Every finding on record at Parkside Center for Nursing and Rehab at Ellijay

Based on observations, record review, staff interviews, and review of the facility's policy titled Administration of Insulin, the facility failed to ensure professional standards were followed when preparing and administering insulin for one of 17 residents (R) (R142) receiving insulin from a pen device. The deficient practice had the potential to result in the resident receiving an incomplete insulin dose, which could lead to ineffective blood glucose control, and adverse clinical outcomes.Findings include:Review of the facility's policy titled Administration of Insulin, updated 03/04/2026, revealed the Policy section documented: 6. Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. h. Prime the insulin pen: i. Dial 2 units by turning the dose selector clockwise. ii. With the needle pointing up, push the plunger and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. j. Injecting the insulin: iv. Fully depress the plunger until the dosing numbers count back to zero. v. While still pressing the plunger, keep the needle in the skin for up to 6-10 seconds and then remove the needle from the skin.Review of the electronic medical record (EMR) revealed, R142 was admitted to the facility on [DATE], with diagnoses including, but not limited to, type 2 diabetes mellitus.Review of physician orders dated 12/12/2025, documented an order for NovoLog Injection Solution 100 units/mL(units per milliliter) (insulin aspart) to be administered subcutaneously with meals per sliding scale as follows: 141-180 = 10 units; 181-220 = 14 units; 221-260 = 18 units; 261-300 = 22 units; 301-350 = 26 units; 351-400 = 30 units. Notify the nurse practitioner if blood glucose is below 60 or above 400.Observation of a medication pass on 03/04/2026 at 7:39 AM revealed, Licensed Practical Nurse (LPN) BB, checked the blood sugar and prepared to administer insulin for R142. The blood glucose reading was 195 mg/dL (milligrams per deciliter), and LPN BB stated she needed to administer 14 units of insulin. She obtained the NovoLog insulin pen and attached the pen needle. She dialed the ordered sliding scale dose of 14 units by turning the dose selector. However, LPN BB did not prime the insulin pen prior to administering the insulin. She administered the insulin in the resident's right arm by fully depressing the plunger and immediately removed the needle from the skin.In an interview following the procedure, LPN BB stated she was not aware that the insulin pen should be wasted prior to administration or that the needle should remain in the skin for several seconds after injection. She stated that she removes the pen immediately after hearing the click.In an interview conducted on 03/05/2026 at 11:26 AM, the Director of Nursing (DON) stated she expects nurses to follow the facility's policy on insulin pen administration and to hold the insulin pen firmly against the skin for five to 10 seconds after pressing the injection button to ensure the full dose is delivered. She stated that removing the insulin pen immediately may result in an incomplete dose because some insulin may leak out.

Based on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure that oxygen (O2) therapy was administered according to physician's orders for one of 17 residents (R) (R69) receiving oxygen. The deficient practice had the potential to place R69 at risk for respiratory complications, adverse clinical outcomes, and diminished quality of life.Findings include:Review of the facility's undated policy titled Oxygen Administration, last reviewed 1/2025, under Policy section documented: 1. Oxygen is administered under orders of a physician. 2. Personnel authorized to initiate oxygen therapy include physicians, RNs, LPNs, and respiratory therapists.Review of the electronic medical record (EMR) revealed R69 was admitted to the facility on [DATE], with diagnoses including but not limited to pneumonia, pleural effusion, acute respiratory failure, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF).Review of the admission Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating little to no cognitive impairment. Review of Section O: (Special Treatments, Procedures, and Programs) documented that R69 was on oxygen therapy. Review of the care plan dated 01/12/2026 for R69 revealed a focus on the resident's diagnosis of chronic obstructive pulmonary disease (COPD), with a goal that the resident will remain free of signs and symptoms of respiratory infection. Interventions included, but were not limited to, administering oxygen as ordered.Review of the physician orders dated 03/03/2026, for R69 revealed an active order related to oxygen, including administering O2 at 2LPM (Liters per minute) via nasal cannula.Review of the physician progress notes dated 03/02/2026 at 1:24 PM documented, On this admission, chest imaging demonstrated right lower lobe pneumonia with bilateral parapneumonic effusions .His course was complicated by acute hypoxic respiratory failure requiring 2 L oxygen.Observation on 03/03/2025 at 10:37 AM revealed R69 oxygen concentrator was set on 3.5 LPM being delivered via nasal cannula.Observation on 03/03/2025 at 2:53 PM revealed R69 oxygen concentrator was set on 3.5 LPM being delivered via nasal cannula.Observation on 03/04/2025 at 9:45 AM revealed R69 oxygen concentrator was set on 3.5 LPM being delivered via nasal cannula. Interview with R69's assigned nurse, Licensed Practical Nurse (LPN) DD, revealed that only nursing staff are allowed to set and adjust oxygen, as the facility does not have respiratory therapists. When asked to check the oxygen flow rate, LPN DD confirmed it was set at 3.5 LPM. She then reviewed the physician's order and confirmed the oxygen should be set at 2 LPM. She stated she did not know who had adjusted the oxygen.In an interview with the Director of Nursing (DON) on 03/04/2026 at 3:00 PM, she stated that oxygen is considered a medication and must be administered according to the physician's order. The DON confirmed that nurses are responsible for ensuring that physician orders and care plans are followed. She added that sometimes residents adjust the oxygen flow rate themselves, and when that occurs, staff provide education and update the care plan as needed.

Based on observations, record review, staff interviews, and review of the facility's policy titled Medication Administration, the facility failed to ensure a medication error rate of less than five percent. Two medication errors were identified out of 31 opportunities observed, resulting in a medication error rate of 6.45 percent. This deficient practice had the potential to place resident (R) (R123) at risk for medical complications and a diminished quality of life.Findings include:Review of the facility's policy titled Medication Administration, updated 5/2022, revealed the Policy section documented: Ensure that the six rights of medication administration are followed: .c. Right dosage. e. Right time. 12. Compare the medication source (bubble pack, vial, etc.) with the EMAR to verify resident name, medication name, form, dose, route, and time.Licensed Practical Nurse (LPN) DD was observed administering 9:00 AM medications to Resident (R)123 on 03/04/2025 at 9:50 AM. She removed the medications from the source and placed them into a medication cup (aspirin, Orgovyx, tamsulosin HCl (hydrochloride), and Tylenol; metoprolol was held due to blood pressure parameters); along with a 6:00 AM dose of Protonix from the blister pack. When asked why she was administering the 6:00 AM medication, which had already been documented in the electronic medical record (EMR) as administered, she stated she did not realize it had already been given and assumed it was due because it appeared as an AM medication on the blister pack card. LPN DD further explained that she could not administer calcium carbonate 600 mg (milligrams) because the correct dosage was not available and only calcium carbonate 500 mg was on hand. LPN DD stated she was unable to locate the bottle with the correct dosage and would need to obtain the appropriate strength of calcium carbonate from the medication room.At 4:00 PM on the same date, 03/04/2026, the surveyor rechecked the medication administration record (MAR) and noted that calcium carbonate was still not documented as administered, and there was no documentation in the progress notes or elsewhere indicating that the pharmacy had been contacted or the physician notified. In a follow-up interview with LPN DD at that time, she stated she had forgotten to address it.In an interview conducted on 03/04/2026 at 4:10 PM, the Director of Nursing (DON) stated she expects nurses to administer medications as ordered by the physician. She stated the facility maintains a stock of various over-the-counter medications in the medication rooms. If the correct dosage is not available on hand, the provider should be contacted for further instructions. If prescribed medication is not available, the facility has an emergency kit (E-kit) containing multiple medications, which nurses are expected to check and follow up immediately. If the required medication is not available in the E-kit, nursing staff are expected to notify the nurse practitioner (NP) and discuss whether the medication can be substituted or if a stat delivery should be requested from the pharmacy.

Based on observations, staff interviews, record review, and review of the facility's policy titled Medication Administration, the facility failed to ensure that one of six residents (R) (R140) reviewed for medication administration was free from significant medication errors. Specifically, the facility failed to ensure medications were administered to the correct resident, resulting in R140 receiving medications intended for another resident. This deficient practice had the potential to place the resident at risk for adverse drug reactions, medication side effects, and adverse clinical outcomes.Findings include:Review of the facility's policy titled Medication Administration, updated 5/2022, documented Policy Explanation and Compliance Guidelines: .3. Identify resident by photo in the MAR (Medication Administration Record).10. Ensure that the six rights of medication administration are followed: a. Right resident; b. Right drug; c. Right dose; d. Right route; e. Right time; f. Right documentation.12. Compare the medication source (bubble pack, vial, etc.) with the EMAR to verify the resident's name, medication name, form, dose, route, and time.An investigation was initiated following a self-reported incident to the state alleging that on 12/10/2025, during the 9:00 PM medication pass, R140 was administered her roommate R6's oral medications and injectable insulins.A review of the electronic medical record (EMR) for the affected resident (R140) revealed diagnoses that included, but were not limited to, rheumatoid arthritis, hypertension, heart failure, atrial fibrillation, pulmonary hypertension, asthma, peripheral vascular disease, lymphedema, morbid obesity, generalized weakness, and cognitive communication deficit.Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed in Section B (Hearing, Speech, Vision) that R140 has adequate hearing, does not wear hearing aids, makes herself understood, and is able to understand others. Review of Section C (Cognition) revealed a Basica Interview for Mental Status (BIMS) score of 13, indicating little to no cognitive impairment. Review of Section N (High-Risk Medications) revealed R140 was receiving anticoagulants, antibiotics, and diuretics. Section N for R140 documented no reference to receiving insulin, antipsychotics, antidepressants, opioids, or hypnotics.Review of the medications ordered for R140 active as of 03/05/2026, revealed the resident was prescribed multiple medications including acetaminophen, albuterol inhaler, amlodipine, apixaban, atorvastatin, azelastine nasal spray, calcitriol, cetirizine, cholecalciferol (vitamin D), ciprofloxacin, dexamethasone, dextrose-sodium chloride IV (intravenous) solution, ertapenem IV, fexofenadine, fluticasone nasal spray, fluticasone-salmeterol inhaler, furosemide, gabapentin, guaifenesin/dextromethorphan (Geri-Tussin DM), hydralazine, hydroxychloroquine, ipratropium-albuterol inhalation solution, lidocaine patch, loratadine, losartan, magnesium oxide, magnesium hydroxide (milk of magnesia), melatonin, menthol topical gel (Biofreeze), methenamine hippurate, methocarbamol, montelukast, multivitamin with lutein, ondansetron, permethrin topical cream, prednisone, sodium chloride IV solution, sotalol, triamcinolone cream, tuberculin PPD, and vitamin C with zinc.Review of the Medication Administration Record (MAR) dated 12/2025 for R140's roommate R6 revealed the following bedtime medications, which were mistakenly administered to R140: Tresiba FlexTouch insulin 8 units subcutaneously; Humalog insulin per sliding scale (4 units administered); melatonin 3 mg (milligrams) two tablets; sertraline HCl (hydrochloride) 50 mg; ferrous sulfate 325 mg; gabapentin 300 mg; hydroxyzine HCl 25 mg; metoprolol succinate ER (extended release) 25 mg, one-half tablet; oxybutynin chloride 2.5 mg; and ranolazine ER 500 mg.Further review of the EMR and the facility's internal investigation report revealed that Registered Nurse (RN) FF was identified as the nurse involved in the incident. The nurse recognized the error immediately, and the incident was promptly reported to the resident's physician and family. As a result of the medication error, the provider issued orders including administration of IV fluids to help flush the medications from the resident's system and close monitoring of vital signs, blood glucose levels, and lung sounds, all of which were completed.The physician evaluated the resident the next day. Following the event, the resident's blood glucose levels remained stable with no documented episodes of hypoglycemia. R140 was closely monitored.In an interview conducted on 03/04/2026 at 3:00 PM, the Administrator confirmed that the facility conducted an internal investigation regarding the incident and provided documentation indicating that a thorough investigation had been completed and that staff had been reeducated.In an interview with RN FF, the nurse involved in the incident on 03/04/2026 at 2:45 PM, she stated that she realized the error immediately and notified the physician and the resident's family. She reported that the resident was closely monitored following the incident. RN FF further stated that she and other nursing staff received re-education on safe medication administration practices. She also stated that laptops are now available for use when assisting other nurses with medication administration.In an interview with the Director of Nursing (DON) on 03/04/2026 at 3:00 PM, she stated that nursing staff are expected to follow the rights of safe medication administration and to properly identify residents by both name and the photograph in the EMR system. She stated that medications are expected to be documented at the time of administration. The DON further stated that if a medication error occurs, staff are expected to report it immediately and complete an incident report, which is then investigated by the facility.

Based on observations, staff interviews, and review of the facility's policies titled Enhanced Barrier Precautions and Cleaning and Disinfection of Resident-Care Equipment, the facility failed to consistently implement enhanced barrier precautions (EBP) and sanitize shared medical equipment (blood pressure machine and glucometer) between resident uses in four of 13 medication administration observations. This deficient practice had the potential to expose residents to harmful pathogens, increasing the risk of cross contamination, and spread of infections.Findings include:Review of the facility policy titled Cleaning and Disinfection of Resident-Care Equipment, reviewed 01/06/2026, documented in the Policy section: 3. Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment. General guidelines include:.b. Each user is responsible for routine cleaning and disinfection of multi-resident items [NAME] each use, particularly before use for another resident.d. Multiple-resident use equipment shall be cleaned and disinfected after each use.Review of the facility policy titled Enhanced Barrier Precautions, reviewed 10/06/2025, documented in the Policy section: 2. Initiation of Enhanced Barrier Precautions: .b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds .and/or indwelling medical devices .even if the resident is not known to be infected or colonized with a MDRO. 3. Implementation of Enhanced Barrier Precautions: .b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. 4. High-contact resident care activities include: a. Dressing. b. Bathing. c. Transferring. d. Providing hygiene. e. Changing linens. f. Changing briefs or assisting with toileting. g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy.On 03/04/2026 at 7:26 AM, a medication pass observation was conducted with Licensed Practical Nurse (LPN) BB. LPN BB was about to enter the room for resident (R) (R122), to check his blood pressure, but stopped at the door and began reading the enhanced barrier precautions (EBP) signage posted on the door. After reviewing the signage, she donned a gown and stated she was required to do so every time she entered the room. When the surveyor asked what the signage meant to her, she stated she was not sure but said, The resident has some kind of condition. Something is going on-I'm not sure what-but the sign tells me to gown up and put gloves on. LPN BB then looked at the surveyor and added, If you want to come in with me, you have to gown up too, even if you are just watching.LPN BB brought a blood pressure machine into the room and obtained the resident's blood pressure. Upon leaving the room, she did not sanitize the blood pressure machine. When asked about her use of personal protective equipment (PPE) upon entering the room compared to not cleaning the equipment after use, LPN BB stated she did not think it was necessary because she was not sure what condition the resident had and believed the roommate, not the resident she was providing care to, likely had the condition. LPN BB confirmed she should have cleaned the blood pressure machine.On 03/04/2026 at 7:39 am, LPN BB stated she needed to check R142's blood sugar. She performed hand hygiene, prepared the necessary supplies, entered the room, and placed the supplies, including the glucometer, on the resident's bed. She checked the resident's blood sugar and then exited the room to obtain insulin. Upon exiting the room, she placed the glucometer back on the medication cart without sanitizing it.LPN BB continued her medication pass, and at 7:59 AM she went into R6's room to check the resident's blood sugar. She brought the necessary supplies, including the same unclean glucometer, into the room and placed them on the resident's bed. After completing the check, she exited the room and again placed the glucometer on the medication cart without sanitizing it. When the surveyor asked why she continued to use the glucometer for different residents without cleaning it and whether shared equipment should be sanitized between uses, LPN BB acknowledged that she should have cleaned the device before placing it back on the cart.On 03/04/2026 at 8:35 AM, Registered Nurse (RN) CC was observed during a medication pass to R12 who received nutrition and medications via tube feeding. RN CC prepared medications by crushing them and brought the medications to the resident's room. Enhanced Barrier Precautions (EBP) signage was posted on the door; however, although the nurse performed hand hygiene, she did not wear personal protective equipment (PPE) while administering medications via the percutaneous endoscopic gastrostomy (PEG) tube.After the medication administration was completed and RN CC exited the room, the surveyor asked the nurse about the EBP signage posted on the door. RN CC stated she was not sure why the signage was present. She stated the resident's roommate had recently had the flu but believed the condition was no longer present and was unsure why the signage remained posted.The surveyor asked whether PPE should have been used prior to administering medications via the PEG tube, given the presence of an external device and the potential for splashing during medication administration. RN CC stated she was not sure. The surveyor then asked about the EBP order and what it meant to her when she documented it daily in the MAR. RN CC stated she was not sure.In an interview conducted on 03/05/2026 at 9:25 AM, the Infection Control (IC) Nurse stated that staff are educated and expected to sanitize shared equipment, such as glucometers and blood pressure machines, using the purple top wipes. She stated that when checking a resident's blood sugar, staff are expected to use a barrier to place supplies on and should not place supplies directly on the resident's bed. She further stated that staff receive regular education on Enhanced Barrier Precautions (EBP).In an interview conducted on 03/05/2026 at 11:26 AM, the Director of Nursing (DON) stated that she expects nursing staff to follow Enhanced Barrier Precautions (EBP) practices to reduce the transmission of infections. She stated that staff are aware of and trained on high-risk care activities that require enhanced barrier precautions. She further stated that she expects staff to sanitize shared equipment between residents' uses.

Based on record review, resident and staff interview, and facility policy review, the facility failed to ensure three of five residents (Resident (R) 8, R18, and R91) and/or their resident representatives (RR) out of a sample of 23 residents reviewed for facility initiated emergent hospital transfer were provided with written transfer notice that contained all required information. This failure has the potential to affect the residents and their RRs by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: Review of the facility's undated policy titled, Transfer and Discharge (including [against medical advice] AMA) revealed the following (12) e. provide orientation for transfer or discharge to minimize anxiety and to ensure safe and orderly transfer or discharge, in a form or manner that the resident can understand .(h) the Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices. 1. Review of R8's Admission Record from the electronic medical record (EMR) Profile tab, showed a facility admitted [DATE] with a diagnosis of gastrointestinal hemorrhage. Review of R8's annual Minimum Data Set (MDS) assessment from 01/08/25 revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Review of R8's Health Status Note, dated 12/27/24 and located under the Progress Notes tab of the EMR, revealed resident sent to [emergency department] ED via [emergency medical services] EMS due to dyspnea and blood in stool. Further review of the EMR Documents tab did not show any documentation of a written notice of transfer provided to R8 or R8's RR. During an interview on 01/28/25 at 12:33 PM, R8 stated she thought she was in the hospital one month ago for pneumonia. 2. Review of R18's Admission Record from the EMR Profile tab showed a facility admitted [DATE] with diagnoses of metabolic encephalopathy, Guillain-Barre Syndrome, /hemiplegia and Hemiparesis following cerebral infarction affecting non-dominant side, polyneuropathy, muscle weakness (generalized, and other abnormalities of gait and mobility. Review of R18's quarterly Minimum Data Set (MDS) assessment from 01/03/25 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating little or no cognitive deficit. Review of R18's Health Status Note, dated 12/01/24 and located under the Progress Notes tab of the EMR, revealed Resident was complaining of fecal impaction last night. After speaking with her and the on-call [nurse practitioner] NP, resident wanted to go to the ER. Resident's abdomen was distended and hard. The [emergency room ] ER is currently waiting on a room at [Hospital Name] to transfer her. According to her nurse at [hospital ER], a scan was done and showed a large amount of impaction. Further review of the EMR Documents tab did not show any documentation of a written notice of transfer provided to R18 or RR. 3. Review of R91's Admission Record from the electronic medical record (EMR) Profile tab showed a facility admitted [DATE] with a diagnoses of nonrheumatic aortic valve stenosis, idiopathic pulmonary fibrosis, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, unspecified dementia, urinary tract infection, type two diabetes, chronic combined systolic (congestive) and diastolic (congestive) heart failure, pulmonary hypertension, and hypertensive heart disease with heart failure. Review of R91's 5-Day Minimum Data Set (MDS) assessment from 01/16/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating little or no cognitive deficit. Review of R91's Health Status Note, dated 09/21/24 and located under the Progress Notes tab of the EMR, revealed The Resident's daughter said she wanted to speak with a doctor, this nurse states the Resident needs to go to the ER, but the Resident's daughter says No, I want to speak with the doctor on call to tell me where we need to go. This nurse called the on-call service number and chose [the] option for them to give a call back. Upon entering the room again, the Resident's daughter said she went ahead and called 911. EMS arrived at 19:00 (7:00 PM). [R91] left with EMS via stretcher at 19:05 (7:05 PM). [The] daughter left and took [the] resident's belongings. EMS states they are taking [the] resident to [Name] ER. DON (Director of Nursing) and admin (Administrator) notified. Resident alert and talking upon discharge. Further review of the EMR Documents tab did not show any documentation of a written notice of transfer provided to R91 or RR. During an interview on 01/31/25 at 10:13 AM, the Administrator stated discharge summaries were not provided to residents or family members in a language they could understand regarding the reason for discharge to the hospital. During an interview on 01/31/25 at 10:08 AM, Unit Manager (UM) 1 stated an [situation, background, assessment, recommendation] (SBAR) form, face sheet, and medication list were sent to the hospital with residents. She stated a separate discharge summary indicating the reason for discharge in a language the resident could understand was not sent with the residents or provided to family members. During an interview on 01/31/25 at 10:29 AM, the DON stated the facility did not have a separate discharge sheet to provide the resident and/or representative indicating why the resident was sent to the hospital in a language they could understand.

Based on record review, staff interview, and facility policy review, the facility failed to complete the comprehensive care plan to include the use of oxygen for one of 23 sample residents (Resident (R) 20) reviewed for care planning. The failure had the potential for R20's medical, nursing, mental, and psychosocial needs not being met. Findings include: Review of the facility's policy titled, Comprehensive Care Plans, indicated .develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the residents comprehensive assessment. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/24 and located in the electronic medical record (EMR) under the MDS tab, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated the resident was moderately cognitively impaired. The MDS revealed the resident was admitted on [DATE] with diagnoses to include hypoxemia, and shortness of breath or trouble breathing when lying flat and had oxygen therapy with intermittent use. Review of R20's EMR located under the Care Plan Tab a comprehensive care plan with an initiated date of 12/16/24 did not display the use of oxygen for R20. During an interview on 01/31/25 at 11:00 AM, Licensed Practical Nurse (LPN) 8 stated yes oxygen (O2) should be on the care plan to help communicate the care needed for that resident. During an interview on 01/31/25 at 12:40 PM, the MDS Coordinator (MDSC) stated that O2 should be on the care plan so that staff knew the needs of the resident. We just missed it. We will get it corrected immediately. During an interview on 01/31/25 at 1:15 PM, the Director of Nursing (DON) stated that O2 should have been on R20's care plan to let the staff know that O2 was being used and how it's being used such as continuous or as needed (PRN). DON stated the care plan let's all nursing staff know how to properly take care of a resident.

The facility failed to ensure medications were received in a manner that allowed administration for one of one resident (Resident (R) 91) reviewed for medication administration of 23 sample residents. This failure has the potential to cause R91 not to receive the therapeutic benefits of their prescribed medications. Findings include: Review of the facility's policy titled, Medication Ordering and Receiving from Pharmacy, dated 10/01/19, revealed (1) medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. Review of the facility's policy titled, Pharmacy Services, dated 2024, under the Compliance Guidelines section revealed the following (1). the facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. Review of R91's Admission Record located in Profile tab of the electronic medical record (EMR) revealed R91 admitted on [DATE] with diagnoses of nonrheumatic aortic valve stenosis, idiopathic pulmonary fibrosis, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, unspecified dementia, urinary tract infection, type two diabetes, chronic combined systolic (congestive) and diastolic (congestive) heart failure, pulmonary hypertension, and hypertensive heart disease with heart failure. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/21/24 and located in the MDS tab of the EMR revealed R91 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating little or no cognitive deficit. Review of the Medication Administration Record (MAR), dated September 2024, located in the EMR under the Order tab, revealed the resident did not receive most of her prescription medication that was ordered on 09/21/24 due to pending pharmacy delivery. She received over the counter (OTC) medications and a nitroglycerin (medication used to treat acute chest pain) that was pulled from the emergency kit and was administered. Review of the Packing Slip Proof of Delivery form, provided by the facility, revealed the following medications were delivered for R91 on 09/20/24 at 9:21 PM but was not provided to the resident: albuterol HFA 90 [micrograms] mcg (for respiratory illness), famotidine 10 mg [milligrams] (for acid reduction), fluoxetine 20 mg (to treat depression), furosemide 20 mg (diuretic), ipratropium/albuterol (for shortness of breath) nebulizer (device for breathing treatments), isosorbide Mono ER (extended release) 30 mg (treat chest pain and heart failure), levothyroxine 100 mcg (for thyroid disorders), and memantine 5 mg (for Alzheimer's), metoprolol SUCC ER 25 mg (for high blood pressure), montelukast 10 mg (for allergies and asthma), pantoprazole 40 mg (for gastroesophageal disease) and potassium CL [chloride] ER 20 MEQ [milliequivalents]. During an interview on 01/29/25 at 4:27 PM, the Director of Nursing (DON) stated new orders were entered into the system and faxed to pharmacy prior to a resident arriving in the facility. She reviewed the MAR and confirmed the MAR indicated medications were not administered pending pharmacy delivery. She stated R91was admitted in the middle of the night and the orders were not entered prior to R91 being admitted . The DON stated R91's orders came with her discharge packet from the hospital and were entered after she arrived at the facility. She stated the pharmacy would need the orders by 4:00 PM on Saturday to deliver them on Sunday. Per the DON, the pharmacy did not deliver medications on Sunday. She stated they kept some Lasix in the e-kit (emergency medication supply). She stated if it was the correct dose for the resident, the nurse could have pulled the Lasix to administer it. She stated R91 had an order for Lasix 20 mg start date 09/21/24. The DON stated the e-kit had 20 mg doses of Lasix in it. She verified and confirmed the charge nurse could have administered the Lasix on 09/21/24. During an interview on 01/30/25 at 9:18 AM, the DON stated the nursing staff could call the pharmacy and ask for medication to be delivered stat [immediate] and/or they could use a local pharmacy. During an interview on 01/30/25 at 1:34 PM, Registered Nurse (RN) 4 stated the charge nurse never informed her she was waiting for R91's medications to be delivered from the pharmacy. RN4 stated if the charge nurse had mentioned this, they could have looked in the e-kit to see what was available to give the resident based on her current orders. RN4 was notified of the medications being delivered to the long-term care side of the facility and not delivered to the rehabilitation side. During an interview on 01/30/25 at 4:34 PM, Licensed Practical Nurse (LPN) 6 stated the pharmacy did not deliver medications on Sundays. She stated they could have called for a stat delivery and could also check the orders and e-kit to see what medications were available to administer. During an interview on 01/31/25 at 1:03 PM, the Medical Director stated his expectations were for nurses to access the e-kit for medications if they were available or to contact the pharmacy for a stat delivery. During an interview on 01/31/25 at 1:19 PM, LPN5 stated medications received on the long-term side of the facility that were for rehab residents should be taken to the rehab unit by a staff member.

Based on observations, record review, resident and staff interviews, and facility policy review, the facility failed to identify target behaviors for monitoring effectiveness of antipsychotic medication for one of five residents (Resident (R) 48) reviewed for unnecessary medications of 23 sample residents. This failure had the potential to contribute to unnecessary antipsychotic medication use in R48 who used the medication to treat behavioral symptoms of anxiety. Findings include: Review of the facility's undated policy titled, Use of Psychotropic Medication, revealed residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documented of the resident response to the medication. 4. The indication for use of any psychotropic drug will be documented in the medical record. Review of R48's undated Admission Record located in the Profile tab of the electronic medical record (EMR), revealed R48 was admitted to the facility on [DATE] with diagnoses including, history of falls, multiple fractures of the left arm and pelvis, panic attacks, anxiety and major depression disorder. Review of R48's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/24 and located in the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating little or no cognitive deficit. Review of R48's Physician's Orders, dated 01/25 and located in the Orders tab of the EMR, revealed an order for lorazepam (an antipsychotic medication), 0.5 milligrams (mg) every eight hours as needed for anxiety, which originated on 01/27/25, with a stop date 02/08/25. Review of R48's EMR Progress Notes under the Notes tab and Medication Administration Records (MAR) under the Orders tab revealed no documentation of monitoring moods and behavioral symptoms to evaluate the nature and circumstances of anxiety and to monitor for continued need of the medication related to behavioral symptoms. During an interview on 01/31/25 at 1:45 PM, Registered Nurse (RN) 3 was asked how the behaviors of R48 were tracked to know when R48 would need the lorazepam, RN3 replied we chart in the MAR. When asked to show the documentation of the behaviors that indicated need for lorazepam, RN3 was unable to show the documentation. During an interview on 01/31/25 at 2:00 PM, the Director of Nursing (DON) stated the behaviors were monitored in the MAR and her expectation would be for behaviors to be documented with each administration. During an observation and interview on 01/31/25 at 2:23 PM, R48 was sitting in her wheelchair in her room. R48 stated she had taken the Ativan (brand name for lorazepam) for approximately [AGE] years and it's the only medication that has consistently helped me and it just makes my life better.

Based on observations, staff interviews, and record review, the facility failed to hire qualified dietary staff certified to serve food in a clean, safe and sanitary manner. The potential for foodborne illnesses could affect 84 of 85 residents. Findings include: Interview on 3/06/2024 at 10:36 am with the Food Service Director revealed he did not know about two essential areas needed to keep residents safe from foodborne illnesses, the appropriate dish machine temperatures to ensure clean, sanitized dishes and utensils, or the safe holding temperature for meals served to residents on their trays. Review of the Food Service Director's employee file revealed no certification for Certified Dietary Manager (CDM) or safe food handling card. His title was Food Service Director and did not claim to be a CDM. He corrected the surveyor twice when called CDM. Interview on 3/7/2024 at 10:54 am with the Human Resource Director revealed the Food Service Director does not have a CDM certificate or safe food handling card.

Based on observations, resident and staff interviews, and record review, the facility failed to serve the appropriate quantities of food according to the prescribed dietary recipe. The deficient practice had the potential for malnutrition and could affect 84 of 85 residents receiving an oral diet from the kitchen. Findings Include: Observation on 3/5/2024 from 11:46 pm to 12:02 pm, the Dietary Cook placed chicken and dumplings, and peas on two resident's plates using a 3-ounce (oz) sized ladle for the chicken and dumplings. When asked about the size of the serving ladle, the Dietary Cook immediately grabbed a 4 oz ladle. She stated that the 4 oz ladle will be used to serve the meal/meat, then the 3 oz ladle will be used to fill the bowl with just the liquid. The Dietary Cook added This is how the chicken and dumplings are served. Review of the chicken and dumplings recipe dated 10/24/2023 revealed the serving utensil sizes as Spoon & 6 oz ladle. Interview on 3/6/2024 at 12:24 pm with the facility's Registered Dietician (RD) revealed that food service staff are required to follow the recipes to the detail. While looking at the recipe, the RD said that chicken and dumplings should be served using the 6 oz ladle and not the 4 oz and 3 oz method. The RD explained that both liquids and solids should have been served together and not separately. Subsequent interview on 3/6/2024 at 2:30 pm with both the Dietary Cook and Food Service, the Dietary Cook stated that she used the additional 3 oz ladle to fill the bowl with liquid. Both the Food Service Director and the Cook were confused about the details of the recipe concerning the serving size of the chicken and dumplings, and correct utensil sizes and usage. Interview 3/4/2024 at 9:20 am with Resident (R) (R8), he stated that they had a serious belief the facility was not serving the required quantities of food.

Based on observations, resident and staff and complainant interviews, and record reviews, and review of the facility policy titled, Temperature for Food Safety, the facility failed to serve food that is palatable, attractive and at required temperatures. The deficient practice had the potential to affect 84 of 85 residents utilizing dining services. Findings Include: Review of the facility policy titled Temperature for Food Safety dated 3/6/2024 indicated 135 [degrees] F [Fahrenheit] minimum temperature for holding hot food. Danger Zone 41 [degrees] -135 [degrees] F Rapid Bacteria Growth Zone. On 3/4/2024 at 5:15 pm, a test tray of Monday's menu Week 4 Dinner was served to this Surveyor, which included stuffed cabbage soup, roast beef sandwich, carrot raisin salad, and mixed melon salad. The stuffed cabbage was flavorless and not edible. The roast beef sandwich was served with just meat and cheese, no lettuce, tomato, onions, etc. The mixed melon salad only contained cantaloupe that appeared to have been frozen and thawed or was fresh and was going bad. The cantaloupe was unappealing and did not appear fresh. Interview on 3/4/2024 at 9:20 am with anonymous residents (A) (A1 and A2) complained of receiving cold food. A1 reported that grits are sometimes delivered in a bowl shape. A2 reported that their eggs were cold, rubbery and resembled mangoes. Interview on 3/5/2024 at 9:03 am, the Food Service Director stated that liquid scrambled eggs take on the appearance of mangoes because they shrivel up and become solid and smooth when cold. Multiple residents described the disk-shaped eggs with a yellow circle in the middle as undesirable and that they wanted real eggs. The Food Service Director stated that he was aware of the egg complaints. Review of Resident Council Minutes showed that residents complained of cold food in the following meetings: 1/17/2024, 11/22/2023, and 7/26/2023. Review of a grievance filed by a resident on 6/21/2023 reads Resident reports food is cold when arriving to the rooms. Residents reporting grievances are anonymous. Interview on 3/4/2024 at 3:25 pm with CNA DD and CNA AA2 revealed that some residents are not willing to eat the food based solely on the food's appearance. When they see the food, they want something else. Some are pickier than others. I sit the tray in front of the residents. Some may not like what is on the tray. In that case, I take the tray and ask if there is something else they would like to eat from the alternative menu. The popular alternatives are peanut butter and jelly, ham and cheese sandwiches, and soups. Interview on 3/4/2024 at 2:59 pm with CNA AA3 revealed they were sometimes embarrassed to serve some meals to the residents, although they serve the meals and tried to convince the residents to eat it. Residents are complaining about the food. It does not look as appetizing as they like. Meals look kind of monochromatic, lacking colors. They complain two or three times daily about how bad the food is. The complaints are constant and are not new. I first try to convince the residents to eat the food. Then, if that is not possible, I offer alternative meals. They like the salads, and they usually request it as an alternative. Interview with anonymous resident (A) (A2), they stated Often they serve 3 chunks pieces or three 1 oz portions of sausage, mystery meat, small potatoes, snack sandwich with just meat, no lettuce, tomatoes, onions, etc. Every once in a while, we get a banana. Grits are served solid. The food is not always warm. Interview 3/5/2024 at 10:25 am with A3 revealed that the quality of the food here is terrible. A3 stated that it has gotten so bad that they are weighing me daily. The meat is overcooked and tasteless. Last night, I received a roast beef sandwich with no tomatoes, lettuce, onion, etc. with really, really, thin slices of roast beef and mozzarella cheese. It was not palatable, though, this time they included a pack of mayo. The turkey sandwich from the night before had no condiments. Corned beef hash is horrible. Veggies are hard like corn and black beans. Interview via telephone on 3/5/2024 at 2:32 pm with a Complainant for A2 revealed the food photos on the menu do not match the actual menu. Sometimes they claim it is gourmet. No may, no mustard, thin slices of luncheon meat. Almost all the food is non-edible [sic]. It has never gotten better. On 3/5/2024 at 1:16 pm, the Food Service Director placed two test trays in the food cart to be delivered to the training room. The Food Services Director was requested to bring the entire cart with the two test trays. However, he stated that if he took the entire cart then the CNAs could not return the dirty dishes/trays to the cart. The Food Service Director was observed as he carried one of the test trays to the conference room. The other test tray remained in the Middle Hall on the cart. The initial temperatures while on the steam table (approximately at 12:00 pm) was 160 degrees Fahrenheit for the chicken & dumplings and 165 degrees Fahrenheit for the peas. The Food Service Director delivered the test tray and returned with the Dietary Cook who then took the temperatures of the food items using a digital thermometer. The chicken and dumplings temperature were 132.9 degrees Fahrenheit and the peas measured at 123.5 degrees Fahrenheit. The Food Service Director stated that the appropriate serving temperature for meals was 110 degrees Fahrenheit. Interview on 3/6/2024 at 9:58 am with the Administrator, he stated that food service was supposed to add at least two garnishments such as an orange slice, apple slice or parsley to lunch/dinner to make it more appealing and appetizing. The Administrator apologized that these items were not included on the test trays or residents' meals.

Based on observations, resident and staff interviews, and record review, the facility failed to serve residents their preferences and alternative meals. The deficient practice had the potential to affect 84 of 85 residents receiving meals from the kitchen. Findings include: During the initial tour on 3/4/2024, multiple residents complained that their food choices were not honored. Interview on 3/4/2024 at 9:14 am with anonymous resident (A) (A5) revealed that the food is okay, but she prefers raw fruit and vegetables like avocados. Interview on 3/4/2024 at 9:28 am with A6 revealed they do not serve fresh fruit or veggies. Interview on 3/4/2024 with A7 revealed that the meat is too tough like the pork shops, steak, and hamburgers, and would like more veggies. Sliced apples in a packet are the only fresh fruit we receive. Interview on 3/4/2024 with A2 revealed that the only fruit usually served is canned fruit, but they do serve fresh sliced oranges or apples. Interview on 3/5/2024 at 8:33 am with A4 revealed he requested that Dietary not to serve him boiled eggs (on at least fifteen occasions), but he keeps receiving them. On 3/4/2024, the Food Service Director provided a copy of the residents' meal preferences and on it stated, no boiled eggs. The Food Service Director stated that he would consult with the resident. On 3/5/2024 at 8:33 am, the same resident A4 stated that he received boiled eggs again. The following morning on 3/6/24 the same resident declined to give an answer. Review of Resident Council Minutes dated 11/23/2024 revealed that residents Received items from dietary that have been requested not to receive and that they Would like little cartons of milk. Resident Council Minutes dated 1/17/2024 references concerns regarding Food preferences/allergies. Resident Council Minutes dated 9/30/2023 read Not able or asked to choose alternate meals and Receiving food they have requested not to. Resident Council Minutes from 6/21/2023 revealed that residents are Not getting alternate meals. A test tray was ordered and sampled on 3/4/2024 at 5:20 pm by a surveyor. They revealed that the stuffed cabbage was flavorless and not edible. They could not swallow the contents of one spoonful of the stuffed cabbage. Observation on 3/5/2024 from 12:02 pm to 1:00 pm revealed alternate meals of meatloaf, mashed potatoes and brown gravy were not on the serving hot steaming tray unit nor were they requested, plated or served to residents during the observation timeframe. There were only two meals from the menu on the steam table ready to be served to the residents: chicken and dumplings and peas. They were served in two forms, regular and pureed. When asked, Is this it? The Cook responded, This is it, and serving began. Only three residents received little cartons of milk during serving observations. There was no milk served on the beverage carts on each of the five units. Each beverage cart contained a hot water dispenser, fresh brewed iced tea, and cups. Interview on 3/6/2024 at 12:24 pm with the Registered Dietician revealed they plan to serve fresh fruit in the Spring, confirming resident's complaints. Interview on 3/6/2024 at 2:30 pm with the Food Service Director, he stated that the alternative meals were not on the serving table along with the main menu because of the lack of space in the steam table/serving area. He also stated that the meals were in a separate compartment that was not visible and that the alternate meals would have been served upon request. Interview on 3/6/2024 at 5:20 pm with the Administrator, he revealed that if the residents do not like what is posted on the menu, they will ask the CNA or someone to place an order from the alternative menu. Their meals are based on their likes and preferences. We brought out the main menu concept to eliminate the need for residents to see what others have ordered. Their eyes make the meal. Food service is supposed to add two garnishments such as orange slice or parsley during lunch/dinner to make meals more appealing and appetizing. They take pictures of each tray line to review for complaints.

Based on observations, staff interviews and record reviews, the facility failed to recognize the dish machine was malfunctioning and producing temperatures too low to kill bacteria and germs for the last 10 months. The potential for foodborne illnesses could affect 84 of 85 residents. Findings include: The facility had no policy for the required temperatures for the dishwashing machine. Review of the Resident Council Minute/Grievance dated 6/21/2023 showed various complaints as follows Residents continue to voice that coffee cups are dirty and Numerous residents report hair being found in their food. Observation and interview on 3/6/2024 at 10:24 am with the Food Services Director, the Food Service Director found dirty utensils in a pile of clean, ready to use silverware. The silverware contained caked on debris that the Food Service Manager was able to flick off or remove with his fingernails. This led to the discovery that the dish machine was not working properly. The Food Service Director revealed that he looked at the temperature logs once a week or maybe once every two weeks. He expected his dishwashers to let him know if the temperature was out of range. He has not trained or in-serviced the dishwashers on the proper temperatures. The Food Service Director was not aware of the proper dishwashing temperatures for the machine. The metal plaque affixed to the machine on the right side of the machine reads NSF Machine Operational Requirements as Manufactured by 'name of manufacturer' Dish Machines. Wash temperatures minimum 155 degrees Fahrenheit. Wash cycle time is 49 seconds. Rinse temperature minimum is 180 degrees F. Rinse cycle time 12 seconds. Steam evacuation 41 seconds. Review of the Dish Machine Ware Washing Log (Low Temp) and Dish Machine Ware Washing Log (High Temp) indicated that proper wash and final rinse temperatures were not met for the last 10 months. The facility called the maintenance contractor company to fix the dish machine temperatures after it was brought to their attention for the second time on 3/6/2024 at 2:46 pm. The company repaired the shut off valve for the cold water and fixed the final rinse temperature for the leased dishwasher and found that the water was turned off the condenser and booster heater for the CMA 180VL (dish machine model). The repairman stated, After turning the water back on, water and the booster heater were lit up and it was reaching the final proper rinse temperature. I had to turn up the water pressure for the final rinse. Interview on 3/6/2024 at 4:30 pm with the Administrator, the Administrator confirmed that he was aware of the dish machine problems and the food temperatures were too low. He has some in-services to do with the kitchen staff and other people as well. Observation on 3/7/2024 at 9:29 am revealed the dish machine was not working again. The machine was shut off and no dietary aides were present in the dishwashing area. According to the Food Service Director, the machine stopped working 10 minutes before the surveyor's arrival to the kitchen. Wash temperatures reportedly read 145 degrees Fahrenheit four consecutive times and final rinse was only 90 degrees Fahrenheit. The Food Service Director did not expect a repair date until the following workday.

Based on observations, resident and staff interviews, record review, and review of the policy titled Comprehensive Care Plans, the facility failed to implement appropriate interventions on the care plan for two of 45 sampled residents (R) (R#39 and R#20) related to (1) pain management during wound care for R#39 resulting in harm; and (2) assessment of the arteriovenous fistula (AVF) access site after dialysis treatment for R#20. Findings included: A review of the policy titled Comprehensive Care Plans, dated March 2023 revealed the policy was to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy explanation and Compliance Guidelines revealed line numbered: The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the residents' progress. Alternative interventions will be documented, as needed. 1. An observation on 4/29/23 at 10:30 a.m. revealed the Wound Care Nurse (WCN) performing wound care to R#39. Throughout the treatment R#39 made verbal expressions of pain. WCN did not stop treatment to reassess pain or report complaints of pain to the nurse. During an interview on 4/29/23 at 11:40 a.m. with the Director of Nursing (DON) she revealed it is her expectation when a resident complains of pain during wound care regardless of if they have been pre-medicated prior to treatment that the nurse stop treatment and assess the resident's pain. She stated the residents nurse should be consulted to determine if the resident has anything else for pain and if so, the resident should be given the medication and treatment should resume after the medication has had time to be effective. A review of the quarterly MDS for R#39 dated 3/28/23 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition, requires extensive 2+ person assist with all Activities of Daily Living (ADLs); has been on a scheduled pain medication in the last five days and received as needed (PRN) pain medication and that a pain interview should be conducted; and R#39 received an Opioid seven out of seven days per week. A review of the care plan dated 1/15/20 (last revision date of 3/29/23) revealed R#39 has alteration in comfort related to generalized pain with a goal that R#39 will have pain managed by current regimen through the review date. Interventions include to administer as needed (PRN) analgesia as per orders, document effectiveness, assess and observe for pain and intervene as indicated, notify Physician if interventions are unsuccessful, and report to nurse complaints of pain or requests for pain treatment. 2. A review of the clinical record revealed that R#20 was an [AGE] year-old female admitted on [DATE] with diagnoses including end stage renal disease and dependence on renal dialysis. A review of R#20's Physician Orders revealed orders included (not all inclusive): Physician Orders dated 3/22/23 Full set of vitals prior to dialysis on Monday, Wednesday, Friday one time a day related to ESRD. Physician Orders dated 3/20/23 Resident is to receive dialysis at DaVita on Monday, Wednesday, Friday. There was no Physician Order to monitor the AVF site or to assess for thrill and bruit. A review of the medication administration record (MARS) revealed there was not a section to monitor the AVF site or assess for thrill and bruit. A review of the admission MDS dated [DATE] revealed R#20 had a BIMS of 15, indicating that the resident is cognitively intact; requires extensive assistance for ADL's; and receives dialysis. A review of the care plan revealed a focus area of resident needs dialysis hemodialysis related to end stage renal disease (ESRD). The goal was that R#20 will have immediate intervention should any signs or symptoms of complications from dialysis occur through the review date. Interventions included: do not draw blood or take blood pressure in the arm with a graft; encourage resident to go for the scheduled dialysis appointments 3 times weekly; monitor vital signs as warranted; notify physician of significant abnormalities. The care plan revealed there were no interventions to monitor and document the AVF site or assess for thrill and bruit. During observations and interviews on 4/29/23 at 8:45 a.m. and at 1:40 p.m. of R#20 revealed she had light blue discoloration around her AVF site on her left upper arm. She stated she was unaware of staff assessing the site on any day. During an observation on 4/30/23 at 12:50 p.m. staff was observed assessing R#20's AVF site. The resident stated again that she did not remember anyone at the facility ever observing her AVF site prior to this date. During an interview on 4/29/23 at 9:00 a.m. with LPN II, she stated she had worked at the facility for two months and that the dialysis access site was assessed for thrill and bruit one time daily but was not documented. She revealed she was unsure why it was not documented. During an interview on 4/30/23 at 1:10 p.m. with the DON she stated that her expectations were for the care plan to include interventions to monitor the dialysis access site and perform thrill and bruit assessment daily and after return from dialysis appointments and to document the assessment. The DON verified there was no documentation of the assessment of the AVF access site on the MARS or the nursing progress notes. She verified there was no intervention on the care plan to assess the AVF site for thrill and bruit daily and upon return from a dialysis appointment. 46691

Based on observation, interview, and record review the facility failed to develop, and implement a plan related to effective communication goals for one of 45 sampled residents (R) (R#55) as it relates to provide care and services for activities of daily living as it related to communication and offering a functional communication system. This failure resulted in psychosocial harm related to R#55 experiencing emotional distress, crying often, and frustrated when she was not able to communicate daily needs with facility staff. Findings included: A review of the clinical record revealed that R#55 was admitted to the facility on [DATE] with a diagnosis of Cerebral Vascular Accident (CVA). A review of the quarterly Minimum Data Set, dated dated dated [DATE] revealed R#55 had a Brief Interview for Mental Status score of 15, indicating intact cognition; requires extensive 2+ person assistance with all Activities of Daily Living; and that R#55 receives an antidepressant seven out of seven days per week. A review of the care plan for R#55 dated 1/25/23 revealed R#55 has a communication problem related to hearing deficit in right ear with a goal that R#55 will be able to make basic needs known on a daily basis through the review date. Interventions include to anticipate and meets needs, be conscious of position when in groups, activities, dining room to promote proper communication with others, and ensure hearing aid (right) is in place. There was no care plan in place for speech concerns. During an interview and observation on 4/28/23 at 11:36 a.m. revealed R#55 resting in bed with eyes open. An interview with R#55 was attempted at this time but she was very difficult to understand. R#55 answered appropriately to yes/no questions by shaking her head up and down for yes and side to side for no. A large communication card was noted on the bedside table of R#55 and when an attempt was made at this time to use the communication card R#55 shook her head in a side to side motion indicating no. R#55 was asked if staff used the communication card to help them understand her needs and she again shook her head side to side indicting no. At this time R#55 was observed to be tearful. When asked if not being able to communicate her needs clearly upset her, she shook her head up and down indicating yes. When asked if she would like to receive help to learn ways to better communicate, she shook her head up and down indicating yes. During an interview on 4/29/23 at 9:20 a.m. with the Corporate Rehab Director revealed speech therapy has been working with R#55 on her swallowing concerns. He stated part of the job of Therapy is to educate and teach the care givers, nurses, and CNAs of resident treatment plans. He stated therapy has been working with R#55 since she was admitted . During this time the therapy notes for R#55 were reviewed by the Corporate Rehab Director to determine education that was provided to staff. During an interview on 4/29/23 at 9:45 a.m. with Licensed Practical Nurse (LPN) LPN EE she revealed R#55 has had a decline over the last month. She stated swallowing for R#55 has gotten worse and that she used to be able to feed herself and communicate well with staff but has had a drastic decline and can no longer do that. LPN EE stated she feels the staff do meet the residents needs but is difficult to understand and sometimes takes a while to figure out what it is she is asking for causing R#55 can become frustrated. LPN EE stated she saw therapy in with the R#55 at one point and the therapist showed her how to use the communication card with R#55 and there are times R#55 cannot point at the card so instead of using the communication card she uses yes and no questions. LPN EE revealed it can be a lot of guessing before it is determined what R#55 needs. During an interview on 4/29/23 at 9:55 a.m. with Unit Manager LPN KK she stated that there had been some communication issues with R#55 since she came to the facility but stated R#55 has Lymphoma and the concern was that it may have metastasized to the brain, and this may be what has caused her decline and stated they have discussed an MRI. She revealed R#55 does not want to use the communication card and refuses it but she does not know why. LPN KK stated therapy continues to work with R#55, but the staff have received no education related to better ways to communicate with the resident and added it is a struggle to understand R#55. She revealed R#55 not being able to communicate with staff may also be part of her decline and depression. During an interview on 4/29/23 at 11:35 a.m. with the Regional Rehab Director revealed he reviewed all notes by the speech therapist for R#55 and there is no documentation that the therapist provided education to staff on ways to effectively communicate with R#55. He revealed he spoke with the therapist on the phone, as she was not available for an in-person interview, and she stated to him that she did not provide a communication card and did not know where it came from. Regional Rehab Director revealed R#55 does not have glasses and she cannot see to use the communication card, but the facility has made her an appointment and she has seen the eye doctor. He stated the therapist told him that she did instruct the staff to use yes and no questions for R#55 but added that her focus was on swallowing and the Medical Doctor has documented the resident is in denial of her medical condition. During an interview on 4/30/23 at 12:45 p.m. with the Regional Rehab Director, he stated he spoke again with the speech therapist for R#55 and she would be coming in Monday morning (5/1/23) to see R#55 and get some documentation in her notes related to the communication concerns. A review of the nurse note dated 4/25/23 noted, Resident was assisted with her morning meal, and she became tearful. It is very hard to understand her now as she will slur and [NAME] words together and most of the time, she will refuse her communication board, or she will be too upset to use it. This morning she wanted to be repositioned. She is usually total care now. She cannot hold her cup well anymore or her spoon. She has allowed her medications to be crushed and put in applesauce, but she will still usually cough with any by mouth intake. She does not watch tv as she did, and she will burst out in tears of frustration during communication with staff as she just can't express herself anymore. She is currently on antibiotics for a urinary tract infection. She is turned and positioned for comfort as much as possible. A review of the Psychotherapy Progress note dated 4/25/23 noted, (R#52) being upset/emotional is frustration due to not being able to communicate well Patient and Therapist discussed goals and patient reported she was emotional and found herself crying often. Therapist helped patients identify why she was upset/emotional, and patient reported she was frustrated about not being able to communicate well. Patient reported she often prays and feels better 'but every day is hard'. A review of the Nurse Practitioner progress note dated 4/12/23 revealed R#55 was seen by her oncologist on 4/11/23. It noted that they were in agreement with current work up and evaluation of advancing neurological symptoms, and they gave orders for a PET scan and MRI of the head and torso with a follow up appointment in one month. During an interview on 4/30/23 at 5:20 p.m. with the Director of Nursing (DON) she revealed the facility does not have a policy related to communication or language barriers.

Based on observation, record review, interview, and review of facility policy Pain Management the facility failed to stop and address verbal expression of pain during wound care for one of three residents (R) (R#39) observed for wound care. The facility staff failed to recognize the need for modified approaches/interventions when R#39 experienced severe pain during wound care treatment resulting in harm for R#39. Findings included: Policy titled Pain Management revised on 1/24/23 revealed the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Pain Assessment: 2. Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team (e.g., nurses, practitioner, pharmacists, and anyone else with direct contact with the resident) may necessitate gathering the following information, as applicable to the resident: g. Identifying activities, resident care or treatment that precipitate or exacerbate pain and those that reduce or eliminate pain. A review of the quarterly Minimum Data Set for R#39 dated 3/28/23 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition; requires extensive 2+ person assist with all Activities of Daily Living (ADLs); has been on a scheduled pain medication in the last five days and received as needed (PRN) pain medication and that a pain interview should be conducted; and R#39 received an Opioid seven out of seven days per week. A review of the care plan dated 1/15/20 (last revision date of 3/29/23) revealed R#39 has alteration in comfort related to generalized pain with a goal that R#39 will have pain managed by current regimen through the review date. Interventions include to administer as needed (PRN) analgesia as per orders, document effectiveness, assess and observe for pain and intervene as indicated, notify Physician if interventions are unsuccessful, and report to nurse complaints of pain or requests for pain treatment. A review of the Physician orders revealed the following: Physician order dated 10/17/22 revealed an order for Mobic 15 milligram (mg) one by mouth daily at 5:00 p.m. Physician order dated 8/23/22 revealed an order for Tramadol 50mg one by mouth every eight hours as needed for moderate to severe pain level 5 to 10. Physician order dated 8/23/22 revealed an order for Acetaminophen 325mg two by mouth every six hours as needed for mild to moderate pain level 1 to 4. A review of the April 2023 Medication Administration Record (MAR) for R#39 revealed the resident received Tramadol 50mg at 8:55 a.m. on 4/29/23 and has an order for Acetaminophen 325mg give two tablets by mouth every six hours for mild to moderate pain level 1 to 4. There is no Acetaminophen documented as being given in April to date. During an observation on 4/29/23 at 10:30 a.m. of Wound Care Nurse (WCN) provide wound care for R#39 revealed when Certified Nursing Assistant (CNA) MM assisted R#39 onto her left side for wound care treatment she stated, It hurts so bad. CNA MM stated to R#39 that the treatment would be over soon. Continued observation of wound care revealed throughout the treatment the resident would yell out, Ouch, oh, oh, oh and CNA MM and the WCN would comfort the resident by telling her the treatment was almost done but the WCN never stopped treatment to assess R#39 verbal complaints of pain. During an interview on 4/29/23 at 10:55 a.m. with the WCN she stated that R#39 was given pain medication approximately an hour prior to receiving wound care treatment but did not respond as to why she did not stop and reassess the resident's complaints of pain throughout the treatment. During an interview on 4/29/23 at 11:40 a.m. with the Director of Nursing (DON) she revealed it is her expectation when a resident complains of pain during wound care regardless of if they have been pre-medicated prior to treatment that the nurse stop treatment and assess the resident's pain. She stated the residents nurse should be consulted to determine if the resident has anything else for pain and if so, the resident should be given the medication and treatment should resume after the medication has had time to be effective. During an interview on 4/30/23 at 12:40 p.m. with the WCN, she stated she has been doing wound care for two years and she understands how to do wound care. She stated she did ask the resident twice during wound care if she was ok and stated she already knew R#39 was on as needed (PRN) Tylenol but she only takes it when she asks for it and that R#39 was premedicated at least an hour prior to the wound treatment. WCN stated she should have stopped treatment when R#39 began complaining of pain during treatment and ask her nurse if she had additional pain medication or called and asked the Doctor for another order, but she did not do that and added that the reason she did not stop and assess the verbal expressions of pain during treatment was because being observed made her nervous.

Based on observation, staff interviews, and recipe review, the facility failed to ensure puree recipes were followed to conserve nutrient value of puree vegetable and puree chicken strips for six of six resident receiving puree consistency. Findings included: A review of the recipe for Puree Vegetable Medley revealed that the recipe yielded 20 servings. Ingredients included vegetable medley, water, butter, salt, vegetable seasoning. A review of the recipe for Puree Chicken Fingers revealed that the recipe yielded 5 servings. Chicken fingers 10 pieces, hot water 3/4 cup, and chicken base 1 tablespoon. Observation on 4/29/23 at 11:10 a.m. of Dietary Cook AA complete puree food items for lunch meal revealed no recipes were used, reviewed, or available for reference. Dietary Cook AA placed an unmeasured amount of cooked vegetable medley in the food processor and pureed. Dietary Cook AA then added an unmeasured amount of vegetable broth two different times to achieve proper puree consistency. An interview on 4/29/23 at 11:10 a.m. with Dietary Cook AA during observation, he confirmed that he did not measure the amount of cooked vegetable or vegetable broth for puree vegetable medley. He stated that there are recipes, but he knows by experience the correct consistency for puree. An observation on 4/29/23 at 11:30 a.m. of Dietary Cook AA complete puree chicken strips revealed he placed 15, three-ounce scoops of chopped chicken strips in the food processor along with an unmeasured amount of chicken broth and pureed. Continued observation revealed Dietary Cook AA added an unmeasured amount of chicken broth four additional times to achieve puree consistency. During an interview on 4/29/23 at 11:30 a.m., Dietary Cook AA confirmed that he added the chicken broth without measuring. During an interview on 4/29/23 at 11:35 a.m., the Interim Dietary Manager (IDM) confirmed that the dietary cook did not follow recipes for puree vegetable medley and puree chicken strips. The IDM revealed that he expects the cooks to follow recipes. During an interview on 4/29/23 at 11:45 a.m. with another dietary cook, Dietary Cook BB, they revealed that they do have recipes but go by eye for proper puree consistency.

Based on observations, staff interviews, and policy review the facility failed to ensure the pipes to the fire suppression system under exhaust hood were clean and free from grease build-up; failed to ensure pans were stored dry to prevent wet nesting; failed to proper store foods in dry storage area; failed to ensure label, date, and securely wrap opened food items in the kitchen and resident nourishment room; failed to ensure kitchen equipment was properly cleaned to prevent cross contamination; failed to ensure food spills were cleaned from walls; and failed to ensure dietary staff wore hair restraint while in the kitchen. This had the potential to affect 90 residents receiving an oral diet. Findings included: 1. An observation on 4/28/23 at 8:50 a.m. of the pipes to the fire suppression system under the exhaust hood revealed they were coated with a heavy layer of grease. Suspended collection of grease was noted attached to the pipe directly under the fryer. An observation on 4/30/23 at 11:10 a.m. of the pipes under the exhaust hood continued to be coated with a heavy layer of grease. Further observation revealed a sticker to the left side on the exhaust hood which revealed the date the exhaust hood was professionally cleaned which was 3/18/23. During an interview on 4/30/23 at 11:10 a.m., the Interim Dietary Manager (IDM) confirmed that there was a heavy grease build-up on the pipes to the fire suppression system to the exhaust hood. The IDM confirmed that the grease build up was hanging from the pipe directly under the fryer and could potentially contaminate the fryer. An interview on 4/30/23 at 11:10 a.m. with the lead dietary aide revealed that she notified the maintenance department about three weeks ago about the grease build-up to the pipes under the exhaust hood. The lead aide stated that dietary staff did not attempt to remove the grease in fear they may set off the fire suppression system. An interview on 4/30/23 at 11:40 a.m. with the Maintenance Director revealed that he had been made aware of the heavy grease build-up on pipes to the fire suppression system under the exhaust hood. He stated that he had not attempted to clean the pipes and has not contacted the professional cleaners to assist with removing the grease. 2. A review of the policy titled Dish Washing Policy revealed that after washing dishes, place on rack evenly spaced out to allow air drying. An observation on 4/28/23 at 8:57 a.m. of the pan rack where food carts were stored revealed a stack of 18-sheet trays and the top tray was turned over and the inside was completely wet and water drops were running off. Continued observation of a stack of five large rectangle steam table pans revealed when the top pan was turned over moisture was found inside. Further observation of the pan rack near the entry door to the kitchen revealed a stack of three medium rectangle steam table pans revealed the top pan was turned over and the inside had a light brown/tan colored food type substance that covered part of the inside. During an interview on 4/28/23 at 9:25 a.m., the lead dietary aide confirmed that the large sheet tray and large rectangle steam table pan were stored on the storage rack wet. The dietary aide stated that the pans should have been air dried before stacking. The lead dietary aide confirmed that the medium rectangle steam table pan had some type of food substance inside and was dirty. The lead aide stated that staff should have looked at the pan before placing it on storage rack to make sure it was clean. 3. A review of the policy titled Food Safety Requirements revealed proper food storage by keeping foods covered or in tight containers. An observation on 4/28/23 at 9:05 a.m. of the dry storage area revealed a 50-pound bag of dried beans wide open exposing the inside contents. Continued observation of the dry storage area revealed a large white storage bin labeled self-rising flour. Inside the bin was a 12-ounce Styrofoam cup that was covered with flour. During an interview on 4/28/23 at 9:30 a.m., the lead dietary aide confirmed that the 50-pound bag of dried beans was open and not securely closed. The lead aide stated that the cook should have closed the bag after use. The lead dietary aide confirmed that there was a white Styrofoam cup in the self-rising flour bin. She stated that the cup was likely used as a scoop and should not have been used and left inside the bin. 4. A review of the policy titled Food Safety Requirements revealed all equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination. An observation on 4/28/23 at 9:12 a.m. of the stand mixer revealed a light brown food substance on the front part of the mixing arm. During an interview on 4/28/23 at 9:37 a.m., the lead dietary aide confirmed that the stand mixer had light brown colored food debris. The lead aide revealed that dietary staff are to clean the mixer after each use. An observation on 4/30/23 at 10:50 a.m. of the stand mixer revealed the light brown colored food substance remained. When touched the food substance flaked off into hand. During an interview on 4/30/23 at 10:50 a.m., the IDM confirmed that the stand mixer had not been cleaned properly and the light brown food substance remained. The IDM confirmed that the food substance could flake off when touched. The IDM revealed that dietary staff should have cleaned the mixer after use. 5. A review of the policy titled Food Safety Requirements revealed labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers so it is used by its use-by date, or frozen/discarded. An observation on 4/28/23 at 9:13 a.m. of the stand-up refrigerator labeled Veg revealed a 16-ounce container of Cool-Whip topping with a facility label date of 1/31. An observation on 4/28/23 at 9:19 a.m. of the stand-up freezer across from walk-in refrigerator revealed a block of frozen hot dogs wrapped in plastic wrap with no label or date. Continued observation revealed a clear plastic bag containing chicken breasts that had been opened with no date. During an interview on 4/28/23 at 9:38 a.m., the lead dietary aide confirmed that the Cool-Whip container was labeled with a date of 1/31/23 and should have been discarded. The lead aide confirmed that the block of hot dogs and bag of chicken breast were not labeled or dated. The lead aide stated that staff have been educated to label and date food items before storing. An observation on 4/29/23 at 8:45 a.m. of the East Wing resident nourishment room refrigerator revealed a one-gallon container of Tropicana orange juice with no label or date. This refrigerator also had gray and black plastic-colored bags containing food items and no label or date noted. During an interview on 4/28/23 at 8:45 a.m., the IDM confirmed that the gallon container of orange juice and the gray plastic bag and black plastic bag with food items had no resident name or date. The IDM stated that all food items in the resident refrigerator should be labeled and dated. An interview on 4/28/23 at 8:50 a.m. with the Director of Nursing (DON) revealed that resident food items should be labeled and dated before storing in nourishment room refrigerator. The DON stated that if food items are not labeled or dated nursing staff should discard. 6. A review of a dietary in-service sheet dated 1/12/23 revealed staff were educated on the dish room, chemicals, floor/wall cleaning, moping, and food carts. A review of the cleaning sheet for week of 4/11/23 - 4/17/23 revealed that dietary staff initialed that the task of wiping down doors/walls daily was completed. No cleaning sheet could be found for the current work week. An observation on 4/29/23 at 11:00 a.m. of the ceramic tile wall behind the food processor revealed a splashed yellow colored food substance. Continued observation of the kitchen walls revealed a red colored food substance splashed above the exhaust hood. An observation on 4/30/23 at 11:05 a.m. of the walls in the kitchen revealed the area behind the food processor and area above the exhaust continued to exhibit splashed food substance. When touched the yellow food substance was able to flake off wall title. During an interview on 4/30/23 at 11:05 a.m. with the IDM, he confirmed that the yellow food substance and the red food substance were on the walls. The IDM revealed that staff should wipe/clean as they go. The IDM revealed that dietary staff have daily, weekly, and monthly cleaning tasks. The IDM revealed that the food substance on the walls should have been cleaned. 7. Review of the policy titled Food Safety Requirements (not dated) revealed: Dietary staff must wear hair restraints (hair net, hat, and/or beard restraint) to prevent hair from contacting food. An observation on 4/30/23 at 11:25 a.m. of Dietary Aide CC revealed that he was in the kitchen and not wearing a hair net. Continued observation revealed a box of hair nets located on the wall next to the door to enter the kitchen. An interview on 4/30/23 at 11:25 a.m. with Dietary Aide CC revealed that he knows he needs to be wearing a hair net when in the kitchen and just forgot to put it on. During an interview on 4/30/23 at 11:25 a.m., the IDM confirmed that Dietary Aide CC was in the kitchen and was not wearing a hair restraint. The IDM revealed that he expects all dietary staff to wear a hair restraint when in the kitchen.

Based on observations and staff interviews the facility failed to ensure that the dumpsters doors/lids were closed at all times and failed to ensure the area surrounding the dumpsters was free from trash debris. This had the potential to affect all 91 residents in the facility. Findings included: An observation on 4/29/23 at 8:40 a.m. of the dumpster area revealed that the facility had three large dumpsters located at the back of the building. The dumpsters were sitting on concrete and a concrete retaining wall was to one side. Continued observation revealed the dumpster closest to the retaining wall, both side doors were wide open exposing trash contents inside. Further observation revealed a white 50-gallon round trash can next to a dumpster with no lid, exposing the inside which consisted of several trash bags as well as an empty eight-ounce carton of milk and an empty individual cereal bowl of mini-wheats. The ground around the dumpsters had several pieces of trash such as plastic spoons, paper masks, blue latex gloves, and pieces of paper. During an interview on 4/29/23 at 8:40 a.m. the Interim Dietary Manager (IDM) confirmed that the side doors to one of three dumpsters were open. The IDM stated that dumpster doors should be closed. The IDM confirmed that the 50-gallon trash can did not have a lid and the inside contents were exposed. The IDM revealed that maintenance or housekeeping was responsible for the cleanliness of the dumpster area. An observation on 4/30/23 at 11:45 a.m. of the dumpster area revealed the dumpster closest to the building, one of the side doors was partially open exposing trash bags and contents inside. Continued observation of the dumpster closest to the back door of the dietary department revealed the right-side top lid was not closed, exposing multiple trash bags. Further observation revealed the trash on the ground noted from the previous day continued to be on the ground. Additional trash items included items such clear plastic gloves and two round shaped paper products (lids from individual ice cream tops). An interview on 4/30/23 at 11:45 a.m. with the Maintenance Director revealed that he is responsible for the dumpster area which includes ensuring the lids and doors are closed, area surrounding the dumpsters is clean, ensuring that the dumpsters are clean and free from food debris. The Maintenance Director confirmed that one dumpster side door was partially open, and another dumpster top lid was not closed. The Maintenance Director confirmed that there was trash on the ground surrounding the dumpsters.

Based on observation, record review, review of facility electronic correspondence and staff interviews the facility's governing body failed to ensure that an unsafe environment for residents of the facility which they were made aware on 7/4/17, was addressed in a timely manner. This failure resulted in the elopement of one resident (R#1) from the facility on 8/25/17, rolling down a steep hill in her wheel chair, with injuries sustained in the accident, resulting in death. The facility census was 81. Findings include: Review of an electronic correspondence, dated 7/4/17 at 11:19 a.m., between the Maintenance Director and the Fire Alarm company, with the Chief Executive Officer (CEO) and the Chief Financial Officer (CFO) copied on the email, revealed that due to a storm on Saturday (7/1/17) the facility was having a few issues with the alarm systems as well as security doors into the North wing of the facility. A second email of the same date at 1:15 p.m., to the same individuals listed above, revealed the issue is also affecting the ER (emergency room ) doors which needs to be rectified as soon as possible. Review of an electronic correspondence, dated 7/10/17 at 2:47 p.m., from the Maintenance Director to the CFO and copied to the CEO, revealed a proposal from the Fire Alarm Company to replace the Fire Alarm panel and installation, including a dollar amount, including text from the Maintenance Director For your review and approval. Please let me know how to proceed. Review of the EG North Georgia Medical Center Capital Expenditure Request, Reason for Capital Expenditure: to install a new fire alarm system due to the current system continues to malfunction. Mandated manual fire watches are being conducted by employees. The State Fire Marshall is requiring a new system to replace current due to the current malfunction. The request was signed off by the CEO and CFO on 8/29/17. Review of a second Capital Expenditure Request dated as approved on 8/21/17 by the CEO and CFO with the reason for Capital Expenditure To install a Fire Control Panel for monitoring and communicating ER fire panel phone lines, ER PIV valve, and battery backup. This is to eliminate the false alarms created by the faculty current system. Review of the Proposal from the Fire Alarm Company revealed the facility is to give a Deposit Check Due for Half Down and the balance due upon completion. An interview with the owner of the Fire Alarm Company on 9/5/17 at 1:00 p.m. Revealed that the facility had not been paying their bills to his business and that he was unable to begin and/or complete the work until he was paid. Additionally, his company required a deposit, from the facility, before work would begin. He stated that the July 2017 proposal did not include bringing the Fire Alarm system up to the current code. He stated that after the State Fire Marshall visit on 8/29/17 the facility was now required to bring the Fire Alarm system up to current code which required a new proposal. A post survey telephone interview with the Maintenance Director on 9/21/17 at 1:23 p.m. revealed that the emails on July 4, 2017 were not related to the lightning strike which occurred on 7/7/17, but instead were related to a storm on 7/1/17. The email dated 7/4/17 at 11:19 a.m. revealed the Maintenance Director relayed to the Fire Alarm Company Due to the Storm that moved through on Saturday we have had a few issues with the alarm system as well as the security doors in to the North Wing of the facility. A second email from the Maintenance Director to the Fire Alarm Company date 7/4/17 at 1:15 p.m. revealed We have just found that the issue is now affecting the ER (emergency room ) doors. This needs to be rectified ASAP (sic). The Maintenance Director revealed that the previous Administrator was notified of the of the lightning strike, in person, on 7/10/17 (three days after the lightning strike) and confirmed the previous Administrator was not copied on the emails as she did not regularly use email. Review of an email correspondence from the CFO to the former Administrator on 9/7/17 at 2:32 p.m. revealed In the past, purchasing held some (name) Fire Alarm Company's invoices. The invoices should have been forwarded to the Accounts Payable for payment. Once Accounts Payable received the invoices, payment was made. During the recent activity, the (name) Fire Alarm Company is paid currently and timely. An interview with the previous Administrator on 9/5/17 at 1:06 p.m. revealed she was unaware of any lightning strike to the building effecting the fire alarm panel. Administrator further revealed her resignation is effective on 9/11/17 and that the Chief Executive Officer (CEO) and Chief Financial Officer (CFO) are handling the facility affairs. The Administrator further revealed she requested some type of fence or guardrail for safety to prevent anyone from going over the steep hill in front of the facility. Review of the previous Administrator's resignation letter dated 8/11/17 revealed that she had concerns of resident safety that were related to other issues in the facility which the Governing Body of the facility did not address. An interview with the facility Medical Director (MD) on 9/8/17 at 10:04 a.m. revealed he is in facility at least four days a week and is available 24/7. He has another physician who can cover for him during emergencies and vacation. Continued interview also revealed that he thinks the current parking lot should be used for staff only and not be accessible to guest for safety reasons. The MD also revealed at the same time that some type of guardrail or extending the fence will help prevent future accidents like the one that occurred on 8/25/17. Cross Refer to F323

Based on record review and staff interviews, it was determined that the facility failed to develop a care plan for three residents (R) (R#1, R#2, and R#3) with a history of wandering and who are at risk for elopement as evidenced by the following: R#1 pulled fire alarm on 8/5/17 and voiced desire to go home, R#2 eloped out the facility and was found in the facility parking lot on 4/7/17, and R#3 demonstrating behaviors of wandering and risk of elopement without care plan being updated until 7/20/17. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form dated 9/6/17, the facility's census was 81 residents. The resident sample was 7. Findings include: 1. R#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A record review of R#1's nurse's notes dated 6/6/17 at 3 a.m. revealed the resident was confused early in shift and was asking to go home. A record review of R#1's nurse's notes dated 8/5/17 at 2:30 p.m. revealed the resident was very agitated, wanted staff to let her out and was difficult to redirect. The same nurse's note revealed the resident pulled the fire monitor and will monitor. A record review of the employee statement given by Certified Nursing Assistant (CNA) EE dated 8/25/17 revealed that on 8/25/17, R#1 was put back in her room from the annex hall (West wing 1 exit door) twice, was going in other resident's rooms, and stating she was going home. A record review of R#1's care plan revealed the resident is not care planned for wandering behaviors or at risk for elopement. R#1's new behavior of pulling the fire alarm was not assessed or care planned. A record review of R#1's Minimum Data Set (MDS) Admission assessment dated [DATE] revealed R#1 was coded in Section E as having delusions but demonstrated no behaviors, including wandering. 2. R#2 was admitted to the facility on [DATE] from an acute hospital with [DIAGNOSES REDACTED]. A record review of the facility's social service summary/brief history form completed at admission revealed R#2 may wander. A record review of the facility's social service review dated 6/26/17 revealed that R#2 has wandering behaviors per the mood/behavior status section. A review of the same form also revealed that R#2 has the potential for wandering/unsafe per the social service intervention status section. A record review of an incident/accident report dated 4/7/17 revealed R#2 was observed by staff standing outside in the parking lot with a rolling walker, and the staff was unsure how resident got outside the facility. A record review of R#2's nurse's note dated 5/13/17 at 10:00 a.m. revealed the resident stated she was moving, had boxes in her room and putting clothes in the boxes. A record review of R#2's nurse's note dated 9/2/17 at 1:30 p.m. revealed the resident attempted to exit the door and was redirected by staff; staff made aware of incident and will monitor. A record review of R#2's care plan for Mood/Behavior revealed resident was initially care planned for wandering behaviors although not for being at risk for elopement. R#2's care plan was not updated to include elopement on 4/7/17. 3. R #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A record review revealed a 5/4/17 plan of care for MOOD/BEHAVIOR focus for difficulty sleeping, poor appetite, trouble concentrating and little interest or pleasure in doing things. A record review of R#3's nurse's notes dated 5/7/17 at 9:00 a.m. revealed that the resident kept hunting for the waiting area, stating that she needed to wait for her family who was going to take her home. A record review of R#3's nurse's notes dated 5/31/17 at 10:00 p.m. revealed that the resident was ad lib (as desired) with rolling walker, wandered within facility, looking for family and a way to go home. A record review of R#3's social service review dated 6/16/17 revealed the resident is confused, sometimes does not know where she is and tries to find a way to return home per the cognitive/mental status section. A record review of R#3's Minimum Data Set ((MDS) dated [DATE] revealed in Section E that the resident exhibited wandering behaviors daily, however, the Quarterly MDS dated [DATE] revealed in Section E that the resident exhibited no behaviors. The facility failed to failed to care plan the resident for new behaviors of wandering as times until 7/2017 and there were no interventions to address these new behaviors. In addition, review of the twenty-four (24) hour report sheets for this resident revealed the following. There was documentation on these sheets that on the 3:00 p.m. to 11:00 p.m. shifts on 7/27/17, 7/28/17, 8/4/17, 8/5/17 and 8/10/17 that the resident was telling staff that she was wanting to go home, very anxious and confused. On 8/27/17 on the 7:00 a.m. to 3:00 p.m. shift, there was documentation on the 24-hour report form that the resident had tried to get out of the building all day long. Record review revealed that none of these incidents had been documented in the nurse's notes or any other portion of the clinical record. Even though the resident had stated that she wanted to go home five (5) times form 7/27/17 to 8/10/17, and had tried to get out of the building all day long on the 7:00 a.m. to 3:00 p.m. shift on 8/27/17, the facility failed to assess the resident for increased risk for elopement and failed to revise the plan of care to include interventions to attempt to prevent wandering/elopement. An interview with the Ombudsman overseeing the facility on 9/5/17 at 2:58 p.m. revealed staff reported to her that R#1 pulled the fire alarm prior to 8/25/17 incident. An interview with the Social Service Director (SSD) on 9/6/17 at 3:45 p.m. revealed the facility's Nursing Flow Sheets wandering section, nurse's notes, and Medication Administration Record [REDACTED]. Continued interview also revealed the SSD is responsible for coding Sections B, C, D, E and Q of the MDS. An interview with the Assistant Director of Nursing (ADON) on 9/6/17 at 5:09 p.m. revealed R#2's care plan was updated on 9/1/17 however, she forgot to date it. Continued interview also revealed residents in the facility are classified as wanderers when the following behaviors are exhibited: repeatedly attempting to get out the door, repeatedly saying they are going home, and packing personal items. An interview with the Director of Nursing (DON) on 9/7/17 at 11:40 a.m. revealed the criteria for wandering residents is the following: family states history of wandering, trying to get out the facility, combativeness, confusion, going to doors constantly, repeatedly packing belongings. Continued interview revealed she expected R#2 to be care planned as a wanderer and/or at risk for elopement. An interview with Licensed Practical Nurse (LPN) II on 9/8/17 at 1:17 p.m. revealed R#2 and R#3 are wanderers and should be care planned as wanderers. An interview with Registered Nurse (RN) SS on 9/8/17 at 1:17 p.m. revealed residents are classified as wanderers when they move around facility without purpose, exit seeking, talking about going home, and confused. An interview with RN TT on 9/8/17 at 1:32 p.m. revealed residents are classified as wanderers if they stay near the exit doors, wander from room to room, mobile (using wheelchair, walker, or independently), [DIAGNOSES REDACTED]. A record review of the facility's Elopement/Missing Resident Policy and Prevention dated October 28, 2016 the policy revealed the following should occur if a resident elopes from the facility: (1) The care plan will be updated with diversion approaches, modifications, and appropriately timed goals that are specific to the residents individual wandering habits (2) The DON will arrange a called Quality Assurance and Performance Improvement (QAPI) Meeting on the next business day after the elopement incident to locate any areas for improvement.(3) The facility will maintain a Missing Resident Identification Form on all residents, which will be located in the resident's chart. Cross Refer to F323

Based on observation, staff interview, record review, and review of the Georgia Nurse Practice Act, Chapter 410-10 and Standards of Practice (410-10.02) the facility failed to ensure that licensed nurses assessed wandering residents and maintained the safety of wandering/exit seeking residents, specifically R#1 who eloped on 8/25/17, in her wheel chair, by pulling the fire alarm, then rolled down a steep hill, resulting in the death of this resident from injuries sustained in the fall. Additionally, R#2, R#3 and R#6 were not assessed for wandering/elopement behaviors and staff were not aware that R#7 was newly assessed for wandering behaviors. The sample was seven residents. Findings include: Review of the Georgia 410.10 Standards of Practice and Unprofessional Conduct for Registered Nurses, revealed Rule 410-10-.01, 2 (a) 3. Plan care which includes goals and prioritized nursing approaches or measures derived from the nursing diagnoses. 4. Implement strategies to provide for patient/client participation in health promotion, maintenance and restoration. (b) 12. Participate in the periodic review and evaluation of the quality and appropriateness of nursing care. Review of the Georgia 410.10.2 Standards of Practice for Licensed Practical Nurses (LPN) revealed 1. (c) Performing comfort and safety measures. 1. R#1 was admitted to the facility on [DATE], from another facility, with no history of wandering. The resident had multiple diagnoses, including but not limited to the following: [MEDICAL CONDITION], above the knee left leg amputation, and [MEDICAL CONDITIONS]. Record review of the nurse's notes, dated 6/6/17 at 3:00 a.m. revealed resident confused early in shift, was asking to go home. Will continue to monitor. Record review of the nurse's notes dated 7/21/17 at 2:00 a.m. revealed the resident was near the nurse's station due to multiple attempts to get out of bed unassisted. Resident is argumentative with staff, will monitor. Review of the nurse's notes dated 8/5/17 at 2:30 p.m. revealed the resident very agitated today. Wanted staff to let her out. Difficult to redirect. Resident pulled the fire alarm. Will monitor. Review of the resident Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was assessed on admission as having a Brief Interview of Mental Status (BIMS) of 3, indicating severe cogitative impairment. The resident was assessed as having delusions. Review of the Activities of Daily Living (ADL), dated 6/27/17 revealed she often sits and stares and if she does talk she is often confused and can be agitated which was update on 7/12/17. There is no care plan developed for wandering or pulling the fire alarm on 8/5/17. On 8/25/17, at approximately 8:45 p.m., after several attempts to get out of bed unassisted, per an interview with Certified Nursing Assistant (CNA) AA on 8/30/17 at 2:15 p.m., she and CNA RR had gotten the resident up into her wheel chair. An interview with CNA RR on 8/30/17 at 3:30 p.m. revealed that after she and CNA AA had gotten the resident up in her wheel chair, the resident was going into other resident's rooms and kept saying I want to go home. The CNA had notified the resident's nurse (LPN HH) of the resident's behaviors. An interview with LPN HH on 8/25/17 at 9:45 p.m. revealed that she had worked at the facility for less than one month and was not aware of which residents were at increased risk of elopement. She was working the night of 8/25/17 on the 3:00 p.m. to 11:00 p.m. shift and that she was R#1's nurse that evening. She revealed that between 9:30 p.m. and 9:40 p.m. the resident was parked near her medication cart, which is near the West wing 1 exit door where the resident had pulled the fire alarm previously on 8/5/17. LPN HH had gone into another resident's room to administer medications when she heard the fire alarm sound. She immediately started clearing the West wing hallway, put her medication cart behind the nurse's station and proceed to make certain resident's doors were closed. She was not aware that R#1 was missing until a gentleman rushed into the facility at approximately 10:05 p.m., saying a resident and her wheel chair were at the bottom of the steep hill outside of the West wing 1 exit door. 2. R#2 was admitted to the facility on [DATE] from an acute hospital with [DIAGNOSES REDACTED]. A record review of the facility's social service summary/brief history form completed on admission revealed R#2 may wander. A record review of the facility's social service review dated 6/26/17 revealed that R#2 has wandering behaviors per the mood/behavior status section. A review of the same form also revealed that R#2 has the potential for wandering/unsafe per the social service intervention status section. A record review of an incident/accident report dated 4/7/17 revealed R#2 was observed standing outside in the parking lot with a rolling walker, and unsure how resident got outside the facility. An interview on 9/1/17 at 10:15 a.m. with the DON, who provided the surveyor with a facility Incident Report Form dated 4/7/17, which documented that R#2 was observed standing outside in the parking lot. Unaware of how she got outside. No injury noted. Will continue to investigate. Under the comments section, there was the following information: Code on door was immediately changed. The record review revealed that the facility nursing staff had failed to document in the nurses' notes or any other place in the record, of the 4/7/17 wandering/elopement outside in the parking lot. In addition, review of the care plan revealed that the facility had failed to revise the plan of care to address this wandering/elopement outside of the facility on 4/07/17 which was confirmed by the DON on 9/1/17 at 10:15 a.m. Review of the nurse's notes dated 8/19/17 at 5:00 p.m. revealed that the resident was at the front door trying to escape. Two CNAs and writer brought her back. Again, review of the care plan revealed that the facility failed to revise the plan of care to address this resident's attempt to escape from the facility on 8/19/17. Interview on 8/30/17 with three new employees, Licensed Practical Nurse (LPN) HH at 1:50 p.m., Certified Nursing Assistant (CNA) AA at 2:15 p.m. and Registered Nurse (RN) XX at 12:45 p.m., revealed that they were not aware of any residents, including this resident, at increased risk for elopement. 3. Resident #3 was admitted to the facility on [DATE]. Record review revealed a 5/4/17 plan of care for MOOD/BEHAVIOR focus for difficulty sleeping, poor appetite, trouble concentrating and little interest or pleasure in doing things. Review of the nurse's notes dated 5/7/17 at 9:00 a.m., it was documented that the resident kept hunting the waiting area, stating that she needed to wait for her family who was going to take her home. Review of the nurse's notes dated 5/31/17 at 10:00 p.m. revealed that the resident was ad lib with rolling walker, wandered within facility, looking for family and a way to go home. Review of this resident's care plan revealed that on 7/20/17 for Mood/Behavior revealed the facility did not address the resident's wandering at times on the behavior care plan. An interview on 8/29/17 at 6:00 p.m. the Director of Nursing (DON) stated that she had not used a specific tool for elopement assessment for residents. She stated that she and her nursing staff looked at the admission assessments, the BIMS scores, cognition levels, mobility status and history prior to admission. She stated that she did not do quarterly review for potential for elopement for residents. She could not provide documentation that any resident had been assessed for elopement risk. The DON stated that if a resident started showing signs of elopement potential, such as wandering in and out of other residents' rooms, going to doors and trying to shake them to get out, verbalizations of wanting to go home or let me out, then the way that she would let staff know of these changes should be an addition of these changes (increased elopement risk) to the resident's care plan with new interventions to attempt to prevent elopement/wandering. The DON stated that the care plans for each resident were kept in books/binders at the nursing stations. In front of these care plans should be an Activities of Daily Living (ADL) check sheet with reflected changes for potential for wandering/elopement on the ADL check sheet for nursing staff to review. An interview with the DON on 9/8/17 at 12:30 p.m. revealed that the facility had not been keeping a list of wandering residents. She had put together a list, last week, that included 11 residents but per their Credible Allegation of Compliance (A(NAME)) submitted to the State Survey Agency on 9/7/17 that all residents had been assessed and there are now are only three wandering residents. An interview with LPN II on 9/8/17 at 1:20 p.m. revealed that she had read the new elopement and Code Red policy. She revealed that just this morning a male resident, that she was not familiar with, was wandering with a rolling walker on the West wing (where she was assigned). She did not know the resident and assumed he must be from the other wing so she directed the resident to the other wing. When asked if she did anything else, she replied that she did not. She then revealed that based on the new policy she should have alerted the charge nurse so that every two-hour check could begin and she did not. An interview with LPN BB on 9/8/17 at 2:00 p.m. revealed that she had one resident with new wandering behaviors, R#7, and had just begun using the every two-hour check form. LPN II was at the nurse's station during this interview and informed the surveyor that this was the resident she had seen wandering this morning, who was a new admit on the West wing. LPN BB further revealed that she was given a paper policy to read and sign but she had not been in-serviced on the new Elopement or Code Red Fire policy and procedure. She was not aware the two-hour checks were needed until LPN II brought it to her attention after speaking to the surveyor. An observation and interview with the DON, in her office, on 9/8/17 at 2:30 p.m. regarding who was responsible for completing the wandering assessments, R#6 was observed in the hallway just outside the DON office with a rolling walker. R#6 was with the Social Worker, who was attempting to re-direct this confused resident who made statements where am I going and where am I to the Social worker. The DON confirmed that this resident was not one of the three wandering residents because she only wanders inside of the building. Cross Refer to F323

Based on observation, record review, review of the facility Code Red (fire alarm) procedure, Elopement policy, State Fire Marshall's report and staff interviews the facility failed to provide an environment that was free of accident hazards for two residents (R#1and R#2), with wandering and elopement behaviors. R#1 who pulled the fire alarm on 8/5/17 and exhibited wandering and exit seeking behaviors per staff and nurse's notes, subsequently pulled the fire alarm on 8/25/17, which led to the elopement and her death after rolling down a steep hill on the facility property in her wheelchair. R#2 was found in the parking lot, by staff, the afternoon of 4/17/17, staff was unaware how resident eloped from the facility. Neither resident was care planned for wandering behaviors or risk for elopement. This had the likelihood effect four other sampled residents (R#3, R#4, R#5, R#6) with wandering behaviors. Review of the CMS-672, Resident Census and Conditions of Residents, dated 9/6/17, the census was 81 and the sample size was seven. On 9/7/17, a determination was made that a situation in which the facility's noncompliance with one or more requirement of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing where informed of the immediate jeopardy on 9/6/17 at 3:20 p.m. The noncompliance related to the immediate jeopardy was identified to exist on 8/5/17. 1. Resident (R)#1 was admitted to the facility on [DATE], from another facility, with [DIAGNOSES REDACTED]. R#1 had made frequent statements since admission of wanting to go home. R#1 utilized a wheel chair for mobility and was independent with mobility. On 8/5/17, R#1 had pulled the fire alarm at the West wing exit door although she did not exit the building. The resident was not care planned for wandering behaviors and the facility did not put interventions in place after the 8/5/17 event to keep the resident safe. On 8/25/17, the resident had been attempting to get out of bed several times, and between 8:45 p.m.to 9:00 p.m. the CNA's got the resident out of bed and into her wheelchair. The resident stated she was going home and proceeded to wander about the facility and into other resident's room in the resident's wheel chair. The resident was placed near the West wing medication cart to allow Licensed Practical Nurse (LPN) HH while one CNA went on break. LPN HH went into a resident's room, to administer medications, while R#1 was in the hallway near the West exit door, where she had previously pulled the fire alarm. While administering medications, in the resident's room, LPN HH heard the fire alarm sound. She exited the room to begin getting residents to their rooms and shutting the doors. Staff was not aware that R#1 was missing until a passerby came to the facility door saying a resident and a wheelchair were at the bottom of the steep hill, near the road. Emergency Medical Staff arrived and transported the resident, via life flight to the nearest trauma center, which was in Tennessee. Per the Medical Examiner's Case Report dated 8/26/17 revealed that R#1 was pronounced dead on 8/26/17 at 2:06 a.m. due to a Cerebral Brain Bleed as a result of head trauma from the fall. Two additional residents were identified with wandering and elopement without a care plan to address these behaviors. 2. R#2 was found in the parking lot of the facility on 4/7/17 after someone left the front door open. Staff observed the resident in the parking lot and brought the resident back inside the facility. An investigation into how this incident occurred was not done, and the resident's care plan was updated regarding wandering and exit seeking behavior although the update was not dated to determine when the update was initiated. Per the nurse notes, dated 9/2/17, the resident attempted to exit the door and was redirected by staff. 3. R#3 who was admitted to the facility on [DATE]. On 5/7/17, it was documented the resident was looking for the waiting area, saying her family was coming to get her. The resident was confused but independent and ambulated with a rolling walker. This new behavior was not care plan until 7/20/17, there wereno interventions added to prevent elopement or keep the resident safe. The facility had no process in place to assess wandering/exit seeking residents and had no process for alerting staff of these behaviors. The facility's Fire Alarm system had been struck by lightning on 7/7/17 and functioned inconsistently, per the Fire Alarm Company, and on the night of 8/25/17 did not send a signal to the monitoring company or the 911 system. Thus, the exact occurrence time could not be verified. Immediate Jeopardy related to the facility's noncompliance with the program. requirements at 42 C.F.R. was identified to have existed on 8/5/17 when R#1 had first pulled the fire alarm. On 8/25/17 R#1 pulled the fire alarm again then eloped in her wheel chair rolling down a steep hill on the facility property resulting in her death due to head trauma. Findings include: 1. R#1 was admitted to the facility on [DATE] from a skilled nursing home in Tennessee with [DIAGNOSES REDACTED]. A record review of R#1's nurse's notes dated 6/6/17 at 3:00 a.m. revealed the resident was confused early in shift and was asking to go home. A record review of R#1's nurse's notes dated 8/5/17 at 2:30 p.m. revealed the resident was very agitated, wanted staff to let her out and was difficult to redirect. The same nurse's note revealed the resident pulled the fire alarm and will monitor. Review of the facility 24-hour report dated 8/5/17, for the 7:00 a.m. to 3:00 p.m. shift, revealed for R#1: very agitated/pulled fire alarm-wanted to get out. It is documented for the 3:00 p.m. to 11:00 p.m. shift: ok this p.m. Review of the resident Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was assessed on admission as having a Brief Interview of Mental Status (BIMS) of 3, indicated severe cogitative impairment. The resident was assessed as having delusions, the resident Functional Status for mobility with a wheel chair, and always incontinent of bowel and bladder function. Review of the resident's care plan dated 6/27/17 revealed a focus area for Activities of Daily Living (ADL), falls, dental and dehydration. She may hit at staff and may refuse meals and drink. She often sits and stares and if she does talk she is often confused and can be agitated. Updated 7/12/17. The resident has a focus area for Cognition/Communication/Vison: She is a new admission from a facility in an adjoining state and wanted to be closer to family. She has trouble expressing full sentences. Can answer simple/direct questions. Cognition is impaired both short and long term are affected. Vision is impaired, she does wear glasses at times. There is no care plan for wandering and no care plan was developed for the behavior of pulling the fire alarm on 8/5/17. Record review of nurse's notes dated 8/25/17 at 9:45 p.m., signed by Licensed Practical Nurse ( LPN) HH, revealed the resident was in wheelchair, in hallway. On the same day at 9:50 p.m. the fire alarm went off. On the same day at 10:05 p.m. a gentleman walked/rushed into the front entrance saying a resident was at the bottom of the hill at the main entrance, 911 was already notified. Registered Nurse (RN) XX went down to investigate. On the same day at 10:10 p.m. LPN HH went down the hill to speak to the Emergency Medical Services (EMS). Report given to the paramedics. Resident transported to (name) emergency transport. Director of Nursing (DON) notified. Review of the EMS Pre-hospital Care Report dated 8/25/17 revealed that EMS was dispatched at 22:00 (10:00 p.m.) and arrived on the scene at 22:13 (10:13 p.m.). Review of the Summary of Events: Upon arrival, the patient was found in a grass ditch at the road below the nursing home, nursing home staff and an ER (emergency room ) paramedic present. A wheelchair was in the ditch near the patient. She had rolled down a steep hill that was approx. (sic) 80 feet long with a approx. (sic) 30 foot drop. The patient was found lying face down, with her legs curled under her. She has a patent airway with labored respirations. She had an altered mental status and was moaning and would respond to voice with moaning. Bystander states he was driving by, saw a wheelchair and turned around to check. He states that the patient was making moaning noises and he went up to the nursing home to advise them that the patient was in the ditch and called 911. The nursing home staff advised EMS that a fire alarm was pulled and the patient had possibly been unaccounted for ten minutes. The resident was moved to the back board. When the resident was laid supine it was apparent she had a possible left flail chest with a seesaw motion to her chest when breathing. There was crepitus (a grating, crackling or popping sound due to the presence of air in the subcutaneous tissue) to her left shoulder and ribs, left elbow and left wrist. Head no instability, bruising to the left orbital region, pupils reactive and equal. Chest unequal expansion with crepitus to left shoulder, elbow and wrist. Lower extremities, Right (R) with a three-inch skin tear below the knee. Left above the knee amputation. One-inch skin tear to the left finger. Cardiac monitor show sinus tach (sic) with occasional PACs (premature Atrial Contraction). The patients room air O2 Sats (oxygen level) are originally in the high 70's and improved to the low 90's on 15 liters of O2. Air transport to a trauma center was requested. The resident was turned over to air ambulance (name) with report. Review of the County Coroner report dated 8/26/17 at 04:56 (4:56 a.m.) revealed he was first informed by the hospital nurse that the resident had fallen at home and hit her head. Later information that was verified that the decedent was in (name) nursing home and on 8/25/17 at approximately 2150 hrs. (9:50 p.m.), decedent activated the fire alarm at the nursing facility, which opened any locked doors and decedent exited the facility in a wheelchair. Decedent apparently lost control of the wheelchair and crashed. Decedent sustained a head injury in the incident. Decedent was flown by air transport (name) to hospital (name) and arrived in the ER (emergency room ), 8/26/17 just after midnight. Decedent was pronounced on 8/26/17 at 0206 hrs (2:06 a.m.) with a Cerebral Brain Bleed (ICH) due to head trauma as the COD (cause of death). An autopsy was to be performed (the results are not available at this time). A record review of the employee statement given by Certified Nursing Assistant (CNA) EE dated 8/25/17 revealed that on 8/25/17, R#1 was put back in her room from the annex hall twice (the area where the West wing exit door was located), was going in other resident's rooms, and stating she was going home. It was documented in the 8/5/17 at 2:30 p.m. nurse's notes that the resident had pulled the fire alarm and would be monitored. An 8/30/17 signed statement by the writer, LPN BB, of this note, revealed that she did not see this resident pull the fire alarm box on 8/5/17. The resident was sitting at the exit door, West wing one, when the alarm went off on 8/5/17. LPN BB never saw the resident try to get out. However, the resident would state I want to go home and Open that door West one exit door. An interview on 8/29/17 at 6:00 p.m. with the DON revealed that she had not used a specific tool for elopement assessment for residents. She stated that she and her nursing staff looked at the admission assessments, the BIMS scores, cognition levels, mobility status and history prior to admission. She stated that she did not do quarterly review for potential for elopement for residents. She could not provide documentation that any resident had been assessed for elopement risk. Further interview at this time revealed that if a resident started showing signs of elopement potential, such as wandering in and out of other residents' rooms, going to doors and trying to shake them to get out, verbalizations of wanting to go home or let me out, then the way that she would let staff know of these changes would be an addition to the resident's care plan with new interventions to attempt to prevent elopement/wandering. The DON stated that the care plans for each resident were kept in books/binders at the nursing stations and that in front of the care plans should be Activities of Daily Living (ADL) check sheet to reflect the changes. However, on 8/30/17 interviews with three new employees, who had worked the 3:00 p.m. to 11:00 p.m. shift on 8/25/17, LPN HH at 1:50 p.m., CNA AA at 2:15 p.m. and RN XX at 12:45 p.m., revealed that they did not know which residents were at risk for potential for elopement/wandering or with a history of elopement from the facility. They were not aware of where to locate the information for high risk for elopement/wandering residents. An interview with LPN HH on 8/30/17 at 1:50 p.m. revealed that she had worked the 3:00 p.m. to 11:00 p.m. shift on 8/25/17 and that she had been R#1's nurse. She stated that between 9:30 p.m. to 9:40 p.m. on 8/25/17 that her medication (med) cart was parked in the front hallway, between rooms 132 and 134, with the resident close to the med cart. LPN HH further stated that about 9:45 p.m. on 8/25/17 that she went to room 136 to administer medications to that resident. LPN HH further revealed that when she was in room 136, she heard the fire alarm sound. She immediately started clearing the hallway of West Wing and checking to make sure that the residents were in their rooms. She stated that this took about five minutes. She then proceeded to the front hallway, around rooms 132 and 134 and moved the med cart behind the nursing station. She stated that she then looked down East hallway and noted it was clear and the doors to the residents' rooms were closed. During this time, she had not observed R#1 in any of the hallways that she had checked. Continued interview with, LPN HH revealed that she had been working at this facility for not quite a month. She stated that she did not know which residents in the facility were at increased risk for elopement. She also had not had orientation in regards to the facility's fire protocol/policy. LPN HH further revealed that after she had checked the hallways for West and East halls, she heard another employee, not sure who, state that the fire alarm had been pulled. She stated that CNA LL and RN SS discovered that the fire alarm box at West wing one, southwest entrance had been pulled. LPN HH stated that she and RN XX had been in the West nursing station about 10:00 p.m., when a young man came through the front door and informed them that a woman and her wheelchair were in the ditch at the base of the hill adjacent to the nursing home. It was then that RN XX went to check on this resident. She then heard banging on the West wing one exterior door by two men. LPN HH revealed that she pushed the door open without having to enter the codes for the keypad at this door. The two men reported to her that a woman was laying in the ditch at the base of the hill adjacent to the nursing home. She proceeded to get more help from other nursing staff in the facility and to assist as needed with obtaining information from R#1s chart to give to the EMS. An interview with CNA AA on 8/30/17 at 2:15 p.m. revealed that she had worked with this resident on the 3:00 p.m. to 11:00 p.m. shift on 8/25/17. CNA AA stated the resident had been trying to get out of bed on 8/25/17, after the supper meal, about 7:30 p.m. and again between 8:45 p.m. to 9:00 p.m. CNA AA and CNA RR got the resident up in her wheelchair between 8:45 p.m. to 9:00 p.m. on 8/25/17. CNA AA then pushed the resident to the East wing nursing station about 9:00 p.m. on this date. CNA AA stated she went on break about 9:15 p.m., leaving her co-worker CNA RR on the hall where the resident's room was. Further interview with CNA AA revealed that she had only worked at the facility for about a month. She stated that she was not aware of a list of residents who had wandered in the past nor was she sure of who (residents) were at risk for elopement An interview with CNA RR on 8/30/17 at 3:30 p.m. revealed that she had worked 7:00 p.m. to 7:00 a.m. shift on the evening of 8/25/17. She also confirmed that she was working with this resident, along with her co-worker, CNA AA. She revealed that she could not remember specific times; however, she did provide a sequence of events of that night of 8/25/17. She stated that this resident had tried to get out of bed several times on 8/25/17 and that she and CNA AA had gotten the resident up in her wheelchair. She stated that the resident would roll and roll in her wheelchair, and that the resident kept saying I want to go home. CNA RR stated that the resident was going in other residents' rooms. Further interview with CNA RR on revealed that she finally placed the resident near LPN HH's medication (med) cart, around room 123 (near the West wing one exit door) and informed LPN HH that the resident was agitated. An interview with CNA EE on 8/30/17 at 4:30 p.m. revealed that she had been working on the 3:00 p.m. to 11:00 p.m. shift on 8/25/17 on the East/Annex hall. She stated that she could not recall the specific time, but this resident had come up to her and had told her that she was going home. CNA EE stated that the resident then started following her around and started going into other residents' room. She then stated that she pushed the resident back up to her room and found CNA RR and told her that this resident had been going in other residents' rooms. Interview with the Maintenance Director on 8/31/17 at 10:15 a.m. revealed that there is a keypad system (Door Guard) for all exit doors in the facility, which keep the doors locked at all times. Review of the information for the Door Guard keypad system noted that when a fire alarm is pulled that all of the exit doors in the facility are unlocked. Continued interview with the Maintenance Director revealed that the Door-Guard (keypad system) had been in place in the facility for about two years and had replaced the Wander Guard system at that time. According to a signed statement and interview with the Maintenance Director on 8/31/17 at 11:35 a.m. the following information was obtained: The Maintenance Director was in the facility on 8/5/17 with some of his family members. As they walked down the hall, West Wing, Southwest exit, R#1 was sitting there (at the West wing one exit door). The resident stated that she wanted to go home. The Maintenance Director told the resident that he would call her family (husband) to let him know, but it would take him (husband) some time to get to the facility. The resident told the Maintenance Director Okay and thanked him. He walked straight down the hall to the far end of East Wing hallway, where he entered the code to exit the nursing home. He heard the alarm go off. He looked down the far end of the East Wing hall and saw R#1 with her arm up on the wall in the area that the alarm was pulled. An interview with CNA MM on 8/31/17 at 1:45 p.m. revealed that she had been scheduled to work on the 11:00 p.m. to 7:00 a.m. shift on 8/25/17 and arrived at the facility parking lot at 9:55 p.m. on 8/25/17. She stated when she pulled into the parking lot, at the top of the steep driveway, that a young man was on his cell phone and motioned for her to come over. He told her that a lady and a wheelchair were at the base of the ditch, at the bottom of the hill adjacent to the nursing home parking lot She immediately ran down the hill to the ditch and discovered the resident. She stated that the resident was on her knees, the left arm was under her abdomen, right hand was palm down on the ground beside her and her face was in the grass, with her glasses pressed against her face. The CNA MM talked to the resident and did not get a response. She asked the young man how he had found her and he responded that he had not touched her; however, the resident's blanket was neatly tucked under her and covering her legs and hips. She then asked the resident if she was okay who attempted to raise her head but she could not. The CNA stated that she tried to call the facility, from her cell phone, but no one answered. She then sent the young man and another passerby to go up the hill, to the facility, to inform staff of what had happened with the resident and that she stayed with the resident. She noted there was bleeding on the resident's right lower leg, got some Kleenex and put pressure on the area to stop the bleeding. About that time, EMS and the police arrived. She left the scene to go get the resident's record from the facility, as she recognized the resident as R#1. She informed the EMS technicians of who the resident was, her [DIAGNOSES REDACTED]. Review of the Facility Incident Report Form dated 8/25/17 for R#1 revealed that at approximately 9:50 p.m. on 8/25/17, a fire alarm sounded in the facility and all doors automatically unlocked. The Code Red procedure was implemented. At approximately 10:00 p.m., a male passerby was in the parking lot and stated to oncoming staff that a lady was in laying in the ditch at the bottom of the hill (adjacent to the facility). The staff member immediately ran down the hill, passerby stated he had already called 911. The resident was found at the foot of the hill at side of facility, face down in the ditch with a wheelchair over near the resident's left side. Staff on scene cared for resident until Emergency Medical Services (EMS) arrived. Upon arrival of EMS, the resident was transported for emergency treatment to a hospital (name) outside of Georgia (name). A follow up interview with this CNA RR on 9/1/17 at 1:10 p.m. revealed that she had informed the resident's nurse, LPN HH, when she first gotten the resident up, that the resident had been going in and out of other residents' rooms and was saying that she (resident) wanted to go home. Continued interview revealed that when she heard the fire alarm on the evening on 8/25/17 that she was in room 117. She immediately started clearing the East hallway. She then started closing doors and looking in the rooms for residents and found that R#1 and another resident were not in their rooms. She stated that she knew she had to locate these residents. She stated that she found the other resident and took her to the dining room then grabbed a fire extinguisher. She discovered that the fire alarm code was on West hall and proceeded that way. She stated that LPN HH had told her that R#1 had been sitting beside LPN HH's med cart, where CNA RR had left her and that this resident must have pulled the fire alarm at West wing one exterior door. CNA RR further revealed that she had a discussion with Registered Nurse (RN) SS and CNA EE on how to turn the fire alarm off manually and on instructions on what to do at that point. CNA RR stated that RN SS instructed her and the CNA EE to go back to their halls and continue their assignments. CNA RR then stated she met co-worker CNA AA on the East hallway, and told CNA AA that LPN HH had informed her that had previously placed R#1 behind the nursing station, West. After that, the CNA RR stated that she did not look further for the resident. An interview with Ombudsman on 9/5/17 at 2:58 p.m. revealed that she had attempted to contact R#1's Physician, as part of her investigation, without success. Continued interview with the Ombudsman overseeing the facility revealed staff reported to her that R#1 pulled the fire alarm prior to 8/25/17 incident. The State Survey Agency attempted to contact the resident's Physician on 9/17/17 at 1:46 p.m. however, the Physician did not return the phone call. Review of the Safety Fire Inspection Report of 8/28/17, by the State Fire Marshall, due to concerns called to our office as to whether the facility's fire alarm system was functioning properly revealed the following: An interview with the previous Administrator revealed that on 8/25/17 the alarm system failed to notify emergency forces. It was reported to Life Safety Code (LSC) inspector, by the Fire Alarm company on that day, that someone had manually placed the notification into by-pass, which prevented the fire alarm system from notifying the monitoring central station. The facility was immediately placed on fire watch. The previous Administrator revealed to the LSC inspector that the system had been struck by lightning on 7/7/17 and the system was scheduled to be replaced. The facility did not notify the State Survey Agency or the State Fire Marshall at the time of the lightning strike. A review of the facility's Code Red-Fire Procedure, updated 8/2017, revealed under 6. Departmental Responsibilities (General Description) C. If the fire is in your area 2. All doors automatically unlock when the fire alarm is pulled. All exits of the facility must be under constant visual observation, to assure no resident exits the building, until the fire alarm resets and the doors automatically lock. Each shift a staff member will be assigned to an observation station. An interview with the previous Administrator on 9/8/17 at 1:15 p.m. revealed that this is a new policy since R#1 eloped on 8/25/17. Before that time, no one was assigned or ask to monitor the doors when the fire alarm was activated, even though the doors automatically unlocked. 2. R#2 was admitted to the facility on [DATE] from an acute hospital with [DIAGNOSES REDACTED]. A record review of the facility's social service summary/brief history form completed at admission revealed R#2 may wander. A record review of the facility's social service review dated 6/26/17 revealed that R#2 has wandering behaviors per the mood/behavior status section. A review of the same form also revealed that R#2 has the potential for wandering/unsafe per the social service intervention status section. A record review of an incident/accident report dated 4/7/17 revealed R#2 was observed standing outside in the parking lot, and unsure how resident got outside the facility. A record review of R#2's nurse's note dated 5/13/17 at 10:00 a.m. revealed the resident stated she was moving, had boxes in her room and putting clothes in the boxes. A record review of R#2's nurse's note dated 9/2/17 at 1:30 p.m. revealed the resident attempted to exit the door and was redirected by staff; staff made aware of incident and will monitor. A record review of R#2's care plan revealed resident was not initially care planned for wander behaviors or for being at risk for elopement. R#2's care plan was updated but not dated to determine the date care are initiated. Review of the current ADL worksheet for this resident revealed an old intervention for Wanderguard. Per an interview with the Maintenance Director on 8/31/17 at 10:15 p.m. revealed the Door-Guard system had replaced the Wanderguard system about two years ago. 3. R #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A record review of R#3's social service review dated 6/16/17 revealed the resident is confused, sometimes does not know where she is and tries to find a way to return home per the cognitive/mental status section. A record review of R#3's Prospective Payment System (PPS) MDS dated [DATE] revealed in Section E that the resident exhibited wandering behaviors daily, however, the Quarterly MDS dated [DATE] revealed in Section E that the resident exhibited no behaviors. An interview with the Social Service Director (SSD) on 9/6/17 at 3:45 p.m. revealed the facility's Nursing Flow Sheets wandering section, nurse's notes, and medication administration record are used to code MDS for wandering or at risk for elopement behaviors. Continued interview also revealed the SSD is responsible for coding Sections B, C, D, E and Q of the MDS. An interview with the Assistant Director of Nursing (ADON) on 9/6/17 at 5:09 p.m. revealed R#2's care plan was updated on 9/1/17 however, she forgot to date it. Continued interview also revealed residents in the facility are classified as wanderers when the following behaviors are exhibited: repeatedly attempting to get out the door, repeatedly saying they are going home, and packing personal items. An interview with the Director of Nursing (DON) on 9/7/17 at 11:40 a.m. revealed the criteria for wandering residents is the following: family states history of wandering, trying to get out the facility, combativeness, confusion, going to doors constantly, repeatedly packing belongings. Continued interview revealed she expected R#2 to be care planned as a wanderer and/or at risk for elopement. An interview with Licensed Practical Nurse (LPN) II on 9/8/17 at 1:17 p.m. revealed R#2 and R#3 are wanderers and should be care planned as wanderers. An interview with Registered Nurse (RN) SS on 9/8/17 at 1:17 p.m. revealed residents are classified as wanderers when they move around facility without purpose, exit seeking, talking about going home, and confused. An interview with RN TT on 9/8/17 at 1:32 p.m. revealed residents are classified as wanderers if they stay near the exit doors, wander from room to room, mobile (using wheelchair, walker, or independently), [DIAGNOSES REDACTED].#4 is wanderer and list has several residents on it. A record review of the facility's Elopement/Missing Resident Policy and Prevention policy revealed the following should occur if a resident elopes from the facility: (1) The care plan will be updated with diversion approaches, modifications, and appropriately timed goals that are specific to the residents individual wandering habits (2) The DON will arrange a called Quality Assurance and Performance Improvement (QAPI) Meeting on the next business day after the elopement incident to locate any areas for improvement.(3) The facility will maintain a Missing Resident Identification Form on all residents, which will be located in the resident's chart. An interview with the facility Medical Director (MD) on 9/8/17 at 10:04 a.m. revealed he is in facility at least four days a week and is available 24/7. He has another physician who can cover for him during emergencies and vacation. Continued interview also revealed that he thinks the current parking lot should be used for staff only and not be accessible to guest for safety reasons. The MD also revealed at the same time that some type of guardrail or extending the fence will help prevent future accidents like the one that occurred on 8/25/17.

Based on review of the facility's Code Red-Fire policy prior to 8/2017 and Elopement/Missing Resident Policy and Prevention dated 10/28/16, review of the previous Administrator's Position Description dated 12/1/13, clinical record review, and staff interviews, the facility failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and/or psychosocial well-being of each resident. The facility failed to ensure that their Code Red-Fire policy and Elopement/Missing Resident Policy and Prevention, and wandering and elopement care planned interventions were being fully carried out to prevent elopement from the facility for Resident (R) #1, #2, an #3. Review of the CMS-672, Resident Census and Conditions of Residents, dated 9/6/17, the census was 81 and the sample size was seven. On 9/7/17, a determination was made that a situation in which the facility's noncompliance with one or more requirement of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing where informed of the immediate jeopardy on 9/6/17 at 3:20 p.m. The noncompliance related to the immediate jeopardy was identified to exist on 8/5/17. 1. Resident (R)#1 was admitted to the facility on [DATE], from another facility, with [DIAGNOSES REDACTED]. R#1 had made frequent statements since admission of wanting to go home. R#1 utilized a wheel chair for mobility and was independent with mobility. On 8/5/17, R#1 had pulled the fire alarm at the West wing exit door although she did not exit the building. The resident was not care planned for wandering behaviors and the facility did not put interventions in place after the 8/5/17 event to keep the resident safe. On 8/25/17, the resident had been attempting to get out of bed several times, and between 8:45 p.m.to 9:00 p.m. the Certified Nursing Assistant (CNA)'s got the resident out of bed and into her wheelchair. The resident stated she was going home and proceeded to wander about the facility and into other resident's room in the resident's wheel chair. The resident was placed near the West wing medication cart to allow Licensed Practical Nurse (LPN) HH while one CNA went on break. LPN HH went into a resident's room, to administer medications, while R#1 was in the hallway near the West exit door, where she had previously pulled the fire alarm. While administering, in the resident's room, LPN HH heard the fire alarm sound. She exited the room to begin getting residents to their rooms and shutting the doors. Staff was not aware that R#1 was missing until a passerby came to the facility door saying a resident and a wheelchair were at the bottom of the steep hill, near the road. Emergency Medical Staff arrived and transported the resident, via life flight to the nearest trauma center, which was in Tennessee. Per the Medical Examiner's Case Report dated 8/26/17 revealed that R#1 was pronounced dead on 8/26/17 at 2:06 a.m. due to a Cerebral Brain Bleed as a result of head trauma from the fall. Two additional residents were identified with wandering and elopement without a care plan to address these behaviors. 2. R#2 was found in the parking lot of the facility on 4/7/17 after someone left the front door open. Staff observed the resident in the parking lot and brought the resident back inside the facility. An investigation into how this incident occurred was not done, and the resident's care plan was updated regarding wandering and exit seeking behavior although the update was not dated to determine when the update was initiated. Per the nurse notes, dated 9/2/17, the resident attempted to exit the door and was redirected by staff. 3. R#3 who was admitted to the facility on [DATE]. On 5/7/17, it was documented the resident was looking for the waiting area, saying her family was coming to get her. The resident was confused but independent and ambulated with a rolling walker. This new behavior was not care plan until 7/20/17, there were no interventions added to prevent elopement or keep the resident safe. The facility had no process in place to assess wandering/exit seeking residents and had no process for alerting staff of these behaviors. The facility's Fire Alarm system had been struck by lightning on 7/7/17 and functioned inconsistently, per the Fire Alarm Company, and on the night of 8/25/17 did not send a signal to the monitoring company or the 911 system. Thus, the exact occurrence time could not be verified. Immediate Jeopardy related to the facility's noncompliance with the program. requirements at 42 C.F.R. was identified to have existed on 8/5/17 when R#1 had first pulled the fire alarm. On 8/25/17 R#1 pulled the fire alarm again then eloped in her wheel chair rolling down a steep hill on the facility property resulting in her death due to head trauma. Findings include: Review of the previous Administrator's Position Description dated 12/1/13 revealed The Position Summary: The purpose of this position is to establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet resident's needs in compliance with federal, state and local requirements. To establish and maintain systems that are effective and efficient to operate the facility in a financially sound manner. An interview with the previous Administrator on 9/5/17 at 1:06 p.m. revealed she was unaware of any lightning strike to the building effecting the fire alarm panel. Administrator further revealed her resignation is effective on 9/11/17 and that the Chief Executive Officer (CEO) and Chief Financial Officer (CFO) are handling the facility affairs. Continued interview revealed no resident wears any type of elopement guard device for at least a year. The Administrator further revealed she requested some type of fence or guardrail for safety to prevent anyone from going over the steep hill in front of the facility. Further interview revealed that she was notified by facility staff on 8/25/17 at approximately 10:15 p.m. the night the incident occurred. She further stated the facility Code Red policy was reviewed and revised and staff were in-serviced on elopement/missing resident policy. Continued interview revealed that the Administrator was not aware of R#1's wandering/exit seeking behavior therefore there were no updates or revisions made. The previous Administrator stated that they can't prove the resident had pulled the fire alarm and since the behavior was not expected from R#1, the behavior was not addressed. She further revealed that the facility had not kept a list of wandering residents prior to last week. The facility had put a list together which included 11 residents that wander but the facility now thinks there are only three residents that wander, R#2, R#3 and R#4. Review of the Safety Fire Inspection Report of 8/28/17, by the State Fire Marshall, due to concerns called to our office as to whether the facility's fire alarm system was functioning properly revealed the following: An interview with the previous Administrator revealed that on 8/25/17 the alarm system failed to notify emergency forces. It was reported to Life Safety Code (LSC) inspector, by the Fire Alarm company on that day, that someone had manually placed the notification into by-pass, which prevented the fire alarm system from notifying the monitoring central station. The facility was immediately placed on fire watch. The previous Administrator revealed to the LSC inspector that the system had been struck by lightning on 7/7/17 and the system was scheduled to be replaced. The facility did not notify the State Survey Agency or the State Fire Marshall at the time of the lightning strike, which would be the Administrator's responsibility. A record review of the facility's Elopement/Missing Resident Policy and Prevention policy revealed the following should occur if a resident elopes from the facility: (1) The care plan will be updated with diversion approaches, modifications, and appropriately timed goals that are specific to the residents individual wandering habits (2) The Director of Nursing (DON) will arrange a called Quality Assurance and Performance Improvement (QAPI) Meeting on the next business day after the elopement incident to locate any areas for improvement. (3) The facility will maintain a Missing Resident Identification Form on all residents, which will be located in the resident's chart. A record review of the facility's QAPI meeting minutes from the May 10, 2017 and August 17, 2017 meetings did not discuss problems with the fire alarm system or elopement risk of wandering residents (R#1, R#2, or R#3). The Administrator provided an Allegation of Credible IJ removal on 9/7/17 although based on record review and staff interviews the facility had not achieved compliance as of 9/8/17. An interview with LPN II on 9/8/17 at 1:20 p.m. revealed that she had been in-service over the phone regarding the Code Red procedure and wandering residents. She revealed that just this morning a resident that she did not know, and assumed was not on the West wing where she was assigned to work, was wandering around with a rolling walker and confused. Continued interview revealed she directed the resident back to the East wing. When asked what else did she do as a result, she replied nothing. When asked what, she should do based upon the new wandering policy and she was not certain. An interview on 9/8/17 at 1:32 p.m. with the Registered Nurse (RN) Supervisor TT and the Assistant Director of Nursing (ADON) revealed that a wandering assessment form had been completed for most of the residents but not 100% yet. Reviewing the assessment sheet revealed that after it is completed they were not clear on exactly how it was to be used. There was not scoring system on the form for determining if the resident is at risk for elopement or wandering. During an observation and interview with the Director of Nursing on 9/8/17 at 2:30 p.m. regarding who was responsible for completing the new wandering assessments, R#6 was in the hallway outside of her office with a rolling walker. R#6 was with the Social Worker who was attempting to redirect the resident to another area although the resident stated I don't think that I should and wasn't sure where she was. When asked if this resident was on the wandering list, the DON said No, she only wanders inside of the building. An interview with LPN BB on 9/8/17 at 2:00 p.m. revealed that she had one resident with new wandering behaviors, R#7, and had just begun using the every two-hour check form. LPN II was at the nurse's station during this interview and informed the surveyor that this was the resident she had seen wandering this morning, who was a new admit on the West wing. LPN BB further revealed that she was given a paper policy to read and sign but she had not been in-serviced on the new Elopement or Code Red Fire policy and procedure. She was not aware the two-hour checks were needed until LPN II brought it to her attention after speaking to the surveyor. Interview with the Admission Coordinator on 9/8/17 at 1:50 p.m. revealed that she is responsible for putting together the resident identification notebooks that are kept at the nursing station. She revealed that the book for only one wing had been completed as she didn't understand that she should put the books together for both wings. She revealed that she came back to work yesterday but hasn't been in-serviced yet. Cross Refer to F323

Based on observation, record review and staff interview, it was determined that the facility failed to maintain a Quality Assurance Performance Improvement (QAPI) committee that identified, developed and implemented corrective action plans to prevent the Elopement of two residents (R#1 and R#2) and to ensure additional residents with wandering behavior did not exit the facility unattended. Review of the CMS-672, Resident Census and Conditions of Residents, dated 9/6/17, the census was 81 and the sample size was seven. Findings include: During an interview on 8/29/17 at 6:00 p.m. with the Director of Nursing (DON) revealed that she had not used a specific tool for elopement assessment for residents; she stated that she and her nursing staff looked at the admission assessments, the BIMS scores, cognition levels, mobility status and history prior to admission. The interview also revealed that she did not do quarterly review for potential for elopement for residents, nor could she provide documentation that any resident had been assessed for elopement risk. An interview with the previous Administrator on 9/5/17 at 1:06 p.m. revealed that she was unaware of any lightning strike to the building effecting the fire alarm panel. She further revealed that the facility has not used an elopement guard device for a least one year. The previous Administrator further revealed she requested some type of fence or guardrail for safety to prevent anyone from going over the steep hill in front of the facility. She further revealed that the Quality Assessment/Assurance Committee (QAPI) had not become involved in the incident of elopement or the fire alarm system to date. She further revealed that she and the DON worked closely to develop the revisions to the Code Red policy and educate staff on Elopement/Missing Resident Policy and Prevention policy although this was not brought to the QAPI committee even after R#1 pulled the fire alarm on 8/5/17. Record review of the facility's Quality Assurance and Performance Improvement Plan policy revealed that the facility shall develop, implement an ongoing, facility-wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. According to the policy the objectives of the QAPI Plan are to: (1) Provide a means to identify and resolve present and potential negative outcomes related to resident care and services (2) Reinforce and build upon effective systems and processes related to the delivery of quality care and services (3) Provide structure and processes to correct identified quality and/or safety deficiencies (4) Establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcome (5) Help departments, consultants, and ancillary services that provide direct or indirect care to residents to communicate effectively, and to delineate lines of authority, responsibility, and accountability (6) Provide a means to centralize and coordinate comprehensive QAPI activities in order to meet the needs of the residents and the facility (7) Establish systems and processes to maintain documentation relative to the QAPI Program, as a basis for demonstrating that there is an effective ongoing program. A record review of the facility's Elopement/Missing Resident Policy and Prevention policy revealed the following should occur if a resident elopes from the facility: (1) The care plan will be updated with diversion approaches, modifications, and appropriately timed goals that are specific to the residents individual wandering habits (2) The DON will arrange a called Quality Assurance and Performance Improvement (QAPI) Meeting on the next business day after the elopement incident to locate any areas for improvement.(3) The facility will maintain a Missing Resident Identification Form on all residents, which will be located in the resident's chart. A record review of the facility's QAPI meeting minutes from the May 10, 2017 and August 17, 2017 meetings did not discuss problems with the fire alarm system or elopement risk of wandering residents (R#1, R#2, or R#3) nor was the Medical Director or other on staff Physicians in attendance. Cross Refer to F323