not applicable. Review of Resident #38's Documentation Survey Report Form for April 2023 revealed documentation for rounds completed on Resident #38 every 2 hours on odd hours that were documented once a shift at 7:00 a.m. and 7:00 p.m. Review revealed no documentation on 04/07/2023 for the time of 7:00 p.m. and on 04/18/2023 for the time of 7:00 p.m. Further review revealed on 04/03/2023 at the time of 7:00 p.m., 04/04/2023 at the time of 7:00 p.m., 04/13/2023 at the time of 7:00 p.m., 04/17/2023 at the time of 7:00 p.m. 04/19/2023 at the time of 7:00 p.m., 04/22/2023 at the time of 7:00 p.m., 04/23/2023 at the time of 7:00 p.m., 04/27/2023 at the time of 7:00 p.m., and 04/28/2023 at the time of 7:00 p.m. the facility documented the task was not applicable. Review of Resident #38's Documentation Survey Report Form for May 2023 revealed documentation for rounds completed on Resident #38 every 2 hours on odd hours that were documented once a shift at 7:00 a.m. and 7:00 p.m. Review revealed no documentation on 05/01/2023 for the time of 7:00 p.m., 05/05/2023 for the time of 7:00 p.m., and on 05/24/2023 for the time of 7:00 p.m. Further review revealed on 05/02/2023 at the time of 7:00 p.m., 05/03/2023 at the time of 7:00 p.m., 05/06/2023 at the time of 7:00 p.m., 05/07/2023 at the time of 7:00 p.m., 05/08/2023 at the time of 7:00 p.m., 05/09/2023 at the time of 7:00 a.m., 05/11/2023 at the time of 7:00 p.m., 05/16/2023 at the time of 7:00 p.m., 05/17/2023 at the time of 7:00 p.m., 05/20/2023 at the time of 7:00 p.m., 05/21/2023 at the time of 7:00 p.m., 05/25/2023 at the time of 7:00 p.m., and 05/30/2023 at the time of 7:00 p.m. the facility documented the task was not applicable. Review of Resident #38's nurse's notes revealed a nurse's note with a date of 02/16/2023 at 10:35 p.m which stated S42LPN was called to the desk phone through the facility's overhead page and was notified that a security officer was at the entrance door with Resident #38. S42LPN then went to the facility's main entrance to retrieve Resident #38. The security guard notified staff that Resident #38 was found walking in parking lot area near the facility entrance door. Review of Resident #38's nurse's notes revealed a nurse's note with a date of 0/28/2023 at 11:39 p.m. which stated Resident #38 was observed at times wandering in another resident's rooms. Observation on 05/31/2023 at 11:36 a.m., revealed Resident #38 lying in bed watching television without direct staff supervision. In an interview on 05/31/2023 11:54 a.m., S39CNA stated Resident #38 was a wanderer and was able to ambulate independently. S39CNA stated Resident #38 has had many incidents of elopement because she is [NAME]. S39CNA further stated Resident #38 would specifically wait for someone to turn around or tend to another resident and then she will attempt to elope. Observation on 05/31/2023 at 12:46 p.m. revealed Resident #38 ambulating without assistance in the Hall Z day room. In an interview on 05/31/2023 at 12:47 p.m., S40CNA, stated she was the CNA on Hall Z at this time. S40CNA stated she was not aware of any residents who resided on the unit who were identified as a wanderer. S40CNA further stated this was her second day working at the facility. In an interview on 05/31/2023 at 2:51 p.m., S35LPN stated Resident #38 is independent and can ambulate without assistive devices. S35LPN stated Resident #38 had a diagnosis of dementia and had wandering behaviors. S35LPN stated Resident #38 did not have a wanderguard in use at this time. S35LPN further stated staff just try to keep an eye out on Resident #38 to prevent her from eloping. Observation on 05/31/2023 1:12 p.m., revealed the exit door to the parking lot on Hall Y was unlocked. Observation revealed surveyor able to open the door at this time and no alarm sounded. Observation further revealed no signage on the door. Observation on 06/01/2023 at 7:39 a.m. revealed, Resident #38 sitting in her chair in her room. Observation further revealed no CNA was in direct sight of Resident #38. In an interview on 06/01/2023 at 7:51 a.m., S25Receptionist stated staff was not always present at facility's front entrance door. In an interview on 06/01/2023 at 8:15 a.m. S10Clinical Coordinator confirmed Resident #38 had eloped from the facility. S10Clinical Coordinator stated when residents got out of the facility, it was generally out of a door that was present on the unit they resided on. S10Clinical Coordinator stated the wanderguard system could have prevented Resident #38 and Resident #71 from eloping out of the facility. In an interview on 06/01/2023 at 8:41 a.m. S45CNA stated Resident #38 was an elopement risk. S45CNA stated some of the doors have alarms on them, but there is no wanderguard system in place. Observation on 06/01/2023 at 8:44 a.m. revealed the door across from the dining room on Hall Y was unlocked, unalarmed, and not supervised. At this time, the surveyor was able to open the door. In an interview on 06/01/2023 at 8:49 a.m. S44MDSNurse stated following Resident #38's incident of elopement on 02/16/2023, the intervention placed by the facility was for staff to keep an eye on her. In an interview on 06/01/2023 9:21 a.m. S42LPN stated on 02/16/2023 Resident #38 eloped through the front door of the facility and Resident #38 was found by the school's, next to the facility, security guard. S42LPN stated the incident occurred at night and there wasn't as many staff in the facility. S42LPN stated Resident #38 still had the potential to elope because she can ambulate without assistance. Observation on 06/01/23 at 9:30 a.m. revealed, the door across from the dining room on Hall Y unlocked. At this time the surveyor was able to open the door and no alarm sounded. Observation on 06/01/2023 at 9:37 a.m. revealed, the exit door on Hall Z across from Room B had a red alarm attachment with the key hole turned to off. At this time the surveyor pushed the door open and no alarm sounded. In an interview on 06/01/2023 at 9:40 a.m., S4 LPN stated Resident #38 and Resident #71 had both eloped while she was working at the facility. S4LPN further stated she assumed both residents had eloped off their previous unit out of the back door and the door had no alarm so staff was unaware the residents had left the facility. S4LPN confirmed not all in the facility had alarms or locked doors and no [TRUNCATED]

Based on interviews, observation, and record review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to have a system in place to prevent and control the transmission of COVID-19 infections in the facility and to provide supervision to residents to prevent elopement by: 1.)failing to ensure staff quarantined and tested a resident (Resident #3) upon symptom onset of COVID-19; 2.)failing to ensure staff quarantined a resident ( Resident #27) who tested positive for Covid-19; 3.)failing to ensure staff used personal protective equipment (PPE) with COVID-19 positive residents (Resident #3 and Resident #27);and 4.) failing to provide supervision to keep residents (Resident #38 and Resident #71) free from elopement This deficient practice resulted in an Immediate Jeopardy situation on 01/08/2023 at 4:40 p.m. when Resident #71, an unsupervised resident identified as an elopement risk, eloped from the facility and was found in the facility's parking lot by staff. The continued failure to provide adequate supervision resulted in the immediate jeopardy continuing on 02/16/2023 at 10:35 p.m. when Resident #38, who was identified as an elopement risk and had severe cognitive impairment, eloped from the facility and was found in the facility's parking lot by a security guard. This deficient practice resulted in an Immediate Jeopardy situation for Resident #3 on 05/28/2023 at 11:30 a.m., when Resident #3 who displayed symptoms of COVID-19 and was not quarantined or tested by the facility. On 05/31/2023 at 11:46 a.m., Resident #27 tested positive for COVID-19 and was not placed on quarantine until 1:17p.m. On 05/31/2023 at 12:43 p.m. S23Agency Certified Nursing Assistant (CNA) entered Resident #27's, a symptomatic COVID-19 positive resident, room without a gown, gloves, or face shield in place. On 05/31/2023 at 1:02 p.m. S24Housekeeper entered Resident #27's room to deliver a clothing item without a gown, gloves, or face shield in place and then entered the housekeeping closet to stock her housekeeping cart. On 5/31/2023 at 1:33 p.m. S4LPN exited Resident #3's, a symptomatic COVID-19 positive resident, room with a contaminated yellow gown in her hands and entered Hall Y Dayroom. Resident #59 and Resident #74 tested positive for COVID-19 on 06/04/2023. As of 06/06/2023, there were 4 active resident COVID-19 cases in the facility. S1Administrator was notified of the Immediate Jeopardy on 06/01/2023 at 4:48 p.m. The Immediate Jeopardy was removed on 06/04/2023 at 4:03 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit, which included: 1. Resident #3 was placed on isolation precautions on 05/30/2023 and Resident #27 was placed on isolation precautions on 5/31/2023. This was completed on 06/01/2023. Resident # 3 was tested for COVID-19 on 05/30/2023, and placed on isolation precautions. Resident #27 was tested for COVID-19 with a positive result and placed on isolation precautions on 05/31/2023. This was completed on 06/01/2023. On 06/01/2023 onsite staff and contracted agency staff were inserviced by S2Directior of Nursing (DON) and S3Assistant Director of Nursing//Infection Preventionist (S3ADON/IP) regarding identification of COVID-19 symptoms, staff responsibilities when symptoms of COVID-19 were observed, and transmission-based precautions including the use of personal protective equipment (PPE) with COVID-19 positive residents in accordance with Centers for Disease Control (CDC) guidelines. Training by S2DON and S3ADON/IP and/or Designee would continue as staff and contracted agency staff on alternate schedules reported to work. Staff and contracted agency staff would not be allowed to work until training was completed. This began on 06/01/2023 and will end on 06/09/2023. On 06/02/2023 onsite licensed nurses and onsite contracted agency licensed nurses were inserviced by S2DON and S3ADON/IP regarding the need to quarantine residents with symptoms of COVID-19, while determining if a resident was positive for COVID-19, and testing residents upon COVID-19 symptom onset in accordance with CDC guidelines. Training would continue as licensed nursing staff and contracted agency licensed nursing staff on alternate schedules reported to work. Licensed Nursing Staff and contracted agency licensed nursing staff would not be allowed to work until training is completed. This began on 06/02/2023 and will end on 06/09/2023. On 06/01/2023 designated employees were trained by S1Administrator, and assigned to provide supervision for Resident #37 and Resident #71 to keep them free of elopement, and their Plan of Care was updated by the facility's MDS Assessment nurses to reflect supervision. This was completed on 06/02/2023. 2. All other 86 residents that resided in the facility had the potential to be affected. On 05/31/2023 S2DON, S3ADON/IP, and Nursing Administration conducted broad based testing of all residents and onsite staff. Resident #27 tested positive for COVID-19 and was placed on isolation precautions on 05/31/2023. Broad based testing was repeated on 06/02/2023 and all tests were negative. Broad based testing conducted by S2DON, S3ADON/IP, and Nursing Administration would continue every 3 days until test results were negative for a two week period. This began on 05/31/2023 and would end once all negative tests were obtained for two weeks. In order to keep the current resident population free from contracting COVID-19, S2DON and S3ADON/IP were educated on 06/02/2023 regarding Infection Control policies and procedures and Infection Surveillance policies by the consultant nurse. This was completed on 06/02/2023. On 06/01/2023 onsite staff and contracted agency staff were inserviced by S2DON and S3ADON/IP regarding identification of COVID-19 symptoms, staff responsibilities when symptoms of COVID-19 were observed, and transmission-based precautions including the use of personal protective equipment (PPE) with COVID-19 positive residents in accordance with CDC guidelines. Training by S2DON and S3ADON/IP and/or Designee would continue as staff and contracted agency staff on alternate schedules reported to work. Staff and contracted agency staff would not be allowed to work until training was completed. This began on 06/01/2023 and will end on 06/09/2023. On 06/02/2023 an MDS/CCC: Risk of Elopement Wandering Review was completed by facility's MDS Assessment nurses on all current residents to identify other residents that may be affected due to being at risk to elope. 10 Residents were identified as being at risk for elopement, and were assigned a designated employee trained by S1Administrator to provide visual supervision at all times to keep them free of elopement, and their Plans of Care were updated by facility's MDS Assessment nurses to reflect supervision. This was completed on 06/02/2023. On 06/02/2023 and 06/03/2023 Nursing Administration indicated that the 10 residents identified as a wandering risk had signage of a W placed over bed. This was completed on 06/02/2023. On 06/02/2023 Nursing Administration was educated on completing the MDS/CCC: Risk of Elopement Wandering Review with the admission/readmission, quarterly, a significant change in condition and annual MDS by the consultant nurse. This was completed on 06/02/2023. On 06/02/2023 the S1Administrator and Nursing Administration were educated on ensuring the 10 residents identified as at risk for elopement had adequate supervision with a designated employee trained by S1Administrator and were assigned to provide supervision by the consultant nurse. This was completed on 06/02/2023. Beginning on 06/01/2023 and continued on 06/02/2023 and 06/03/2023, all onsite staff and onsite contracted agency staff received inservice training conducted by facility's MDS Assessment Nurses and Nursing Administration in regards to residents at risk for wandering identified by a W posted on the wall above their bed, and in an Elopement Binder, accessible to all staff and contracted agency staff, at each nurses station, which contained a document with each residents name and picture and a photo document located at the receptionist desk, also easily accessible by all staff and contracted agency staff. This began on 06/01/2023 and will end on 07/01/2023. Moving forward, staff and contracted agency staff that were not inserviced already, would receive inservice training as they were scheduled to work, and were also called in for training. Facility staff and contracted agency staff would not be allowed to work until the training was completed. 100% compliance would be obtained by 06/09/2023. This began on 06/01/2023 and will end on 06/09/2023. On 06/02/2023 a Patient Wandering system designed to secure facility egresses to prevent residents at risk for eloping from exiting the facility was ordered, and would be installed upon delivery. Once the Patient Wandering system would be installed, and staff were inserviced on use of the system, the monitoring of residents at risk for elopement by trained designated employee would be discontinued as advised by the QAPI Committee. This began on 06/03/2023 and will end on 07/01/2023. 3. On 06/03/2023 S1Administrator was educated regarding job description and responsibilities by President of facility's management company. This was completed on 06/03/2023. Responsible Employee: S3ADON/IP was responsible for ensuring that Infection Control policies and procedures and Infection Surveillance policies were implemented and that staff were inserviced and monitored for adherence to the policies and procedures to prevent the transmission of COVID-19. S2DON would provide oversight of S3ADON/IP that ensured compliance of the Infection Prevention and Control Program. On 06/02/2023 S2DON and S3ADON/IP were educated on Infection Control policies and procedures and Infection surveillance policies by the consultant nurse. This was completed on 06/02/2023. On 06/01/2023 onsite staff and contracted agency staff were inserviced by S2DON and S3ADON/IP regarding identification of COVID-19 symptoms, staff responsibilities when symptoms of COVID-19 were observed, and transmission-based precautions including the use of personal protective equipment (PPE) with COVID-19 positive residents in accordance with CDC guidelines. Training by S2DON and S3ADON/IP and/or Designee would continue as staff and contracted agency staff on alternate schedules reported to work. Staff and contracted agency staff would not be allowed to work until training was completed. This began on 06/01/2023 and will end on 06/09/2023. On 06/01/2023 licensed nurses onsite and contracted agency licensed nurses were inserviced by S2DON and S3ADON/IP regarding the need to quarantine residents with symptoms of COVID-19, while determining if resident was positive for COVID-19, and testing residents upon COVID-19 symptom onset in accordance with CDC guidelines. Training would continue as licensed staff nursing and contracted agency licensed nurses on alternate schedules reported to work. Licensed Nursing Staff and contracted agency licensed nursing staff would not be allowed to work until training was completed. This began on 06/01/2023 and will end on 06/09/2023. On 06/01/2023 licensed nurses onsite and contracted agency licensed nurses were inserviced by S2DON and S3ADON/IP regarding the need to quarantine residents with symptoms of COVID-19, while determining if resident was positive for COVID-19, and testing residents upon COVID-19 symptom onset in accordance with CDC guidelines. Training would continue as licensed staff nursing and contracted agency licensed nurses on alternate schedules reported to work. Licensed Nursing Staff and contracted agency licensed nursing staff would not be allowed to work until training was completed. This began on 06/01/2023 and will end on 06/09/2023. On 06/02/2023 S2DON and S3ADON/IP were educated on Infection Control policies and procedures and Infection surveillance policies by the consultant nurse. This was completed on 06/02/2023. On 06/02/2023 Nursing Administration was educated on completing the MDS/CCC: Risk of Elopement Wandering Review with the admission/readmission, quarterly, a significant change in condition and annual MDS by the consultant nurse. This was completed on 06/02/2023. On 06/02/2023 S1Administrator and Nursing Administration were educated on ensuring residents identified as at risk for elopement had adequate supervision with a trained designated employee assigned to provide supervision by the consultant nurse. This was completed on 06/02/2023. Beginning on 06/01/2023 and continued on 06/02/2023, and 06/03/2023 all onsite staff and onsite contracted agency staff received inservice training conducted by facility's MDS Assessment Nurses and Nursing Administration in regards to residents at risk for wandering identified by a W posted on the wall above their bed, and in an Elopement Binder, accessible to all staff and contracted agency staff, at each nurses station, which contained a document with each residents name and picture and a photo document located at the receptionist desk, also easily accessible by all staff and contracted agency staff. This began on 06/01/2023 and will end on 07/01/2023. Moving forward, staff and contracted agency staff that were not inserviced already, would receive inservice training as they were scheduled to work, and were also called in for training. Facility staff and contracted agency staff would not be allowed to work until the training was completed. 100% compliance would be obtained by 06/09/2023. This began on 06/01/2023 and will end on 06/09/2023. On 06/02/2023 a Patient Wandering system designed to secure facility egresses to prevent identified residents at risk for elopement from exiting the facility was ordered and would be installed upon delivery. Once the Patient Wandering system would be installed, and staff were inserviced on use of the system, the monitoring of residents at risk for elopement by trained designated employee would be discontinued as advised by the QAPI Committee. S2DON and/or Designee would conduct random interview audits of staff from both shifts that ensured knowledge of COVID-19 symptoms 3 times a week for 4 weeks, then 2 times a week for 4 weeks, then as deemed necessary by the QAPI Committee. This began on 06/03/2023 and will end on 07/29/2023. S2DON and/or Designee would conduct 10 random visual audits that ensured the proper use of transmission-based precautions, that included the use of personal protective equipment (PPE) with COVID-19 positive residents in accordance with CDC guidelines 3 times a week for 4 weeks, then 2 times a week for 4 weeks, then as deemed necessary by the QAPI Committee. This began on 06/03/2023 and will end on 07/29/2023. S2DON would conduct documentation audits of COVID-19 testing 3 times per week for 4 weeks, then 2 times per week for weeks, then as deemed necessary by the QAPI Committee. This began on 06/03/2023 and will end on 07/29/2023. S2DON and/or Designee would conduct 10 random interview audits of staff from both shifts that ensured knowledge of COVID-19 symptoms 3 times a week for 4 weeks, then 2 times a week for 4 weeks, then as deemed necessary by the QAPI Committee. This began on 06/03/2023 and will end on 07/29/2023. S1Administrator, S2DON, and/or Designee would conduct 5 random chart audits of residents who have been admitted or readmitted , had quarterly or annual MDS review, or a significant change in condition for completion of the MDS/CCC: Risk of Elopement Wandering Review 3 times a week for 4 weeks, then 2 times a week for 4 weeks, then as deemed necessary by the QAPI Committee. This began on 06/03/2023 and will end on 07/29/2023. S2DON and/or Designee would conduct 10 random interview audits of staff from both shifts that ensured knowledge of COVID-19 symptoms 3 times a week for 4 weeks, then 2 times a week for 4 weeks, then as deemed necessary by the QAPI Committee. This began on 06/03/2023 and ended on 07/29/2023. S2DON and/or Designee would conduct 10 random visual audits that ensured the proper use of transmission-based precautions, including the use of personal protective equipment (PPE) with COVID-19 positive residents 3 times a week for 4 weeks, then 2 times a week for 4 weeks, then as deemed necessary by the QAPI Committee. This began on 06/03/2023 and will end on 07/29/2023. S2DON and/or Designee would conduct 10 random chart audits to review for residents with COVID-19 symptoms being placed in quarantine while determining if resident is positive for COVID-19, and that residents were tested upon COVID-19 symptom onset in accordance with CDC guidelines 3 times a week for 4 weeks, then 2 times a week for 4 weeks, then as deemed necessary by the QAPI Committee. This began on 06/03/2023 and will end on 07/29/2023. S1Administrator and/or Designee would conduct visual audits for the presence of trained designated employee supervising residents identified as at risk for elopement and documentation review audits for all residents identified as at risk for elopement. These audits would occur 3 times a week for 4 weeks, then 2 times a week for 4 weeks, then as deemed necessary by the QAPI Committee. This began on 06/03/2023 and will end on 07/01/2023. Results of audits including tracking and trends would be reviewed weekly in the QAPI meeting, and any identified issues would be addressed with re-education, plan modification and progressive discipline. 4. S1Administrator would review all audits implemented for this plan of correction for completion and for documentation of re-education, plan modification and progressive discipline as necessary 3 times a week for 4 weeks, then 2 times a week for 4 weeks, then as deemed necessary by the President of facility's management company and/or RDO. This began on 06/03/2023 and will end on 07/29/2023. President of facility's management company and/or RDO would review S1Administrator's audits for completion and followed up with re-education, plan modification and progressive discipline as necessary. This began on 06/03/2023 and will end on 07/29/2023. 5. This was completed on 06/03/2023. This deficient practice had the potential to cause serious injury, harm, or death to the remaining 8 residents identified as elopement risks by the facility and the remaining 86 non-positive COVID-19 residents residing in the facility who were at risk for contracting COVID-19. Findings: Cross reference F689, F880, and F882. In an interview on 06/01/2023 at 10:25 a.m., S1Administrator confirmed the facility had two elopements in 2023. S1Adminsitrator stated Resident #38 and Resident #71 eloped out of the facility through the facility exits, but she is unsure of which one. S1Adminstrator stated the facility added alarms to the doors they think the residents utilized to elopement from the facility. S1Adminstrator stated the facility did not have a wanderguard system and not all doors had alarms because alarming all 39 doors was not in the budget. S1Adminstrator stated until the wanderguard was installed, it was the facility's plan to rely on the alarms on the doors to alert staff that residents were attempting to elope. She also stated residents that are an elopement risk still have the possibility of eloping. In an interview on 06/01/2023 at 11:46 a.m., S2DON stated staff should never enter a COVID-19 positive resident's room without PPE in place and should never exit a COVID-19 positive resident's room with contaminated PPE on their person. S2DON further stated the observations reflected above puts the facility at risk for a facility wide COVID-19 outbreak. S2DON further stated Resident #27 should have been placed on COVID-19 precautions immediately following her positive COVID-19 test. In an interview on 06/05/2023 at 5:15 p.m., S1Administrator confirmed she did not ensure the facility used its resources to effectively prevent the spread of COVID-19 in the facility. S1Adminsitrator further stated she was not up to date on current COVID-19 guidance and regulations because she was not a nurse. S1Adminsitrator further stated it had been very difficult for her to and keep up with the regulations. In an interview on 06/06/2023 at 12:15 p.m., S2DON confirmed Resident #3 should have been tested for COVID-19 and placed in quarantine immediately upon the onset of COVID-19 symptoms. S2DON further stated if the facility had acted upon Resident #3's symptoms on 05/28/2023 when they began, the facility could have implemented precautions to prevent Resident #27, Resident #59, and Resident #74 from contracting COVID-19. In an interview on 06/05/2023 10:47a.m. S36Senior [NAME] President, stated she was unaware of any other interventions implemented for the elopement incidents for Resident #71 on 01/08/2023 and Resident #38 on 02/16/2023. S36Senior [NAME] President stated there was a lack of communication to ensure staff were all aware of the expectations for COVID-19. S26Senior [NAME] President further stated she was responsible for monitoring the administration and nursing administration to ensure they were implementing the correct processes for COVID-19 and elopement and she would perform the audits stated in the above plan of removal until the new company took over the facility.

Based on record review, observation, and interview, the facility failed to take steps to prevent the transmission of COVID-19 by: 1.) failing to ensure staff quarantined and tested a resident (Resident #3) upon symptom onset of COVID-19; 2.) failing to ensure staff quarantined a resident ( Resident #27) who tested positive for Covid-19;and 3.) failing to ensure staff used personal protective equipment (PPE) with COVID-19 positive residents (Resident #3 and Resident #27). This deficient practice resulted in an Immediate Jeopardy situation on 05/28/2023 at 11:30 a.m. when Resident #3 who displayed symptoms of COVID-19 and was not quarantined or tested by the facility. The Immediate Jeopardy situation continued for the following: On 05/31/2023 at 11:46 a.m., when Resident #27 tested positive for COVID-19 and was not placed on quarantine until 1:17p.m. On 05/31/2023 at 12:43 p.m. S23Agency Certified Nursing Assistant (CNA) entered Resident #27's, a symptomatic COVID-19 positive resident's room without a gown, gloves, or face shield in place. On 05/31/2023 at 1:02 p.m. S24Housekeeper entered Resident #27's room to deliver a clothing item without a gown, gloves, or face shield in place and then entered the housekeeping closet to stock her housekeeping cart. On 5/31/2023 at 1:33 p.m. S4LPN exited Resident #3's, a symptomatic COVID-19 positive resident, room with a contaminated yellow gown in her hands and entered Hall Y Dayroom. Resident #59 and Resident #74 tested positive for COVID-19 on 06/04/2023. As of 06/06/2023, there were 4 active resident COVID-19 cases in the facility. S1Administrator was notified of the Immediate Jeopardy on 06/01/2023 at 4:48 p.m. The Immediate Jeopardy was removed on 06/04/2023 at 4:03 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit, which included: 1. Resident #3 was placed on isolation precautions on 05/30/2023 and Resident #27 was placed on isolation precautions on 05/31/2023.This was completed on 06/01/2023. On 06/01/2023, onsite staff and contracted agency staff were inserviced by S2Director of Nursing (DON) and S3Assistant Director Of Nursing (ADON)/Infection Preventionist (IP) regarding identification of COVID-19 symptoms, staff responsibilities when symptoms of COVID-19 are observed, and transmission-based precautions including the use of personal protective equipment (PPE) with COVID-19 positive residents in accordance with Centers for Disease Control and Prevention(CDC) guidelines. The Training by S2DON and S3ADON/IP and/or Designee continued as staff and contracted agency staff on alternate schedules reported to work. Staff and contracted agency staff were not allowed to work until training was completed. This began on 06/01/2023 and will end on 06/09/2023. On 06/02/2023 licensed nurses onsite and contracted agency licensed nurses were inserviced by S2DON and S3ADON/IP regarding the need to quarantine residents with symptoms of COVID-19 while determining if the resident was positive for COVID-19 and testing residents upon COVID-19 symptom onset in accordance with CDC guidelines. The Training would continue as licensed staff nursing and contracted agency licensed nurses on alternate schedules reported to work. Licensed Nursing Staff contracted agency licensed nursing staff would not be allowed to work until training was completed. This began on 06/02/2023 and will end on 06/09/2023. 2. The other 86 residents who resided in the facility had the potential to be affected. The initial round of broad based COVID-19 testing was completed on 05/31/2023 to identify any further positive cases of COVID-19 with 1 additional resident who tested positive and was placed on isolation precautions. The second round of broad based testing was completed on 06/02/2023 with no further positive tests. Testing would continue every third day until 2 weeks of negative results are achieved. This began on 05/31/2023 and would end when 2 weeks of negative results was achieved. On 06/02/2023, S2DON and S3ADON/IP was educated on Infection Control policies and procedures, and Infection Surveillance policies by consultant nurse. This was completed on 06/02/2023. On 06/01/2023, onsite staff and contracted agency staff were inserviced by S2DON and S3ADON/IP regarding the identification of COVID-19 symptoms, staff responsibilities, when symptoms of COVID-19 are observed, and transmission-based precautions including the use of personal protective equipment (PPE) with COVID-19 positive residents in accordance with CDC guidelines. The training by S2DON and S3ADON/IP and/or Designee continued as staff and contracted agency staff on alternate schedules reported to work. The staff and contracted agency staff would not be allowed to work until training was completed. This began on 06/01/2023 and will end on 06/09/2023. On 06/01/2023, licensed nurses onsite and contracted agency licensed nurses were inserviced by S2DON and S3ADON/IP regarding the need to quarantine residents with symptoms of COVID-19 while determining if a resident was positive for COVID-19 and testing residents upon COVID-19 symptom onset in accordance with CDC guidelines. The training would continue as licensed staff nursing and contracted agency licensed nurses on alternate schedules reported to work. Licensed Nursing Staff and contracted agency licensed nursing staff would not be allowed to work until training was completed. This began on 06/01/2023 and will end on 06/09/2023. 3. On 06/02/2023, S2DON and S3ADON/IP were educated on Infection Control policies and procedures, and Infection surveillance policies by consultant nurse. This was completed on 06/02/2023. On 06/01/2023, onsite staff and contracted agency staff were inserviced by S2DON and S3ADON/IP regarding identification of COVID-19 symptoms, staff responsibilities, when symptoms of COVID-19 are observed, and transmission-based precautions including the use of personal protective equipment (PPE) with COVID-19 positive residents in accordance with CDC guidelines. The training by S2DON and S3ADON/IP and/or Designee continued as staff and contracted agency staff on alternate schedules reported to work. Staff and contracted agency staff would not be allowed to work until training was completed. This began on 06/01/2023 and ended on 06/09/2023. On 06/01/2023, licensed nurse's onsite and contracted agency licensed nurses were inserviced by S2DON and S3ADON/IP regarding the need to quarantine residents with symptoms of COVID-19 while determining if resident is positive for COVID-19 and testing residents upon COVID-19 symptom onset in accordance with CDC guidelines. Training will continue as licensed staff nursing and contracted agency licensed nurses on alternate schedules report to work. Licensed Nursing Staff and contracted agency licensed nursing staff will not be allowed to work until training is complete. This began on 06/01/2023 and ended on 06/09/2023. 4. S2DON and/or Designee will conduct 10 random interview audits of staff from both shifts to ensure knowledge of COVID-19 symptoms 3 times a week for 4 weeks, then 2 times a week for 4 weeks, then as deemed necessary by the Quality Assurance and Performance Improvement (QAPI) Committee. This began on 06/03/2023 and will end on 07/29/2023. S2DON and/or Designee will conduct 10 random visual audits to ensure the proper use of transmission-based precautions including the use of personal protective equipment (PPE) with COVID-19 positive residents 3 times a week for 4 weeks, then 2 times a week for 4 weeks, then as deemed necessary by the QAPI Committee. This began on 06/03/2023 and will end on 07/29/2023. S2DON and/or Designee will conduct 10 random chart audits to review for residents with COVID-19 symptoms who were placed in quarantine while determining if resident is positive for COVID-19, and testing residents upon COVID-19 symptom onset in accordance with CDC guidelines 3 times a week for 4 weeks, then 2 times a week for 4 weeks, then as deemed necessary by the QAPI Committee. This began on 06/03/2023 and will end on 07/29/2023. Results of audits including surveillance will be reviewed weekly by QAPI Committee, and any identified issues will be addressed with re-education, plan modification and progressive discipline. This was completed on 06/03/2023. This deficient practice had the potential to cause serious injury, harm, or death for the remaining 86 non-positive COVID-19 residents residing in the facility who were at risk for contracting COVID-19. Findings: 1.) Review of the facility's Coronavirus Disease Testing Residents Policy revealed, in part, any resident, regardless of their vaccination status, with even mild symptoms of COVID-19 would receive a viral test as soon as possible. Review revealed, symptomatic residents, regardless of vaccination status, were placed on transmission-based precautions (TBP) according to CDC guidelines. Review revealed, asymptomatic residents with close contact with someone with SARS-CoV-2(COVID-19) infection, regardless of vaccination status, would have a series of three viral tests for SARS-CoV-2(COVID-19) infection. Review revealed testing would be conducted immediately (but not until 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, 48 hours after the second negative test. Further review revealed, source control should be worn by all individuals being tested . Review of Resident #3's Diagnosis List revealed, in part, Resident #3 had a diagnosis of essential hypertension and Type 2 Diabetes Mellitus. Review of Resident #3's Minimal Data Set with an Assessment Reference Date of 04/12/2023 revealed, in part, Resident #3's Brief Interview for Mental Status Score was 15, which indicated Resident #3 was cognitively intact. Review of Resident #3's Careplan, with a revision date of 04/25/2023, revealed, in part, Resident #3 was at risk for COVID-19 related to her comorbidities, and the CDC guidelines should be followed. Further review revealed Resident #3 should be monitored for signs and symptoms of infection and the medical director should be notified if any symptoms occurred. Further review revealed, Resident #3's cough, temperature, and shortness of breath should be evaluated and the medical director should be informed. Review of Resident #3's nurse's notes, revealed no nursing notes documented from 05/25/2023-05/30/2023 regarding Resident #3 having symptoms of COVID-19. Review of Resident #3's May 2023 electronic Medication Administration Record (eMAR) revealed, in part, no documented evidence that Resident #3 was assessed for signs and symptoms of COVID-19 on 05/28/2023 and 05/29/2023. Review of the facility's Covid Testing Log revealed, Resident #3 tested positive for COVID-19 on 05/30/2023, Resident #27 tested positive for COVID-19 on 05/31/2023, Resident #59 tested positive for COVID-19 on 06/04/2023, and Resident #74 tested positive for COVID-19 on 06/04/2023. Observation on 06/01/2023 at 8:12 a.m., revealed Resident #3 lying on her left side in her bed coughing into a white tissue. In an interview on 06/01/2023 at 8:15 a.m., Resident #3 stated her symptoms of COVID-19 began on Sunday, 05/28/2023, after she got out of church around 11:30 a.m. Resident #3 further stated she informed S34AgencyLPN she had a sore throat, headache, and body aches. Resident #3 further stated S34Agency LPN told her she had a cold and it would pass in a few days. Resident #3 stated her symptoms continued on Monday, 05/29/2023 and Tuesday, 05/30/2023. Resident #3 stated the facility tested her for COVID-19 on Tuesday, 05/30/2023. In an interview on 05/31/2023 at 9:20 a.m., S10ClinicalCoordinator stated Resident #3 had symptoms of COVID-19 on Monday, 05/29/2023. S10ClinicalCoordinator further stated Resident #3 complained of a headache, body aches, and weakness on 05/29/2023. S10ClinicalCoordinator further stated she noticed Resident #3 was extremely weak, but she did not notify Resident #3's physician because she assumed S5Licensed Practical Nurse took care of it. S10ClinicalCoordinator further stated Resident #3 now had a loss of appetite and a cough. In an interview on 05/31/2023 at 2:36 p.m., S3ADON/IP stated COVID-19 testing was currently being completed on all residents in the facility and would not be completed again until 06/03/2023. S3ADON/IP further stated she had not interviewed Resident #3 and she was unaware of when her COVID-19 symptoms began. In an interview on 06/01/2023 at 3:26 p.m., S34AgencyLPN stated she did not recall if Resident #3 told her she was feeling unwell. S34AgencyLPN further stated she was aware of the signs and symptoms of COVID-19, but she did not know the facility's policy on COVID-19 or the facility's process for a resident with COVID-19 symptoms. In an interview on 06/01/2023 at 3:30 p.m., S10ClinicalCoordinator stated Resident #3 should have been tested on Sunday, 05/28/2023 upon COVID-19 symptom onset. In an interview on 06/01/2023 at 5:30 p.m., S15CNA stated she witnessed Resident #3 report to S34AgencyLPN she was not feeling well around 2:00 p.m. on Sunday, 05/30/2023. In an interview on 06/02/2023 at 11:32 a.m., Resident #3's physician stated it was his expectation that COVID-19 testing was completed upon the identification of symptoms of COVID-19. Resident #3's physician further stated following the identification of a positive COVID-19 result, the resident should be isolated. In an interview on 06/06/2023 at 12:15 p.m., S2DON confirmed Resident #3 should have been tested for COVID-19 and placed in quarantine immediately upon the onset of COVID-19 symptoms. S2DON further stated if the facility had acted upon Resident #3's symptoms on 05/28/2023 when they began, the facility could have implemented precautions to prevent Resident #27, Resident #59, and Resident #74 from contracting COVID-19. 2.) Review of the facility's Coronavirus Disease Testing Residents Policy revealed, symptomatic residents, regardless of vaccination status, were placed on transmission-based precautions (TBP) according to CDC guidelines. Review of Resident #27's nurse's notes dated 05/31/2023 at 3:14 p.m. revealed, in part, Resident #27 tested positive for COVID-19. In an interview on 05/31/2023 at 12:02 p.m., S10Clinical Coordinator stated Resident #27 tested positive today at 11:46 a.m. Observation on 05/31/2023 at 12:54 p.m. revealed, Resident #27's door open without PPE or COVID-19 signage present. Observation on 05/31/2023 at 1:17 p.m. revealed, S10Clinical Coordinator placed PPE and COVID-19 signage on Resident #27's door. In an interview on 05/31/2023 at 3:46 p.m., S10Clinical Coordinator confirmed she should have placed PPE and COVID-19 isolation signage on Resident #27's door. In an interview on 05/31/2023 at 3:57 p.m., S3ADON/IP stated PPE and COVID-19 isolation signage should be placed on a COVID-19 positive resident's door immediately and all staff should be made aware. In an interview on 06/01/2023 at 11:46 a.m., S2DON stated Resident #27 should have been placed on COVID-19 precautions immediately following her positive COVID-19 test. 3.) Review of the facility's Droplet Precautions policy revealed, in part, gloves, gown, and goggles should be worn when a resident is on droplet precautions. Review of the facility's Personal Protective Equipment (PPE) policy revealed, in part, PPE provided to the facility's personnel included gowns, gloves, masks, and eye wear. Review of Resident #3's nurses notes dated 05/30/2023 at 6:03 p.m. revealed, in part, Resident #3 tested positive for COVID-19. In an interview on 05/31/2023 at 11:00 a.m., S4LPN stated Resident #3 remained symptomatic of COVID-19. S4LPN further stated Resident #3's symptoms included cough, body aches, and weakness. In an interview on 05/31/2023 at 12:30 p.m., S23Agency CNA stated the only resident positive for COVID-19 was Resident #3. Observation on 5/31/2023 at 1:33 p.m. revealed, S4LPN exited Resident #3's room with a gown, face shield, gloves, and an N95 mask on and entered Hall Y's Dayroom. In an interview on 05/31/2023 at 2:13 p.m., S10Clinical Coordinator stated she witnessed S4LPN exit Resident #3's room with a gown, face shield, gloves, and an N95 mask and entered Hall Y's Dayroom. S10Clinical Coordinator stated S4LPN should have removed her gown, gloves, and face shield prior to exiting Resident #3's room. S10Clinical Coordinator further stated S4LPN should have removed her N95 mask, discarded it, and replaced it with a new one and she did not. Review of Resident #27's nurse's notes dated 05/31/2023 at 3:14 p.m. revealed, in part, Resident #27 tested positive for COVID-19. In an interview on 05/31/2023 at 12:02 p.m., S10Clinical Coordinator stated Resident #27 was symptomatic. S10Clinical Coordinator further stated Resident #27's symptoms included cough, body aches, and a sore throat. Observation on 05/31/2023 at 12:43 p.m., revealed, S23Agency Certified Nursing Assistant (CNA) entered Resident #27's resident's room without a gown, gloves, or face shield in place. Further observation revealed S23CNA assisted Resident #27 with her clothing and then exited Resident #27's room and gave a cup of ice to Resident #74. Observation on 05/31/2023 at 12:54 p.m. revealed, Resident #27's door open without PPE or COVID-19 signage present. Observation on 05/31/2023 at 1:02 p.m. revealed, S24Housekeeper entered Resident #27's room without a gown, gloves, and a face shield. Observation further revealed S24Housekeeper handed Resident #27 a clothing item and then proceeded to the Hall Y's housekeeping closet to restock her cart. In an interview on 05/31/2023 at 1:36 p.m., S24Housekeeper confirmed she entered Resident #27's room without a gown, a face shield, and gloves. S24Housekeeper further stated she was unaware that Resident #27 tested positive for COVID-19. Observation on 05/31/2023 at 1:17 p.m. revealed S10Clinical Coordinator placed PPE and COVID-19 signage on Resident #27's door. In an interview on 05/31/2023 at 1:36 p.m., S23Agency CNA confirmed she entered Resident #27's room without a gown, a face shield, and gloves. S23Agency CNA further stated she was unaware that Resident #27 tested positive for COVID-19. In an interview on 05/31/2023 at 3:46 p.m., S10Clinical Coordinator confirmed she should have placed PPE and COVID-19 isolation signage on Resident #27's door and educated staff immediately after Resident #27 tested positive and she did not. In an interview on 05/31/2023 at 3:57 p.m., S3ADON/IP stated staff should wear a face shield, gown, N95 mask, and gloves prior to entering a COVID-19 isolation room and all PPE should be removed prior to exiting a COVID-19 isolation room. S3ADON/IP further stated PPE and COVID-19 isolation signage should be placed on a COVID-19 positive resident's door immediately and all staff should be made aware. In an interview on 06/01/2023 at 11:46 a.m., S2DON stated staff should never enter a COVID-19 positive resident's room without PPE in place and should never exit a COVID-19 positive resident's room with contaminated PPE on their person. S2DON further stated the observations reflected above puts the facility at risk for a facility wide COVID-19 outbreak.

Based on observation and interview, the facility failed to have current nurse staffing information posted on a daily basis. Findings: In an interview on 05/30/2023 at 9:20 a.m., S25Receptionist stated S11Clinical Coordinator posted the nursing staffing information daily; however, the posted staffing reflects the hours provided on the prior (or previous) day. Observation on 05/31/2023 at 10:32 a.m. revealed nurse staffing information posted at the front desk for the hours provided on 05/30/2023. Observation on 05/31/2023 at 2:30 p.m. revealed nurse staffing information posted on Hall A for the hours provided on 05/30/2023. Observation on 05/31/2023 at 10:30 a.m. revealed nurse staffing information posted at the front desk for the hours provided on 05/29/2023. Observation on 06/01/2023 at 10:33 a.m. revealed nurse staffing information posted on Hall A for the hours provided on 05/30/2023. Observation on 06/01/2023 at 10:36 a.m. revealed nurse staffing information posted on Hall B for the hours provided on 05/30/2023. Observation on 06/02/2023 at 12:05 p.m. revealed nurse staffing information posted on Hall B for the hours provided on 06/01/2023. Observation on 06/02/2023 at 1:56 p.m. revealed nurse staffing information posted on Hall A for the hours provided on 06/01/2023. Observation on 06/05/2023 at 9:19 a.m. revealed nurse staffing information posted on Hall B for the hours provided on 06/02/2023 and 06/03/2023. Observation on 06/05/2023 at 9:20 a.m. revealed nurse staffing information posted on Hall A for the hours provided on 06/02/2023 and 06/03/2023. In an interview on 06/05/2023 at 1:38 p.m., S11Clinical Coordinator stated the daily posted staffing should reflect the staffing for the current day. In an interview on 06/05/2023 at 1:38 p.m., S2Director of Nursing stated that the nurse staffing information posted daily should be for the current date and not a previous date.

Based on interviews, record reviews and observation, the facility failed to have a system in place to maintain an effective pest control program to ensure that residents were not bitten by ants for 2 (Resident #1, and Resident #5) of 9 sampled residents. This deficient practice had the potential to affect all the 100 residents residing in the facility as documented on the facility's census list. An Immediate Jeopardy occurred for Resident #1 on 09/10/2020 at approximately 11:15a.m., when ants were found crawling all over the resident's body and bed linens. Resident #1 was cognitively impaired, totally dependent for bed mobility, received feedings via Percutaneously Endoscopic Gastrostomy tube (PEG) tube and was unable to call for assistance. After the ants were removed from the resident's body, the resident was observed to have numerous raised bumps to his body including to the right scapula, left scapula, upper vertebra, right palm of hand, right back of hand, right front of thigh, right rear of thigh, right front of shoulder, left front of shoulder, and right rear of shoulder. Prior to Resident #1 being bitten by ants, on 09/02/2020 Resident #5, who was alert, and able to communicate, reported being bitten by ants while in bed with resulting ant bites to various parts of her body. Resident 5's room was sprayed for ants on 09/02/2020, 09/03/2020, 09/04/2020, 09/11/2020, 09/14/2020, 09/15/2020, and 09/22/2020 after reports of ants in her room. During the survey, staff reported continuing citing of ants inside of the facility. There was no evidence that any other rooms where ants were not sited was sprayed for ants. The facility was notified of the Immediate Jeopardy on 09/23/2020 at 4:10pm. On 09/24/2020 at 5:00pm, the facility submitted an acceptable plan of removal which included the following specify actions the entity will take to prevent fire ant bites: 1.) Maintenance Director visually inspected every room of the cognitively and/or physically impaired residents who are unable to report if ants are in their room and sealed any penetrations in the walls which was completed on 09/24/2020. 2.) Maintenance made rounds on the exterior perimeter of the building to observe for and treat any signs of ants which was completed on 09/24/2020. On 09/24/2020 at 4:00pm, S4Maintenance Director completed a walkthrough around the exterior of the grounds and found five active new ant mounds. These were found in grassy areas of the property and not in close proximity of the building and mounds were treated with a fire ant chemical. 3.) _____________Pest Control Company will treat the entire perimeter of the facility for Fire Ants on 09/25/2020, assuming that it does not rain. Pest Control Company is not able to treat with the Fire Ant spray when the ground is wet. If it is raining, the treatment will be rescheduled to the next dry day. 4.) On the evening of 09/23/2020, in-service training for all Nursing and Housekeeping and Maintenance staff was started and the in-service training was continued on 09/24/2020. This training is anticipated to be completed on 09/25/2020 when the new 12 hour team reports to duty. The in-service training is being done by Nursing Administration and covered the following topics: a. How to monitor resident rooms for the presence of ants; b. What steps to take if ants are observed in a resident's room; and c. How to document on monitoring form 5.) Beginning 09/24/2020 Nursing staff and/or _________ (Community Training Program) employee to monitor identified resident's room every hour for ants and document on monitoring form for two weeks. At the end of the two week of hourly monitoring, the monitoring forms will be reviewed by the Administrator and the Quality Assurance Committee and a decision will be made on the frequency of monitoring necessary for the next three weeks. 6.) Beginning on 09/24/2020, Housekeeping staff will monitor every resident room once per day for ants and document of monitoring form. At the end of the two weeks of daily monitoring, the monitoring forms will be reviewed by the Administrator and the Quality Assurance Committee and a decision will be made as to how long the daily rounds will be continued. 7.) Any sign of ants in a resident room will be reported to the Maintenance Director, Director of Nursing, or Administrator immediately. 8.) Upon reports of ants, resident room will be treated with appropriate chemical as necessary. 9.) Maintenance staff and/or Designee will visually monitor the remainder of the resident rooms and seal any penetrations in the walls. This will begin on 09/24/2020 and will be completed by 09/30/3030. 10.) Maintenance staff and/or designee will visually monitor every resident room daily and document on monitoring form. 11.) Beginning 09/24/2020, Maintenance staff to monitor the exterior perimeter of the facility daily for two weeks for signs of ants and/or ant mounds and treat with appropriate chemical as necessary and document on monitoring form. 12.) The facility implemented an hourly room monitoring form with was begun on 09/24/2020 at 1:00pm. When in a resident room look for presence of ants in the following areas: in doorway, floor around edges of room and around furniture, in bathroom, around bed and in resident bed, wheelchair, and resident. Initial monitoring form in appropriate box to verify that you monitored room and sign and initial signature sheet. 13.) Review of the in-service sheets dated 09/24/2020 revealed staff were informed of the one hour rounds on ants in room, on resident, on floor, monitor for resident who cannot physically call for help, cognitively impaired. Inform Maintenance, DON immediately if ants observed. Remove resident from room. The Immediate Jeopardy was removed on 09/24/2020 at 5:10pm. This deficient practice continued as a potential for actual harm for 22 residents who were identified as cognitively and/or physically impaired and were unable to report if ants were in their rooms and a potential for more than minimal harm for the 78 other residents in the facility. Findings: Review of the facility's Pest Control Agreement dated 01/22/2020 revealed in part, the pest control company would perform scheduled service for the following pests, ants were checked and further review revealed ants that were excluded: carpenter, fire and pharaoh ants. Further review of the pest control contracts revealed in part, it was not until 09/14/2020 that a pest control agreement for was put in place for fire ants, crazy ants, pharaoh ants, big ants and little black ants. Review of the facility's room census list revealed Resident #1 room f and Resident #6 room e were located on the same hall. Resident #1 Resident #1 was admitted on [DATE] with a diagnoses, in part, of Cerebral Vascular Disease, Dysphagia, Protein Calorie Nutrition, [MEDICAL CONDITION] and [MEDICAL CONDITION] following Cerebral Vascular Disease affecting the right dominant side. Resident #1 resided in Room f Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/02/2020 revealed in part, Resident #1 was rarely or never understood. Resident #1 was cognitively impaired and unable to call for assistance. Further review revealed Resident #1 required total dependence and one person assist for bed mobility, toilet use, dressing, and personal hygiene. Resident #1 had a wheelchair checked for mobility and had a feeding tube for nutritional support. Review of the Resident #1's September 2020 physician orders [REDACTED]. [MEDICATION NAME] Cream 1% apply to affected areas topically every 8 hours as needed for skin irritation for 5 days with a start date of 09/11/2020. [MEDICATION NAME] 10 milligrams (mg) once a day for allergies [REDACTED]. Daily baths until skin irritation was resolved every day/shift with a start date of 09/11/2020. Monitor for skin irritation (scalp, neck, chest, right hand, left inner elbow, left axilla, left truck, left inner and outer thigh), document every shift until resolved, and update physician as needed with a start date of 09/10/2020. Keflex 500mg per PEG (medication used to prevent or treat infection) one time only for one day with a start date of 09/10/2020. Keflex 500 mg one per PEG for 7 days with a start date of 09/11/2020. Review of Resident #1's nurse's note dated 09/10/2020 at 11:15am revealed in part, called to the room per Certified Nursing Assistant (CNA). Resident noted to have ants crawling all over his body and linens. Ants immediately removed from resident body and linens removed from bed. Numerous bumps noted to upper chest, shoulders, right hand/fingers and back area. Review of Resident #1's skin assessment dated [DATE] at 11:15am revealed in part, raised bumps on the following areas: right scapula, left scapula, upper vertebra, right palm of hand, right back of hand, right front of thigh, right rear of thigh, right front of shoulder, left front of shoulder, and right rear of shoulder. Further review under comments revealed insect bites. Review of Resident #1's weekly skin report dated 09/12/2020 revealed in part under impaired skin yes was checked with skin irritant to left scapula, chest, abdomen, left antecubital, left front ileac crest, left hip trochanter, left palm of hand, right rear shoulder, and left rear shoulder. Review of Resident #1's wound care notes dated 09/10/2020 revealed in part, skin assessment: resident noted with red bumps to scalp, neck chest, right hand (palm and dorsal) left axilla, left inner elbow, left shoulder to left lower back, and left lower an outer thigh (suspected insect bites). Further record review revealed [MEDICATION NAME] Cream 1% every 8 hours as needed for skin irritation for 5 days. In an interview on 09/21/2020 at 11:19am, S2Director of Nurses (DON) stated she was called out of a meeting (09/10/2020) and told by Resident #1's nurse, he had been bitten by ants. In a telephone interview on 09/21/2020 at 1:40pm, S11Licensed Practical Nurse (LPN) said S12CNA came running out of Resident #1's room saying ants were on him (09/10/2020.) She said she ran into Resident #1's room and he was covered with ants. She further said she immediately flipped Resident #1 over and she was on one side and S12CNA was on the other. She further said they were brushing ants off of him. She said the ants were coming from under the furniture and they were coming up the leg of the bed. She said he had many ant bites on his back, and on the right side of his chest, shoulder and some on his right leg. In a telephone interview on 09/21/2020 at 2:24pm, S12CNA said she went into Resident #1's room around 7:20am (09/10/2020) and checked on Resident #1. She said she went back into Resident #1's room around 10:15am and cut the light on, lifted the bed up, and ants were on his neck. She further stated she ran to get the nurse. She further said she called out for Resident #1's nurse and said, who has Resident #1, he is full of ants. Resident #1 was not observed due to not being in the facility during the time of the survey. Resident #5 Review of Resident #5's record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Resident #5 resided in room a. Review of Resident #5's MDS with ARD of 07/29/2020 revealed in part, a Brief Interview for Mental Status (BIMS) of 11, and that she required a one person supervision with toileting and personal hygiene. Resident #5 used a wheelchair for mobility. Review of Resident #5's investigative report dated 09/03/2020 revealed, in part, that the nurse was notified by the resident that she had been bitten by ants last night while she slept. The injury locations documented were on the back of left hand, back of right hand, abdomen and front of left thigh with insect bites noted to upper extremities and left thigh. Further review of the investigative report revealed Resident #5 denied pain and complained of itching. Review of Resident #5's care plan dated 09/03/2020 revealed in part, a problem identified for ant bites to abdomen, left and right hands, and left thigh with approaches to treat injury per physician order [REDACTED]. Review of Resident #5's physician progress notes [REDACTED]. Review of the facility's Maintenance Repair Requisition dated 09/02/2020 revealed ants in room a. Review of the facility's Maintenance Repair Requisition dated 09/03/2020 room a sprayed for ants. Review of the facility's Maintenance Repair Requisition dated 09/04/2020 room a sprayed for ants with a note on the requisition form -sprayed room a three times today. Review of the facility's Maintenance Repair Requisition dated 09/11/2020 rooms a spray for ants. Review of the facility's Maintenance Repair Requisition dated 09/14/2020 - room a spray for ants. Review of the facility's Maintenance Repair Requisition dated 09/15/2020- room a spray for ants. Review of the facility's Maintenance Repair Requisition dated 09/22/2020 room a spray room for ants. Review of the facility's Pest Audit tool revealed the only audit of all resident rooms was completed on 09/10/2020 and 09/21/2020. In an interview on 09/22/2020 at 10:40am, S1Administrator stated she was unaware of Resident #5 having insect bites on 09/02/2020 and was not informed that Resident #5 experienced ant bites until the morning meeting on 09/18/2020. S1Administration stated she should have been informed when Resident #5 got bitten by ants. S1Administrator confirmed nothing was done on 09/02/2020 because she was unaware the incident had taken place with Resident #5. In an interview on 09/22/2020 at 10:50am, S2Director of Nursing (DON) stated she reviewed incident reports once a week, if time permitted. S2DON stated she was unaware Resident #5 having ants in her room and unaware Resident #5 received ant bites on 09/02/2020. S2DON stated she was not informed of the incident with the ants and Resident #5 getting ant bites until the morning meeting on 09/18/2020. S2DON stated the nurse reported the ant issue with Resident #5 to the Maintenance Department, but stated she should have reported it to the Administrator. In an interview on 09/22/2020 at 11:00am, S4Maintenance Director stated Resident #5 reported ants in her room and Maintenance went to spray her room for the ants on 09/02/2020. S4Maintenance Director stated she did not see ants in her room when she went in her room on 09/02/2020. S4Maintenance Director stated she should have reported Resident #5 getting bit by ants to the Administrator and she did not. In an interview on 09/22/2020 at 11:15am, S3ADON stated she was responsible for reviewing the incident reports. S3ADON stated the managers on each unit are responsible for reviewing the incident reports on each unit and that she was on vacation for several days in September. S3ADON stated she became aware of the ant bites to Resident #5 on 09/17/2020 when she pulled the incident reports for her safety meeting that was held on 09/18/2020. She confirmed the last safety meeting prior to 09/18/2020 was on 09/01/2020. In an interview on 09/22/2020 at 11:30am, S5Unit Manager stated Resident #5 had reported to her that there were ants in her room. S5Unit Manager stated she assessed Resident #5 and she had bites to the top of both her hands, left thigh and her abdomen. Resident #5 was in her bed when the ant bites occurred. S5Unit Manager stated when she went into Resident #5's room on 09/03/2020, she did not look under everything in her room, but housekeeping had just cleaned her room and she did not observe any ants. S5Unit Manager did not recall informing the S2DON or S1Administrator about Resident #5 having ant bites. S5Unit Manager stated there were three cognitively impaired residents on her unit and they would not be able to alert staff if ants were present in their rooms or on their bodies. In a telephone interview on 09/22/2020 at 12:00pm, S6Housekeeper stated on the morning of 09/03/2020 Resident #5 told S6Housekeeper that she had ants in her room. S6Housekeeper verbally reported the ants to S7Housekeeping Director and maintenance staff went into Resident #5's room and sprayed for ants. S6Housekeeper stated she went to clean Resident #5's room after the room was sprayed for ants and she saw dead ants on the floor on the side and back of Resident #5's bed. In an interview on 09/21/2020 at 12:25pm, S8LPN was questioned about ants or pests in the facility and S8LPN stated the resident in room a (Resident #5) sustained ant bites to her hand about two weeks ago. S8LPN stated she could not recall the exact time the resident in room a informed her of the ant bites, but presented surveyor a copy of a fax to the Physician dated 09/02/2020 at 6:00pm. S8LPN stated she could not remember who she reported the incident regarding ant bites to resident in room a. She stated the unit manager completed the incident report regarding the ant bites to resident in room a on 09/03/2020. S8LPN stated she received an order for [REDACTED]. In an interview on 09/22/2020 at 1:50pm, S8LPN stated Resident #5 only had ant bites on her hand and S8LPN did not go into Resident #5's room to look for ants when Resident #5 reported the ant bites to her hand on 09/02/2020. In an interview on 09/22/2020 at 2:05pm, S9Housekeeper stated she normally works the 6:00am to 2:00pm shift on Resident #5's hall. S9Housekeeper stated Resident #5 showed her ants in her room, which were located in her bathroom and behind her television stand. S9Housekeeper stated she reported the ants to the Maintenance staff and she recalled the Maintenance staff going to Resident #5's room and sprayed for ants, but unsure of the exact date. S9Housekeeper confirmed she was not informed to do any room observations or document the room observations after the ants were found in Resident #5's room. In an interview on 09/22/2020 at 2:15pm, S10CNA stated she was assigned to Resident #5's hall. S10CNA recalled Resident #5 complaining of ants in her room, but unsure of exact date. An observation on 09/22/2020 at 2:20pm revealed Resident #5 sitting in her wheelchair awake, alert and able to answer questions. In an interview, the resident stated she had gotten bitten by ants on both hands, both arms, thigh and left foot, but stated they were all healed up now. In a joint interview on 09/23/2020 at 1:00pm, S13CNA and S15CNA stated they were both CNAs on Resident #5's hall. Surveyor questioned them if they had observed ants in any resident room and they both stated room f on 09/10/2020 and room e on 09/20/2020. S15CNA and S16CNA stated they received two in-services involving ants. The first in-service occurred the day of or the day after Resident #1 had ants in his room. They were instructed to notify the nurse and housekeeping staff if they saw ants and housekeeping staff would notify the maintenance staff. S15CNA and S16CNA stated the in-service was held on each hall. The second in-service concerning ants was held on 09/15/2020 and they were instructed to check rooms when it rains and check rooms for open food and remove the food if they find food out. S15CNA and S16CNA confirmed they were not given an audit tool to complete and they were not notified to check resident rooms at a certain time for ants. In a joint interview on 09/23/2020 at 1:25pm, S17CNA and S18CNA stated they were in-serviced on 09/15/2020 for the first time regarding ants in the facility. S17CNA and S18CNA confirmed they were not given an audit tool to complete and they were not notified to check resident rooms at a certain time for ants. In an interview on 09/23/2020 at 2:45pm, S5Unit Manager stated after Resident #5 sustained ant bites on 09/02/2020, she completed the incident report the following day. S5Unit Manager stated S8LPN should have reported the ant bites to S2DON on 09/02/2020 and she did not. S5Unit Manager stated she inspected Resident #5's room and assessed Resident #5 on 09/03/2020 and she should have reported the ants to S1Administrator and she did not. Resident #6 Review of Resident #6's MDS with an ARD dated 07/15/2020 revealed she was cognitively intact. In an interview on 09/21/2020 at 12:30pm, S4Maintance Director said she was notified on the night of 09/20/2020 of ants in room e. She further indicated S1Administrator came out and checked room e and sprayed. In an interview on 09/21/2020 at 12:45pm, Resident #6 who resides in room e stated S13CNA came into her room toward the end of her shift on 09/20/2020 and noticed ants on the floor. She further indicated she can't see too well but S13CNA noticed the ants and went and told the nurse. In an interview on 09/22/2020 at 3:30pm, S1Administrator was questioned after ants were found in Resident #6's room on 09/20/2020, she stated she only checked the resident rooms in that area by Resident #6. S1Administrator was questioned if she had checked 100% of all resident rooms after finding ants in Resident #6's room on 09/20/2020 and she said no. In an interview on 09/23/2020 at 11:47am, S1Administrator stated she requested a contract for adding ant control on 09/10/2020, received a contract on 09/11/2020 and she signed the contract on 09/14/2020. In an interview on 09/22/2020 at 3:30pm, S1Administrator was questioned after ants were found in Resident #6's room, and she indicated she only checked the resident rooms in that area. In an interview on 09/23/2020 at 11:47am, S1Administrator indicated she requested a contract for adding ant control on 09/11/2020 and she signed the contract on 09/14/2020. In a telephone interview on 09/23/2020 at 3:31pm with a Terminex employee, she stated as she was reviewing the service work invoice and indicated on 09/22/2020 they found fire ants in resident rooms and identified trailing ants and nests in the exterior grounds and treated the exterior area where they found ants. She further indicated they are going to do a thorough treatment on 09/25/2020. She stated the 09/10/2020 service work invoice was a monthly treatment and there were no notes regarding ants, only exterior treatment. She stated the 08/25/2020 service work invoice revealed they had replaced bait stations and treated the interior and exterior for normal pests. She indicated the monthly treatments do not cover fire ants. In an interview on 09/24/2020 at 09:36am, S13CNA stated she was going into Resident #6's room to change her around 5pm or 6pm in the evening and noticed a trail of ants by Resident #6's dresser and her air condition unit on 09/20/2020. Resident #6 resided in room e. In an interview on 09/24/2020 at 2:15pm, S14Housekeeper said she found live ants by the entrance of rooms, g and b on 09/22/2020. In an interview on 09/24/2020 at 12:00pm, S4Maintenance Director stated she caulked the hole in Resident #1's room, where they suspected the ants were coming in from, on two different occasions on 09/22/2020 and 09/23/2020. S4Maintenance Director was questioned if she had checked for any cracks or holes in the walls in any other resident room, since the incident with Resident #1 or Resident #5, and she stated she had not.

Based on observations, record reviews, and interviews the facility failed to ensure residents were free from physical restraints imposed for convenience and not being used to treat a medical condition for 2 of 5 sampled residents (#1 and #2) and 6 of 19 random sampled residents (#R6, #R7, #R8, #R9, #R10, and #R11). The facility is licensed for 138 beds and had a current census of 122. The facility: 1. used a lap belt restraint and side rail restraints without a medical condition that required the use of the restraints; 2. used side rail restraints and seat belt restraints without a physician's order; 3. failed to obtain signed informed consent from the resident/ responsible party before using side rail restraints and seat belt restraints; 4. failed to ensure that nurses and CNAs knew which residents used seat belt restraints; 5. failed to ensure the safety of the resident while in a lap restraint and a seat belt restraint. Residents #1 and #2 were placed in Immediate Jeopardy when the facility began using a lap belt restraint and using side rails (#2) on the residents without consulting with the physician, obtaining a physician order, determining the medical symptom the restraint was needed to treat, and ensuring the safety of the residents before placing them in a lap restraint or use of side rails. The Immediate Jeopardy was removed for #2 when she died on [DATE]. The Immediate Jeopardy was removed for #1 when the lap belt was removed on [DATE] at 4:00 PM. Resident #1, #R6, #R7, #R8, #R9, #R10, and #R11 were in Immediate Jeopardy on [DATE] at 3:50 PM. Resident #1 was in a wheelchair with a lap belt around her waist. #R7, #R8, #R9, #R10, and #R11 were in wheelchairs with lap belts attached to the wheelchairs. #R6 was not observed sitting in the wheelchair but had an assigned wheelchair with a lap belt. The Immediate Jeopardy was removed on [DATE] at 4:00 PM when maintenance removed all of the lap belts that were attached to wheelchairs used by residents who had not been assessed and care planned with increased supervision and safety for lap belts and when maintenance remove the lap belts from all the wheelchairs in the facility that was not in current use. S1, DON had started an in service training regarding the use of restraints on [DATE] at 4:30 AM. The deficient practice continued at a potential for more than minimal harm that is not immediate jeopardy for residents who could be placed in a restraint for convenience and without a medical symptom that warranted the use of a restraint. The facility has not put a plan in place with quality assurance to ensure the deficient practice does not occur again. Findings: Policy: ...to prevent the resident from injury to self and others by restricting his/her movement with the use of the least restricted physical restraint device Equipment: 1. Order by physician 2. Signed consent 3. Device to be used Procedure: Wheelchair/Bed 1. Assess for the need of restraint use. 2. Consult Occupational Therapy for an evaluation for the least restricted restraint. 3. Call responsible part to explain the need and get approval to use a restraint. 4. Notify M.D. to obtain an order for [REDACTED]. During an interview with S1, DON on [DATE] at 11:30 AM she acknowledged that the facility did not follow the established policy and procedure for the use of restraints. Resident #2: Resident #2 was a 90 y/o female who was admitted to the facility on [DATE] from an acute hospital with the following Diagnoses: [REDACTED]. She was a Do Not Resuscitate (DNR) and was receiving Hospice care. Review of the Physician's Orders for January and February failed to provide any evidence that the facility had consulted the physician, obtained a physician order, or obtained an informed consent with benefits and risks for the restraint before placing the resident in a lap restraint. Review of the resident ' s record revealed no documentation regarding informed consent regarding the lap restraint. Record review for Resident #2 revealed that there was a Restraint Consent Form which noted in part: I understand that all restraints are ordered by the physician and all residents are assessed on a continual basis to assure that the least restrictive device is in use. I understand that the following physical restraint is being ordered by the physician for the following medical symptom: .... Further review of this form revealed a handwritten note dated [DATE] with the signature of S13, Rehabilitation Director (Occupational Therapy) which indicated that the resident would require a Geri chair while out of bed secondary to postural instability and lap tray for positioning. Further review of this form revealed that the form was not signed by the Responsible Party (RP). The signature, date, and witness signature spaces were blank. Review of the resident ' s medical record failed to include an evaluation for the use of a lap belt restraint. There was a recommendation from Occupational Therapy(OT) for Geri Chair with Lap tray, but the recommendation had not been followed; no doctor's orders, no consent from the family/responsible party, and no care plan. During an interview with S1, DON on [DATE] at 11:30 she acknowledged that the recommendation of OT for a Geri Chair with a Lap tray had not been followed through with a physician's order, signed informed consent by the resident/responsible party, and a plan of care. In addition, S1, DON stated that there had been no recommendation regarding the use of a lap restraint and that this resident should not have been placed in a lap restraint. Review of the Nurse's Notes dated [DATE] and signed by S4, LPN revealed in part the following: 07:15 AM - the resident was sitting up in a wheelchair with restraint intact, alert and awake in room. Resting quietly. No distress noted. Will monitor. 07:30 AM - the nurse and the aide were called to the room by housekeeper. Resident was on the floor in front of the wheelchair with the restraint around her neck. Restraint was loosely around neck. 3 fingers were able to be placed between the restraints. No bruising or marks were noted to neck area. Resident was transferred to bed by nurse and aide. No pulse or respirations noted. 07:35 AM - Hospice was notified that the resident had expired. Awaiting for hospice to arrive. 07:35 AM - MT notified that the resident had expired. Requested to have an EKG strip done. 8:05 AM - resident was pronounced dead by Dr_____ at _____hospital. During an interview with S4, LPN on [DATE] at 11:30 AM, she stated that she worked every other weekend at the facility and that this was her first time working with Resident #2. S4,LPN stated that she had made rounds on [DATE] at 6:15 AM, before she received morning report. She stated that she observed the resident at 6:15 AM sitting up in a wheelchair with a lap belt around her waist and that the resident was in no distress. S4, LPN further stated that during shift report that S9, LPN (off going nurse) informed her that the resident was a hospice resident, NPO(nothing by mouth), had been up all night, and was now sitting up in a wheelchair in her room. S4, LPN stated that she could not recall if the off going nurse told her in report that the resident was in a lap belt restraint but she knew that the resident was because she had already observed the resident and noted that she was. During an interview on [DATE] at 12:51 PM with S6, CNA, she stated that she had worked at the facility for about 2 years and that the unit where the incident occurred was her usual assigned unit. However, she stated that this was her first time working with Resident #2. S6, CNA further stated that the resident had not slept at all that night, had been restless, trying to pull off her clothes and trying to get out of the bed. S6, CNA stated that she asked S9, LPN if she wanted her to get the resident out of the bed around 5:50 AM on [DATE]. S6, CNA stated that she went into the room and noticed that there were two chairs in the room, one in the rest room and one by the bed. S6, CNA stated that she asked S9, LPN which chair to get the resident up into because she had not worked with the resident before. She was told by S9, LPN to get her up into the chair by the bed which was the wheelchair which had a lap belt attached to it. S6, CNA stated that after she finished providing AM care to Resident #2, she got the resident up into the wheelchair and fastened the lap belt around her waist. S6, CNA stated that this was the last time she had seen the resident because her shift ended at 6:00 AM. When asked about change of shift report, S6, CNA stated that she did not give a report to anyone that Resident #2 was up in a wheelchair with a lap belt restraint. S6, CNA stated that she thought that the nurses may give a report, but CNAs were told that they need to be off the clock by their shift end and so they do not report or make rounds with the oncoming CNAs. During an interview on [DATE] at 2:19PM with S9, LPN, she stated that she had been with the facility since [DATE] and had worked with Resident #2 before. She stated that she came to work on [DATE] at 09:45PM and worked until 06:15 AM on [DATE]. She stated that she was told in the beginning of the shift report that the resident had been restless, no longer on hospice meds, and only receiving [MEDICATION NAME]. S9, LPN stated that she was told that the resident had received both dosages of [MEDICATION NAME]. S9, LPN stated that the resident was restless during her shift and that she had made frequent rounds on the resident and had instructed S6,CNA to also make frequent rounds on Resident #2 because she was so restless. S9, LPN stated that she did not document the rounds but made a summary note at the end of her shift that the resident had been restless all night. S9, LPN stated that she and S6, CNA both entered the resident's room at 5:50 AM. S9, LPN stated that S6, CNA had started to provide AM care to #2 before she left the room. When asked if she had instructed S6, CNA to get the resident up into the wheelchair, S9, LPN denied any discussion with S6, CNA about getting the resident up into any chair. S9, LPN stated that she left S6, CNA in the resident's room and went on to complete her work. S9, LPN stated that this was the last time she saw Resident #2, and at this time the resident was still in the bed. Resident #2: Further review of the Nurse's Notes dated [DATE] at 1:00 PM with S14, LPN's signature revealed that Resident #2's legs had gotten caught between the mattress and the side rails of the bed causing an abrasion, the physician was notified via fax, and that pillows were placed between the rails and the mattress. Review of the medical record for Resident #2 failed to provide any evidence that the resident had been assessed for the use side rails, there was no physician order or care plan for the use of side rails prior to the use of the side rails on [DATE]. Record review revealed a Side-Rail Preference Form had been partially completed, it contained #2's name and room number, a witness signature dated [DATE] and a handwritten note signed by S13, Rehab Director indicating that #2 would require the bed in the lowest possible position with scoop mattress, 2 side rails up for positioning and mats on the floor. During an interview on [DATE] at 5:44AM with S14, LPN (the nurse who was assigned to #2 and documented the incidence on [DATE]) stated that she did not recall if the resident had an order for [REDACTED]. Review of the admit Physician's Orders for January and February failed to provide any evidence that the facility had consulted the physician, obtained a physician order, or obtained an informed consent with benefits and risks for use of side rails before using the side rails in the up position. During an interview on [DATE] at 11:30 AM, S1, DON stated that the facility does not consult the physician to obtain an order for [REDACTED]. Review of resident #2's medical records revealed no plan of care to address Resident #2 found lying in the bed with her lower extremities caught between the bed's mattress and side rails. During an interview on [DATE] at 9:45am with S12, MDS Coordinator and S1, Director of Nursing on [DATE] at 10:30 am, they indicated a plan of care had never been developed to address Resident #2's need for the use of a restraint to treat her medical symptom of agitation resulting in the resident having an incident of falling between the mattress and side rails. S#1 and S#12 further indicated there should have been approaches developed to prevent incidents which could result in a negative outcome for Resident #2. Resident #1 Observations on [DATE] at 3:50PM revealed that Resident #1 was sitting in a wheelchair with a lap belt around her waist. S11, CNA was wheeling #1 to the dining room. During an interview with S11, CNA at this time, she stated that the resident can remove the belt. However, when she asked the resident to remove the belt, the resident just began to pick at the belt and was unable to remove the lap belt restraint. S11, CNA stated then that most times the resident can remove the belt. Record review for Resident #1 revealed that she did not have an order for [REDACTED]. for the lap belt. S1, DON accompanied the surveyor to the dining room at 4:00 PM. Observations at this time revealed that Resident #1 no longer had the lap belt around her waist. During an interview with S11, CNA (who had just informed the surveyor that the resident can remove the lap belt most times), she stated that she did not know that Resident #1 was not suppose to be in the lap belt. She further stated that the lap belt was on the chair and she assumed that the resident was suppose to be in it so she fastened the resident in the lap belt. S1, DON stated that the first wheelchair that S11, CNA had placed #1 in was not her wheelchair. S1, DON further stated that she does not know what happens around dining times, but that it seems as though the staff will grab the nearest available to wheelchair to put the residents in and bring them to the dining room. Residents R#6 - R#11: Observations on ,[DATE] and on [DATE] at 4 pm, revealed 19 wheelchairs that had lap belts attached to the wheelchairs. Residents S#7, #8, #9, #10 and #11 were observed with the lap belt attached to the wheelchair, but the lap belts were not in use. Medical Record reviews and interviews with S#1 on dated [DATE] at 10am revealed that 5 of the 19 chairs were assigned to residents who had not been evaluated for the use of a lap belt (R#7 - R#11). Resident #R6 was not observed sitting in the wheelchair but observation revealed the resident ha an assigned wheelchair with a lap belt attached to the wheelchair.

Based on record review and interviews the facility failed to ensure residents received increased supervision to prevent accidents and that the resident ' s environment remain free of accident hazards for 2 of 5 sampled residents (#1 and #2) and 6 of 19 random sampled residents (#R6, #R7, #R8, #R9, #R10, and #R11). The facility is licensed for 138 beds and had a current census of 122. The facility failed to: 1. for residents who were not to use lap belts, removed lap belts from resident's wheelchairs; 2. ensure nurses and CNAs knew which resident were to use lap belts; 3. ensure nurses increased supervision of residents using lap belts; 4. ensure the safety of residents in wheelchairs with lapbelts and siderails; 5. recognize that side rails were an accident hazard after resident #2 was found with her legs caught between the mattress and the side rails; 6. stop using side rails after resident #2 was found with her legs caught between the mattress and the side rails; 7. recognize that side rails which a resident could not remove were restraints. Resident #2 was in a private room. Resident #2 was placed in Immediate Jeopardy on [DATE] at 1:00 PM when the resident got her legs caught between the mattress and the side rails of the bed causing an abrasion and the facility failed to recognize the side rails were accident hazards and failed to stop using the side rails. Resident #2 was placed in Immediate Jeopardy on [DATE] when a wheelchair with a lap belt was in the resident's room and the resident was placed in the wheelchair with the lap belt secured. On [DATE] at 07:30 AM, the resident was on the floor in front of the wheelchair with the restraint around her neck and no pulse and respiration. The Immediate Jeopardy situations ended for the resident at 8:05 AM when the resident was pronounced dead. Resident #1, #R6, #R7, #R8, #R9, #R10, and #R11 were in Immediate Jeopardy on [DATE] at 3:50 PM. Resident #1 was in a wheelchair with a lap belt around her waist. #R7, #R8, #R9, #R10, and #R11 were in wheelchairs with lap belts attached to the wheelchairs. #R6 was not observed sitting in the wheelchair but had an assigned wheelchair with a lap belt. The Immediate Jeopardy was removed on [DATE] at 4:00 PM when maintenance removed all of the lap belts that were attached to wheelchairs used by residents who had not been assessed and care planned with increased supervision and safety for lap belts and when maintenance remove the lap belts from all the wheelchairs in the facility that was not in current use. S1, DON had started an in service training regarding the use of restraints on [DATE] at 4:30 AM. The deficient practice continued at a potential for more than minimal harm that is not immediate jeopardy for residents who could be placed in a restraint without being assessed, care planned with supervision in place to prevent accident hazards and accidents. The facility has not put a plan in place with quality assurance to ensure the deficient practice does not occur again. Findings: Resident #2: Resident #2 was a 90 y/o female who was admitted to the facility on [DATE] from an acute hospital with the following Diagnoses: [REDACTED]. She was a Do Not Resuscitate (DNR) and was receiving Hospice care. Observation revealed resident #2 resided in a private room. Review of the Physician's Orders for January and February failed to provide a physician order for [REDACTED]. Review of the resident's record revealed no documentation regarding informed consent regarding the lap restraint. Record review for Resident #2 revealed a Restraint Consent Form which noted in part: I understand that all restraints are ordered by the physician and all residents are assessed on a continual basis to assure that the least restrictive device is in use. I understand that the following physical restraint is being ordered by the physician for the following medical symptom: .... Further review of this form revealed a handwritten note dated [DATE] with the signature of S13, Rehabilitation Director (Occupational Therapy) which indicated that the resident would require a Geri chair while out of bed secondary to postural instability and lap tray for positioning. Further review of this form revealed that the form was not signed by the Responsible Party (RP). The signature, date, and witness signature spaces were blank. Review of the resident's medical record failed to include an evaluation for the use of a lap belt restraint. There was a recommendation from Occupational Therapy(OT) for Geri Chair with Lap tray. Review revealed the recommendation had not been followed; no doctor's orders, no consent from the family/responsible party, and no care plan. During an interview with S1, DON on [DATE] at 11:30 she acknowledged that the recommendation of OT for a Geri Chair with a Lap tray had not been followed through with a physician's order, signed informed consent by the resident/responsible party, and a plan of care. S1, DON stated that there had been no recommendation regarding the use of a lap restraint and that this resident should not have been placed in a lap restraint. Review of the Nurse's Notes dated [DATE] and signed by S4, LPN revealed in part the following: 07:15 AM: the resident was sitting up in a wheelchair with restraint intact, alert and awake in room. Resting quietly. No distress noted. Will monitor. 07:30 AM: the nurse and the aide were called to the room by housekeeper. Resident was on the floor in front of the wheelchair with the restraint around her neck. Restraint was loosely around neck. 3 fingers were able to be placed between the restraints. No bruising or marks were noted to neck area. Resident was transferred to bed by nurse and aide. No pulse or respirations noted. 07:35 AM: Hospice was notified that the resident had expired. Awaiting for hospice to arrive. 07:35 AM: MT notified that the resident had expired. Requested to have an EKG strip done. 8:05 AM: resident was pronounced dead by Dr_____ at _____hospital. During an interview with S4, LPN on [DATE] at 11:30 AM, she stated that she worked every other weekend at the facility and that this was her first time working with Resident #2. S4,LPN stated that she had made rounds on [DATE] at 6:15 AM, before she received morning report. She stated that she observed the resident at 6:15 AM sitting up in a wheelchair with a lap belt around her waist and that the resident was in no distress. S4, LPN further stated that during shift report that S9, LPN (off going nurse) informed her that the resident was a hospice resident, NPO(nothing by mouth), had been up all night, and was now sitting up in a wheelchair in her room. S4, LPN stated that she could not recall if the off going nurse told her in report that the resident was in a lap belt restraint but she knew that the resident was because she had already observed the resident and noted that she was. During an interview on [DATE] at 12:51 PM with S6, CNA, she stated that she had worked at the facility for about 2 years and that the unit where the incident occurred was her usual assigned unit. She stated that this was her first time working with Resident #2. S6, CNA further stated that the resident had not slept at all that night, had been restless, trying to pull off her clothes and trying to get out of the bed. S6, CNA stated that she asked S9, LPN if she wanted her to get the resident out of the bed around 5:50 AM on [DATE]. S6, CNA stated that she went into the room and noticed that there were two chairs in the room, one in the rest room and one by the bed. S6, CNA stated that she asked S9, LPN which chair to get the resident up into because she had not worked with the resident before. She was told by S9, LPN to get her up into the chair by the bed which was the wheelchair which had a lap belt attached to it. S6, CNA stated that after she finished providing AM care to Resident #2, she got the resident up into the wheelchair and fastened the lap belt around her waist. S6, CNA stated that this was the last time she had seen the resident because her shift ended at 6:00 AM. When asked about change of shift report, S6, CNA stated that she did not give a report to anyone that Resident #2 was up in a wheelchair with a lap belt restraint. S6, CNA stated that she thought that the nurses may give a report, but CNAs were told that they need to be off the clock by their shift end and so they do not report or make rounds with the oncoming CNAs. During an interview on [DATE] at 2:19 PM with S9, LPN, she stated that she had been with the facility since [DATE] and had worked with Resident #2 before. She stated that she came to work on [DATE] at 09:45 PM and worked until 06:15 AM on [DATE]. She stated that she was told in the beginning of the shift report that the resident had been restless, no longer on hospice meds, and only receiving Haldol. S9, LPN stated that she was told that the resident had received both dosages of Haldol. S9, LPN stated that the resident was restless during her shift and that she had made frequent rounds on the resident and had instructed S6,CNA to also make frequent rounds on Resident #2 because she was so restless. S9, LPN stated that she did not document the rounds but made a summary note at the end of her shift that the resident had been restless all night. S9, LPN stated that she and S6, CNA both entered the resident's room at 5:50 AM. S9, LPN stated that S6, CNA had started to provide AM care to #2 before she left the room. When asked if she had instructed S6, CNA to get the resident up into the wheelchair, S9, LPN denied any discussion with S6, CNA about getting the resident up into any chair. S9, LPN stated that she left S6, CNA in the resident's room and went on to complete her work. S9, LPN stated that this was the last time she saw Resident #2, and at this time the resident was still in the bed. Resident #2: Further review of the Nurse's Notes dated [DATE] at 1:00 PM with S14, LPN's signature revealed that Resident #2's legs had gotten caught between the mattress and the side rails of the bed causing an abrasion, the physician was notified via fax, and that pillows were placed between the rails and the mattress. Review of the medical record for Resident #2 failed to provide any evidence that the resident had been assessed for the use side rails, there was no physician order or care plan for the use of side rails. Record review revealed a Side-Rail Preference Form had been partially completed, it contained #2's name and room number, a witness signature dated [DATE] and a handwritten note signed by S13, Rehab Director indicating that #2 would require the bed in the lowest possible position with scoop mattress, 2 side rails up for positioning and mats on the floor. During an interview on [DATE] at 5:44 AM with S14, LPN (the nurse who was assigned to #2 and documented the incidence on [DATE]) stated that she did not recall if the resident had an order for [REDACTED]. S14, LPN further stated that the #2 could not physically get out of the bed and that the two top side rails were used for safety. Review of the Physician's Orders for January and February failed to provide any evidence that the facility had consulted the physician, obtained a physician order, or obtained an informed consent with benefits and risks for use of side rails before using the side rails in the up position. During an interview on [DATE] at 11:30 AM, S1, DON stated that the facility does not consult the physician to obtain an order for [REDACTED]. However, she acknowledged that the facility had failed to failed to obtain an informed consent and failed to care plan this resident for the use of side rails in the up position. Review of resident #2's medical records revealed no plan of care to address Resident #2 found lying in the bed with her lower extremities caught between the bed's mattress and side rails. During an interview on [DATE] at 9:45am with S12, MDS Coordinator and S1, Director of Nursing on [DATE] at 10:30 am, they indicated a plan of care had never been developed to address Resident #2's need for the use of a restraint to treat her medical symptom of agitation resulting in the resident having an incident of falling between the mattress and side rails. S#1 and S#12 further indicated there should have been approaches developed to prevent incidents which could result in a negative outcome for Resident #2. Resident #1 Observations on [DATE] at 3:50 PM revealed that Resident #1 was sitting in a wheelchair with a lap belt around her waist. S11, CNA was wheeling #1 to the dining room. During an interview with S11, CNA at this time, she stated that the resident can remove the belt. However, when she asked the resident to remove the belt, the resident just began to pick at the belt and was unable to remove the lap belt restraint. Record review for Resident #1 revealed that she did not have an order for [REDACTED]. S1, DON accompanied the surveyor to the dining room at 4:00 PM. Observations at this time revealed that Resident #1 no longer had the lap belt around her waist. During an interview with S11, CNA on [DATE] at 4:00 pm, she stated that she did not know that Resident #1 was not suppose to be in the lap belt. She further stated that the lap belt was on the chair and she assumed that the resident was suppose to be in it so she fastened the resident in the lap belt. At this time, S1, DON stated that the first wheelchair that S11, CNA had placed #1 in was not her wheelchair. S1, DON further stated that she does not know what happens around dining times, but that it seems as though the staff will grab the nearest available to wheelchair to put the residents in and bring them to the dining room. Residents R#6 - R#11: Observations on ,[DATE] and on [DATE] at 4 pm, revealed 19 wheelchairs that had lap belts attached to the wheelchairs. Residents R#7, R#8, R#9, R#10 and R#11 were observed with the lap belt attached to the wheelchair, but the lap belts were not in use. Medical Record reviews and interviews with S#1 on dated [DATE] at 10 am revealed that 5 of the 19 chairs were assigned to residents who had not been evaluated for the use of a lap belt (R#7 - R#11). Resident #R6 was not observed sitting in the wheelchair but observation revealed the resident ha an assigned wheelchair with a lap belt attached to the wheelchair.

Based on observations, interviews, and record reviews, the Administrator (S2, Administrator) and the DON (S1, DON) failed to use resources effectively to maintain the highest physical well-being for 2 of 5 sampled residents and 6 of 19 random sampled residents (#R6, #R7, #R8, #R9, #R10, and #R11). The facility is licensed for 138 beds and had a current census of 122. The facility failed to: (1) have a system in place to provide clinical supervision to ensure policies and procedures regarding restraints were implemented; (2) ensure that the resident's environments remained as free from accidents hazards as possible by keeping wheelchairs with lap belt restraints attached to the wheelchairs out in the hall instead of a storage area; (3) develop and implement a policy and procedure regarding staff awareness of which residents required the use of a lap belt restraint and side rails. Resident #2 was in a private room. Resident #2 was in Immediate Jeopardy when the facility used restraints without a medical symptom that warranted the use of the restraints. Resident #2 was in Immediate Jeopardy on 02/01/11 at 1:00 PM when the resident got her legs caught between the mattress and the side rails of the bed causing an abrasion and the facility failed to recognize the side rails were accident hazards and continues to use the side rails. Resident #2 was in Immediate Jeopardy on 2/5/11 when a wheelchair with a lap belt was in the resident ' s room and the resident was placed in the wheelchair and the lap belt secured. On 2/5/11 at 07:30 AM, the resident was on the floor in front of the wheelchair with the restraint around her neck and no pulse and respiration. The Immediate Jeopardy situations ended for the resident at 8:05 AM when the resident was pronounced dead. Resident #1, #R6, #R7, #R8, #R9, #R10, and #R11 were in Immediate Jeopardy on 02/10/11 at 3:50 PM. Resident #1 was in a wheelchair with a lap belt around her waist. #R7, #R8, #R9, #R10, and #R11 were in wheelchairs with lap belts attached to the wheelchairs. #R6 was not observed sitting in the wheelchair but had an assigned wheelchair with a lap belt. The Immediate Jeopardy was removed on 02/11/11 at 4:00 PM when maintenance removed all of the lap belts that were attached to wheelchairs used by residents who had not been assessed and care planned with increased supervision and safety for lap belts and when maintenance remove the lap belts from all the wheelchairs in the facility that was not in current use. S1, DON had started an in service training regarding the use of restraints on 02/11/11 at 4:30 AM. The deficient practice continued at a potential for more than minimal harm that is not Immediate Jeopardy for residents who could be placed in a restraint without a medical symptom that warranted the use of restraints and without being assessed, care planned with supervision in place to prevent accident hazards and accidents. The facility has not put a plan in place with quality assurance to ensure the deficient practice does not occur again. Findings: 1. The facility failed to monitor and provide clinical supervision to ensure policies and procedures regarding restraints were implemented. Cross refer F221, 323 2. The facility failed to ensure that the resident's environments remained as free from accidents hazards as possible by keeping wheelchairs with lap belt restraints attached out in the hall instead of a storage area; Cross refer F323 3. The facility failed to develop and implement a policy and procedure regarding staff awareness of which residents required the use of a lap belt restraint and side rails. Cross refer F221, F323