Every finding on record at Parkway Health and Rehabilitation Center

Based on personnel file review, facility document review and interview, Administration failed to ensure that nursing services were provided by qualified personnel when the facility hired an imposter nurse (Imposter Nurse A) to function as a Registered Nurse (RN) using another RN's (RN C) Tennessee license. The findings include: Review of the background check dated 06/14/2024, revealed the Social Security (SSN) used was not the SSN submitted on the Social Security Card. The number used was the number listed on the I-9 (Employment Eligibility Verification) form and the Consumer Information Sheet. Review of the I-9 form used to verify the identity and legal authorization of individuals hired for employment in the United States dated 06/15/2024, revealed Imposter Nurse A's legal first and last name, along with a copy of her Social Security Card issued on 04/22/2022 and a valid Driver's license from the State of Tennessee. The SSN listed on the I-9 form was a different number than the SSN listed on the Social Security Card used as identification of Imposter Nurse A. The I-9 form was not filled out and was not signed or dated by any representative of this facility. Review of the time punch data dated 6/2024, revealed Imposter Nurse A worked in this facility June 17, 21, 24, 26, 26, 27, and 28. Review of the time punch data dated 6/2024, revealed Imposter Nurse A worked in this facility July 1, 2, 8, 11, and 12. Review of the Separation Notice dated 07/31/2024, showed Imposter Nurse A's real first and last name with a SSN that did not match the SSN listed on the I-9 form. The separation form showed her employment dates from 06/12/2024 to 07/31/2024 with the reason for the termination listed as No call/no show. The abuse registry search was done on 08/04/2025, after Imposter Nurse A had been terminated. During an interview with the Administrator on 10/07/2025 at 11:20 AM, the Administrator confirmed they use a background check company, but the facility used onboarding software. The Administrator stated they send the link to potential employees, and they do all that from home, then we get online and get things to copy on day of hire. Review of an undated Consumer Information Sheet revealed Imposter Nurse A's first and last name with RN C's (Registered Nurse who had the real license) last name as her middle name. Imposter Nurse A listed a birthdate with a year that didn't match the I-9 form and a SSN that did not match the SSN listed on the W-4 form or the separation notice. The facility did not provide any hiring policies. There was no evidence that the facility questioned the differences in names, birth dates, or Social Security Numbers on the pre-employment forms submitted by Imposter Nurse A. Imposter Nurse A was hired as a Registered Nurse to render nursing services, and she was only terminated for a no call/no show. The facility employed an unqualified person.

Based on facility policy review, medical record review, quarterly statement review, and interview, the facility failed to notify residents and/or representatives of account balances over the eligibility limit for 5 of 56 (Residents #11, #57, #65, #94, and #113) sampled residents reviewed for personal funds. The findings include: 1. Review of the undated facility policy titled, Resident Trust Fund, revealed .Notification of Certain Balances .Residents or their legal representatives must be notified by a Trust Fund Balance Notification when their trust fund balances are within $200 of Medicaid eligibility limit . 2. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Dementia, Schizophrenia, and Traumatic Brain Injury. Review of Resident #11's Resident Fund Statement from 4/1/2025 through 6/30/2025, revealed the Resident's account balance was $3,489.10. 3. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Diabetes, and Depression. Review of Resident #57's Resident Fund Statement from 4/1/2025 through 6/30/2025, revealed the Resident's account balance was $4,332.75. 4. Review of the medical record revealed Resident #65 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Hypertension, Dysphagia, and Anxiety. Review of Resident #65's Resident Fund Statement from 4/1/2025 through 6/30/2025, revealed the Resident's account balance was $4,794.72. 5. Review of the medical record revealed Resident #94 was admitted to the facility on [DATE], with diagnoses including Encephalopathy, Aphasia, Dementia, and Hemiplegia. Review of Resident #94's Resident Fund Statement from 4/1/2025 through 6/30/2025, revealed the Resident's account balance was $3,581.45. 6. Review of the medical record revealed Resident #113 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Malnutrition, Depression and Anxiety. Review of Resident #113's Resident Fund Statement from 4/1/2025 through 6/30/2025, revealed Resident's account balance was $3,241.54. During an interview on 8/5/2025 at 11:43 AM, the Assistant Business Office Manager confirmed that residents and/or their representatives had not been notified of their account balances and should be informed when the account balances are over the eligibility limit.

Based on policy review, medical record review, and interview, the facility failed to follow physician orders when staff administered medications outside of ordered parameters and failed to report blood glucose levels for 1 of 5 (Resident #4) sampled residents reviewed for unnecessary medications. The findings include: Review of the facility policy titled, Administration of Drugs, dated 6/2025, revealed .Drugs will be administered in a timely manner and as prescribed by the resident's attending physician.Drugs must be administered in accordance with the written orders of the attending physician. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Chronic Kidney Disease, Diabetes, Heart Failure, and Chronic Obstructive Pulmonary Disease. Review of the annual Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #4 was cognitively intact. Resident #4 received a hypoglycemic medication. Review of the Physician's Order dated 8/8/2024, revealed NovoLOG Solution [used to treat elevated blood glucose] 100 UNIT/ML [Milliliter].Inject as per sliding scale.401 - 1000 = 12 units Notify MD [Medical Director] for further orders.subcutaneously [under the skin] two times a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. Review of the Physician's Order dated 5/11/2025, revealed Amiodarone .[used to treat irregular heartbeats] Oral Tablet 200 MG [Milligram].Give 1 tablet by mouth every 12 hours related to PAROXYSMAL ATRIAL FIBRILLATION [irregular heart rate].Hold for HR [Heart rate] < [less than] 60 bpm [beats per minute].notify provider. Review of the Physician's Order dated 5/26/2025, revealed Lantus Subcutaneous Solution [used to treat elevated blood glucose] 100 UNIT/ML.Inject 42 unit subcutaneously in the morning related to TYPE 2 DIABETES MELLITUS WITH DIABETIC POLYNEUROPATHY.Hold for BG [Blood Glucose] < 100 and notify the provider. Review of the Medication Administration Record (MAR) dated 6/2025, revealed Resident #4's blood glucose level was greater than 400 and the staff failed to notify the physician on the following dates. a. 6/6/2025 at 9:00 PM for a glucose of 510 b. 6/21/2025 at 9:00 PM for a glucose of 407 c. 6/23/2025 at 9:00 PM for a glucose of 428 d. 6/25/2025 at 9:00 PM for a glucose of 552 e. 6/28/2025 at 9:00 PM for a glucose of 506 f. 6/29/2025 at 9:00 PM for a glucose of 550 Review of the MAR dated from 6/2025, revealed Resident #4 received Lantus 42 units when resident's blood glucose level was less than 100 on the following dates. a. 6/8/2025 at 7:30 AM for a glucose of 93 b. 6/9/2025 at 7:30 AM for a glucose of 86 c. 6/12/2025 at 7:30 AM for a glucose of 95 d. 6/17/2025 at 7:30 AM for a glucose of 86 e. 6/18/2025 at 7:30 AM for a glucose of 87 f. 6/26/2025 at 7:30 AM for a glucose of 89 g. 6/30/2025 at 7:30 AM for a glucose of 92 Review of the MAR dated 6/2025, revealed Resident #4 received Amiodarone 200 mg when the heart rate was outside of ordered parameters to hold for heart rate less than 60 on the following dates. a. 6/1/2025 at 9:00 PM HR was 56 b. 6/3/2025 at 9:00 AM HR was 55 c. 6/9/2025 at 9:00 PM HR was 57 d. 6/10/2025 at 9:00 PM HR was 56 e. 6/11/2025 at 9:00 AM HR was 56 f. 6/12/2025 at 9:00 AM HR was 56 g. 6/18/2025 at 9:00 AM HR was 59 Review of the MAR dated 7/2025, revealed Resident #4's blood glucose level was greater than 400 and the staff failed to notify the physician on the following dates. a. 7/6/2025 at 9:00 PM for a glucose of 404 b. 7/19/2025 at 9:00 PM for a glucose of 574 c. 7/26/2025 at 9:00 PM for a glucose of 482 Review of the MAR dated 7/2025, revealed Resident #4 received Lantus 42 units when resident's blood glucose level was less than 100 on the following dates. a. 7/15/2025 at 7:30 AM for a glucose of 96 b. 7/30/2025 at 7:30 AM for a glucose of 88 c. 7/31/2025 at 7:30 AM for a glucose of 71 Review of the MAR dated 7/2025 revealed Resident #4 received Amiodarone 200 mg when heart rate was outside of ordered parameters to hold for heart rate less than 60 on the following dates. a. 7/3/2025 at 9:00 AM HR was 59 b. 7/8/2025 at 9:00 AM and 9:00 PM HR was 59 c. 7/29/2025 at 9:00 AM HR 59 Review of the MAR dated 8/2025, revealed Resident #4's blood glucose level was greater than 400 and the staff failed to notify the physician on 8/1/2025 at 9:00 PM, for a glucose of 430. Review of the MAR dated 8/2025, revealed Resident #4 received Lantus 42 units when the resident's blood glucose level was less than 100 on 8/4/2025 at 7:30 AM, for a glucose of 93. During an interview on 8/5/2025 at 11:18 AM, the Director of Nursing acknowledged that medications should be held when vital signs are outside of ordered parameters, and staff should have notified the physician when the resident's glucose level and heart rate were outside of parameters.

Based on policy review, facility documentation review, observation, and interview, the facility failed to ensure proper infection control practices were followed when 2 of 14 staff members (Certified Nursing Assistant (CNA) A and CNA E) touched food and flatware with their bare hands and failed to properly perform hand hygiene for 4 residents (Residents #9, #93, #94, and #103) reviewed for dining, and when the Infection Preventionist (IP) failed to track and monitor organisms being treated in the facility, which could potentially affect 114 out of 114 residents. The findings include: 1. Review of the facility policy titled, Hand Hygiene, dated 6/2025, revealed .Handwashing/hand hygiene shall be regarded by this Center as a means of preventing the spread of infections.All personnel shall follow our established handwashing procedures to prevent the spread of infection and disease to other personnel, patients, and visitors.Associates must perform appropriate handwashing procedures under the following conditions.Between passing out meal trays.Before and after eating.Hand hygiene (HH) e.g. [for example]handwashing and/or alcohol based hand rub (ABHR)) Soap and other detergents help in the cleaning process, but the most important part of hand washing is the mechanical scrubbing of the hands under running water for at least 20 second. Review of the facility policy titled, Infection Control Monitoring, dated 6/2025, revealed .It is the policy of the Center to investigate the cause of infections (nosocomial and community and hospital acquired) and the manner of spread.The Infection Preventionist will also use an Infection Control Trending Map of Center to identify any trends/specific organism.The objectives of our Infection Control Policies and Practices are to.Preventing, identifying, reporting, investigating, and controlling infections and other communicable diseases. 2. Observation during dining in Resident #103's room on 8/3/2025 at 12:49 PM, revealed CNA A took the resident's cookie out of the plastic wrap with her bare hand and placed it on the resident's tray. Observation during dining in Resident #93's room on 8/3/2025 at 1:03 PM, revealed CNA A entered the resident's room, set up the meal tray, exited the room, obtained a towel from the linen cart, re-entered the room and placed the towel on Resident #93. CNA A exited Resident #93's room, obtained a tray from the meal cart, and entered Resident #42's room without performing hand hygiene. Observation during dining in Resident #94's room on 8/3/2025 at 1:11 PM, revealed CNA E performed hand hygiene at the resident's sink and turned the faucet off with her wet hand. Observation during dining in Resident #9's room on 8/3/2025 at 1:15 PM, revealed CNA A touched the end of the resident's spoon with her bare hands when removing it from the package. During an interview on 8/05/2025 at 11:35 AM, the Director of Nursing (DON) confirmed that staff should not touch food with their bare hands during dining and hand hygiene should be performed after contact with a resident. 3. Review of the [Named Facility] INFECTION LOG. dated 4/2025, 5/2025, and 6/2025, revealed .ROOM # [number] ONSET, LAST NAME, FIRST NAME, RELATED DX [Diagnosis], Antibiotic, Nosocomial [facility acquired infection].END DATE. Tracking for organisms of residents was not listed. There was no column for tracking of organisms. Review of the Infection Control Monthly Summary Report dated 4/2025, 5/2025, and 6/2025, revealed the Culture and Sensitivity section was blank for the months dated 4/2025, 5/2025, and 6/2025. During an interview on 8/5/2025 at 2:10 PM, the IP confirmed that she does not track the organisms being treated in the facility. During an interview on 8/5/2025 at 2:15 PM, The DON confirmed that organisms should be tracked and monitored.

Based on policy review, observation, and interview, the facility failed to provide and maintain a safe, functional, and sanitary environment for 2 of 60 (Resident #6, #44, #60, and #121) shared occupied bathrooms, when a toilet was clogged with feces and when the biohazard red bag (bag used for disposal of potentially infectious or hazardous materials) was overflowing with trash and Personal Protective Equipment (PPE), and when 1 of 60 (Resident #60 and #121) occupied resident rooms had floors dirty with trash and marks, the over bed tables had a spill of dried shiny substance, and the resident's bed would not adjust positions. The findings include: 1. Review of the facility policy titled, Safe Environment, dated 6/2022, revealed .It is the policy of the facility to provide a safe environment in accordance with State and Federal Regulations .The facility will maintain all essential mechanical, electrical and patient care equipment in safe operating condition .The facility will provide a safe, clean, comfortable, and homelike environment . Review of the facility policy titled, Resident Rights, dated 6/2025, revealed .Federal and state laws guarantee certain basic rights to all residents of this facility .include the resident's right to .a dignified existence . Review of the facility policy titled, Biohazardous Waste Handling, dated 6/2025, revealed .Biohazardous articles, waste will be handled and disposed of safely and in accordance with regulatory requirements .biohazardous waste include human blood and blood-soiled articles, contaminated items .soiled dressing .disposable items contaminated .believed to be infectious must be placed in plastic bags and sealed .General trash that is placed in containers with medical waste will be handled as regulate biohazardous waste . Review of the facility policy titled, Waste Disposal, dated 6/2025, revealed .All infectious and regulated waste shall be handled in a safe and appropriate manner .It shall be the responsibility of the Infection Preventionist in conjunction with the environmental services director to ensure the waste is properly disposed of . 2. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Rhabdomyolysis (a breakdown of muscle tissue), Dementia, and Schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated Resident #6 was moderately cognitively impaired. Resident #6 required max assistance of staff with toileting. 3. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Hemiplegia, Depression, and Malnutrition. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 9, which indicated Resident #44 was moderately cognitively impaired. Resident #44 was dependent on staff with toileting. Observations in Resident #6 and Resident #44's shared bathroom on 8/3/2025 at 9:40 AM and 11:42 AM, 2:57 PM, and on 8/4/2025 at 8:02 AM and 8:08 AM, and on 8/5/2025 at 8:06 AM, revealed the toilet was clogged with feces. A strong, foul odor was noted in the resident's shared room and bathroom. During an interview on 8/3/2025 at 2:57 PM, Resident #6 confirmed that maintenance was aware, and the toilet had been messed up for 2 weeks. During an observation and interview in the Residents' room on 8/3/25 at 3:40 PM, the Maintenance Manager confirmed that the resident's toilet was clogged and shouldn't have been left in disrepair over an extended period of time. During an interview on 8/5/2025 at 11:39 AM, the Administrator confirmed that a plumbing company should be contacted if a toilet has ongoing issues with clogging that is unresolved by maintenance. 4. Review of the medical record revealed Resident #60 was admitted to the facility on [DATE], with diagnoses including Heart Disease, Urogenital Candidiasis (a fungal infection affecting the urinary tract), Basal Cell Carcinoma of Skin, and Diabetes. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated Resident #60 had intact cognition. Review of the Physician's Order dated 3/26/2025, revealed .Contact Precautions . 5. Review of the medical record revealed Resident #121 was admitted to the facility on [DATE], with diagnoses including Acquired Absence of Right Leg Below Knee, Urogenital Candidiasis, Gastro-Esophageal Reflux Disease, and Type 2 Diabetes. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #121 had intact cognition. Review of the Order Summary Report dated 7/24/2025, revealed .Contact Precautions . Observations in the Residents' room on 8/4/2025 at 8:10 AM, 10:59 AM, and at 4:12 PM, revealed Resident #60's and Resident #121's over the bed tables were dirty with a spill of shiny dried substance, the room's floor was dirty with trash and dark marks, the bathroom's biohazard red bag overflowed with PPE and trash, and the bathroom smelled of urine. During an interview on 8/4/2025 at 10:59 AM, Resident #121 confirmed he would like to be able to be in bed with the head of bed raised and cannot because the bed does not work to allow it. During an observation and interview in the Residents' room on 8/4/2025 at 4:18 PM, the Administrator confirmed the biohazard red bag overflowed with PPE and trash needed to be removed and the room and bathroom needed to be cleaned. During an interview on 8/4/2025 at 4:33 PM, the Environmental Service Director confirmed the housekeeping staff failed to check the residents' bathroom to see if the biohazard red bags needed to be removed and replaced, and failed to clean the resident's room, over the bed tables, and bathroom. During an interview on 8/5/2025 at 10:14 AM, the Director of Nursing confirmed nursing staff should inform and ask housekeeping staff to remove biohazard red bags when observed to be overflowing with trash and PPE. During an interview on 8/5/2025 at 2:22 PM, Certified Nurse Assistant (CNA) B confirmed that since Resident #121's admission on [DATE], the head of the bed could not be raised. During an interview on 8/5/2025 at 2:29 PM, the Administrator confirmed a resident's bed should be in good working order. The facility failed to provide and maintain a safe, sanitary, and functional environment for the resident.

Based on policy review, observation, and interview, the facility failed to ensure a safe and sanitary environment in the kitchen and failed to clean the East Hall ice machine. The findings include: 1. The facility policy titled, Food Safety and Sanitation, dated 2021, revealed .local, state, and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition services department . The facility's undated Resident Rights Notice revealed .right to a safe, clean, comfortable and homelike environment . The facility policy titled Ice Machines and Ice Storage Chests dated 4/2024, revealed .Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice . 2. Observation in the kitchen bathroom on 2/24/25 at 9:50 AM, revealed a large rectangular hole, approximately 3-4 foot high, cut out of the drywall on the inner right wall. A sheet of black plastic covered the opening, and when pulled back revealed the wooden inner framing of the wall. Observation in the Storage Room on 2/25/2025 at 12:10 PM, and on 2/27/2025 at 8:58 AM, revealed what appeared to be mouse excrement (small cylindrical black pellets) on top of one large can of green beans and in an open box containing 7 cans of chicken noodle soup. During an observation and interview in the Nutrition Room on the East Hall on 2/25/2025 at 12:30 PM, a white hard powdery build up was discovered on the plastic casing and coolant tubes inside of the ice machine. The Dietary Manager (DM) stated, .That looks like hard water build-up .I will make sure that gets cleaned . Observation in the Emergency Food Supply closet on 2/25/25 at 3:50 PM, and on 2/27/2025 at 8:58 AM, revealed what appeared to be mouse excrement and small shredded up pieces of paper and cardboard on the floor under the metal rack that held the food. 3. During an interview on 2/25/2025 at 4:41 PM, the Administrator presented an invoice showing Rodent Control with named pest control company had been started as of 2/25/2025 and stated, .I just signed this today During an interview on 2/27/2025 at 9:00 AM, the DM confirmed that mouse excrement should not be found in the Storage Room.

Based on policy review, medical record review, and interview the facility failed to ensure staff reported an allegation of resident-to-resident abuse to the facility Administrator in a timely manner for 1 of 4 (Resident #37) sampled residents for allegations of abuse. The findings include: 1. Review of the facility policy titled, Abuse Prevention Policy, dated 3/1/2018, revealed .The resident has the right to be free from verbal, sexual, physical and mental abuse .The abuse coordinator in the facility is the administrator. Reports of allegations or suspected abuse .will be reported immediately to [the] Facility Abuse Coordinator, Director of Nursing, State Agencies, local Ombudsman Office .Abuse means the willful infliction of injury .physical harm, pain, mental anguish .Abuse maybe resident to resident .When abuse .is suspected the Licensed Nurse should .Respond to the needs of the resident, and protect them from further abuse, Notify the Director of Nursing and Administrator, Complete an incident report and initiate an immediate investigation to prevent further potential abuse, notify the attending physician, resident's family/legal representative and Medical Director, Obtain witness statements .Monitor and document the resident's condition .Provide initial and follow-up counseling for the resident(s), Document actions taken .in the medical record .It is the responsibility of all staff to provide a safe environment for the resident .Ensure that all alleged violations involving abuse .are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . Review of the facility policy titled, Resident to Resident Altercations, dated 9/2022, revealed .All altercations, including those that may represent resident to resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator . 2. Review of the medical record revealed Resident #37 was readmitted to the facility on [DATE], with diagnoses including Hemiplegia, Chronic Obstructive Pulmonary Disease, Heart Failure, Depression, and Dementia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #37 was cognitively intact. Resident was dependent on staff assistance to perform Activities of Daily Living (ADLs). During an interview in the Resident's room on 2/25/2025 at 9:22 AM, the resident stated he was asleep in bed during the night when his roommate (Resident #112) walked over to his bed calling him the N . word and hit him several times on the chest. Resident #37 confirmed that a nurse walked in and instructed his roommate to return to bed. The incident report confirmed this occurred on 2/18/2025. Review of medical record revealed Resident #112 was admitted to the facility on [DATE], with diagnoses including Coronary Artery Disease, Hypertension, and Chronic Kidney Disease. Review of the admission MDS dated [DATE], revealed a BIMS score of 14, which indicated Resident #112 was cognitively intact. Review of Resident #112's Care Plan revised on 2/20/2025, revealed .Resident has demonstrated physical aggression initiated towards roommate .Resident Will Not Harm Self or Others .behavior monitoring .if Resident poses a potential threat to injure self or others notify provider .If safe, allow Resident personal space .Monitor for cognitive, emotional or environmental factors that may contribute to violent .Monitor for signs / symptoms of agitation .psych consult .Residents separated . Review of the Facility Reported Incident documentation dated 2/20/2025, revealed .[the] Administrator was made aware of a resident-to-resident altercation on 2/20/2025 which occurred on 2/18/2025 AT 11:30 PM . During an interview on 2/26/2025 at 2:37 PM, the Administrator confirmed that the incident occurred on 2/18/2025 and the nurse failed to report the incident to the Director of Nursing or to the Administrator. The Administrator confirmed that allegations of abuse should be reported within 2 hours.

Based on policy review, medical record review, and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance was provided related to showering for 2 of 2 (Resident #82 and #320) sampled residents reviewed for ADLs. The findings included: 1. Review of the undated policy titled, .Activities of Daily Living (ADL's) Abilities, revealed It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good .grooming, and personal and oral hygiene . 2. Review of the medical record review revealed Resident #82 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Chronic Kidney Disease, Diabetes, Atrial Fibrillation, and Chronic Obstructive Pulmonary Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #8 was cognitively intact. Resident #82 required substantial/maximal assistance from staff with showers and bathing. During an interview on 2/24/2025 at 3:37 PM, Resident #82 was asked about his shower/ bathing habits, he stated he should be receiving his showers 3 times a week, on Tuesday, Thursday and Saturday and he hasn't received one since January. Review of the Certified Nursing Aide (CNA) Shower Sheet revealed Resident #82 did receive a shower as stated on Thursday, 1/2/2025, Tuesday 1/7/2025, Tuesday, 1/14/2025, Thursday 1/16/2025, and Thursday 1/23/2025. Review of the [NAME] Wing Shower Schedule form revealed room [ROOM NUMBER], Resident #82's room, Resident #82 should have received a shower on Monday, Wednesday, and Friday. Review of the .Documentation Survey Report . CNA Bathing Task for January 2025 and February 2025, revealed Resident #82 did not receive a shower on 1/1/2025, 1/3/2025, 1/6/2025, 1/8/2025, 1/10/2025, 1/13/2025, 1/15/2025, 1/17/2025, 1/20/2025, 1/22/2025, 1/24/2025, 1/27/2025, 1/29/2025, 1/31/2025, 2/3/2025, 2/5/2025, 2/7/2025, 2/10/2025, 2/12/2025, 2/14/2025, 2/17/2025, 2/19/2025, 2/21/2025, and 2/24/2025. 3. Review of the medical record revealed Resident #320 was admitted to the facility on [DATE], with diagnoses including Spinal Stenosis, Morbid Obesity, Neuropathy, Hepatitis B, and Paraplegia. Review of the Baseline Care Plan dated 2/16/2025 revealed Resident #320 is dependent on staff for showers/bath. During an interview on 2/25/2025 at 9:22 AM, Resident #320 was asked about his shower/bathing habits, Resident #320 stated, I have not received a shower since I got here. Review of the facility's [NAME] Wing Shower Schedule, form revealed room [ROOM NUMBER], Resident #320's room should get a shower on Monday, Wednesday, and Friday. Review of the Documentation Survey Report, CNA Bathing Task for February 2025, revealed Resident #320 did not receive a shower on 2/17/2025, 2/19/2025, 2/21/2025, and 2/24/2025. 4. During an interview on 2/26/2025 at 9:30 AM, the Director of Nurses (DON) confirmed she was unable to provide documentation for showers, the DON stated, .Point Click Care (PCC) did not have an area to address showers versus baths .and PCC now has been corrected to address this issue by her Regional Nurse on 2/25/2025.

Based on medical record review and interview the facility failed to administer the prescribed medication for 1 of 5 (Resident #90) sampled residents reviewed for unnecessary medications. The findings include: 1. Review of the medical record revealed Resident #90 was admitted to the facility on [DATE], with diagnoses including Viral Hepatitis, Malnutrition, Bipolar Disorder, Depression, and Schizophrenia. Review of the quarterly Minimum Data Set assessment dated [DATE], revealed a Brief Interview of Mental Status score of 9, which indicated Resident #90 was moderately cognitively impaired. Review of Physician's Order dated 6/6/2023, revealed .Famotidine [used to treat heart burn or acid reflux] Oral Tablet 20 MG [milligram] .Give 1 tablet by mouth two times a day .Trazodone [used to treat depression] Oral Tablet 50 mg Give 1 tablet by mouth one time a day .Atorvastatin Calcium [used to treat high cholesterol] Oral Tablet 20 MG. Give 1 tablet by mouth one time a day . Review of Physician's Order dated 8/22/2024, revealed .Baclofen [used to treat muscle spasms] Oral Tablet 5 MG .Give 10 mg by mouth two times a day . Review of Physician Order dated 11/20/2024, revealed ZyPREXA, [used to treat mental disorders] Oral Tablet 5 MG (Olanzapine) Give 1 tablet by mouth one time a day . Review of the Medication Administration Record (MAR) dated 1/2025, revealed blanks on 1/4/2025 and 1/5/2025 for the medications of Zyprexa 5mg daily, Baclofen 10mg at bedtime, Famotidine 20mg at bedtime, Trazodone 50mg daily, and Atorvastatin 20 mg daily. During an interview on 2/27/2025 at 8:59 AM, revealed the Director of Nursing (DON) was asked what the blanks on the resident's MAR indicated. The DON confirmed that the blanks meant that the night shift nurse didn't sign the medications off. The DON confirmed that the medications should have been signed out, and she could not confirm that medications were administered.

Based on policy review, medical record review, and interview, the facility failed to ensure residents' right to be free from neglect for 1 of 9 (Resident #10) sampled residents reviewed for allegations of abuse. Resident #10 was severely cognitively impaired, bedridden and totally dependent on staff for all needs. On 4/5/2024 staff noted Resident #10's left arm swollen with nonpitting edema. On 4/8/2024 the practitioner was notified and orders obtained for x-rays. On 4/9/2024 an x-ray revealed a comminuted (A broken bone that has shattered into 3 or more pieces. This type of fracture is usually caused by a serious trauma) humeral fracture to the left arm of unknown source. The facility's failure to provide timely services to address Resident #10's left arm swelling resulted in Actual Harm. The findings include: 1. Review of the facility's policy titled ABUSE Prevention Policy, dated 11/2021, revealed .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .also includes the depravation [deprivation] by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being .Neglect means failure to provide goods and services necessary to avoid physical harm .Injury of Unknown source means source was not observed by another person or injury could not be explained by the resident. Injury is suspicious because of the extent of the injury, location of injury (e.g. injury is located in an area not generally vulnerable to trauma such as facial injuries, bruising of inner thighs, wrap around bruises of arms, legs or torso, skin tears, on sites other than arms/legs) or the number of injuries observed at one point in time or the incidence of injuries over time . Review of the facility's policy titled, INCIDENT REPORT - DOCUMENTATION, INVESTIGATING, AND REPORTING, dated November 2022, revealed .The Charge Nurse at the time of the incident is responsible for documenting the incident in the resident's medical record. The nurses note should contain the following documentation .Clear, objective facts about what occurred .A thorough assessment of the resident's condition at the time of the accident/incident. (This assessment should include a description of the resident, vital signs, and any other physical characteristics apparent as a result of the accident/incident) .Any treatment provided .Any contacts made or attempted with the resident's physician, family .The Administrator/Director of Nursing should obtain signed and dated written statements, from all witnesses with knowledge of the event .Indicate .the follow up interventions put into place to prevent reoccurrences . 2. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure with Hypoxia (An absence of enough oxygen in the tissues to sustain bodily functions), Tracheostomy (a surgical opening to help air and oxygen into the trachea to provide an alternate airway), Gastrostomy Status (a surgical procedure to insert a tube through the abdomen and into the stomach to provide nutritional support), Functional Quadriplegia (complete immobility due to severe disability or frailty from medical condition without injury to the brain or spinal cord), Dementia, Cerebral Infarction (Stroke), and Contracture Left Hand. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #10 had severe cognitive impairment and was totally dependent on staff for all activities of daily living (ADLs). Review of the Progress Note dated 4/5/2024 at 2:32 PM by Licensed Practical Nurse (LPN) A, revealed .left arm swollen nonpitting edema, placed in MD [medical doctor] book . LPN A noted the left arm swelling in the MD book to notify the MD on the next onsite facility visit and failed to immediately notify the MD or practitioner. Review of the Situation, Background, Assessment and Recommendation (SBAR) note dated 4/8/2024 at 10:10, revealed .Recommendations: resident noted with nonpitting edema to left upper extremity. Extremity repositioned and elevated with pillow. PRN [as needed] Acetaminophen [another name for Tylenol, for pain] administered, New orders obtained for Left Shoulder, Humerus, Elbow and Forearm X-ray and Doppler . The MD/practitioner was not notified of Resident #10's left arm swelling until 3 days after the swelling was initially noted on 4/5/2024. Review of the Incident Report dated 4/9/2124, revealed No Injuries observed at time of incident .No Injuries Observed Post Incident .Notes 4/9/2024, Educate staff on transfers and use of Hoyer lifts . The facility was unable to provide documentation the staff education was provided. The facility X-Rays were obtained on 4/9/2024 and resulted in a comminuted left humerus fracture. Review of the Care Plan dated 4/9/2024, revealed The resident [#10] has left arm Fracture and is at risk for complications .Monitor limb for swelling and skin changes . On 4/10/2024 Resident #10 was sent out to the hospital per family request. Resident #10 was admitted to the hospital on 4/10/2024 - 4/15/2024. Review of the [Named Hospital Progress Note] dated 4/15/2024, by Doctor M revealed .Left humeral fracture - occurred at NH [Nursing Home]. Ortho [Orthopedics] consulted and evaluated the patient. Not a surgical candidate with underlying hemiplegia from CVA [Cerebrovascular Accident] Sling, non-weightbearing in LUE [Left Upper Extremity]. Hx [history] of CVA s/p [status post] trach [tracheostomy], PEG [percutaneous endoscopic gastrostomy tube], nonverbal - Pt [patient] is bed bound; will refer to SW [Social Worker] for APS [Adult Protective Services] referral .Social Determinants of Health that impact treatment or disposition: non-verbal patient with unknown POA [Power of Attorney]. Need to discuss with SW about referral to APS to investigate further nature of this patient's injuries (non-verbal, bedridden patient develops left humeral fracture-how?). Review of the quarterly MDS dated [DATE], revealed Resident #10 had severe cognitive impairment. During an interview on 8/15/2024 at 1:59 PM, LPN A was asked about the injury of unknown origin for Resident #10. LPN A stated, The shower aide [Certified Nursing Assistant (CNA) N], came and got me, they were in the shower on 4/8/2024, to look at her left arm. The whole left side shoulder to her hand were [was] swollen. I assessed her arm it was swollen I let the [Named Medical Director] know and he came to the facility later that day. He advised me to get an x-ray. Got x-ray the next day on 4/9/2024. I'm not sure if results came back that evening or the next day 4/10/2024. It was on 4/10/2024, a Wednesday, when got results, it [was] fractured. They had gotten an appointment with [named Orthopedic Clinic], but the daughter came in that day and insisted she go to ER [emergency room ]. She came back a couple days later with a hard brace on the upper left shoulder area. She had the brace until she went to the ortho appointment [and] came back without the brace. LPN A did not report or act on the findings when she noticed the left arm swelling on 4/5/2024, 3 days prior to notifying the facility's Medical Director. During an interview on 8/15/2024 at 2:11 PM, CNA N, confirmed she took Resident #10 to the shower on a shower bed and noticed her left arm was swollen. She said she finished her shower because she could not leave her alone. Then she got the Nurse, LNP A, to come and look at her arm. It was swollen. We used the lift and put her back in the bed. LPN A said she would notify the doctor. During an interview on 8/15/2024 at 4:04 PM, CNA O, working 2nd shift, was asked about the injury of unknown origin for Resident #10. CNA O stated, .She is a heavy wetter, so I do her early. When I pulled the cover back [to do perineal care in Resident #10's room on 4/8/2024] it looked like Popeye's arm, Left [arm] was so swollen and Right [arm] was normal. I went to get the nurse on the 3 to 11 shift. [CNA O didn't remember which nurse] She looked at her arm and said she may need to go out to the ER. She called the doctor. I moved on to another resident. We had to write statements. CNAs do not give report to oncoming shift . During an interview on 8/16/2024 at 12:28 PM, the DON was asked, should an injury of unknown origin be investigated. The DON stated, Yes. The DON stated, . X ray was ordered 4/9/2024 and received results on 4/9 [2024] but I know we didn't get them on 4/9/24 [2024], it was later. The DON was asked, do you have documentation where you interviewed other staff. The DON stated, No, I don't . The DON was asked, why did it take so long to send her out to the hospital. The DON stated, .out to hospital on 4/10/2024. They didn't have an order to send her out sooner. No one knew anything about her arm being injured .First time noted swelling was in shower on 4/9/24 [4/8/2024]. No reason for the fracture. We did not find the reason or cause of fracture. The DON confirmed there was no monitoring for Resident #10 on 4/16/2024 one day after she was readmitted and there should have been. During a telephone interview on 8/29/2024 at 10:55 AM, after the survey team had exited the facility, Medical Doctor M returned the surveyor's call after several attempts were made to contact the doctor during the survey. Medical Doctor M was asked about Resident #10's humeral fracture. Medical Doctor M was asked, would it take a hard force or hit to cause a comminuted humeral fracture. Medical Doctor M stated, .a fall could do that. Medical Doctor M was asked, could transferring the resident by a lift with a lift pad cause that type fracture. Medical Doctor M stated, I don't think so. In summary, the swelling was first noted in Resident #10's left arm on 4/5/2024 per the note documented by LPN A, the MD/practitioner wasn't notified until 4/8/2024. The x-rays were obtained on 4/9/2024 and the resident was sent to the hospital on 4/10/2024. The hospital admitted Resident #10 from 4/10/2024 - 4/15/2024. The facility's failure to provide timely services to address Resident #10's left arm swelling resulted in Actual Harm.

Based on policy review, medical record review, and interview, the facility failed to thoroughly investigate an injury of unknown source/origin for 1 of 9 (Resident #10) residents reviewed for abuse. The facility failed to thoroughly investigate an injury of unknown origin when Resident #10, a severely cognitively impaired, bedridden resident sustained a comminuted (A broken bone that has shattered into 3 or more pieces. This type of fracture is usually caused by a serious trauma) humeral fracture. This resulted in Actual Harm for Resident #10. The findings include: 1. Review of the facility's policy titled, ABUSE PREVENTION POLICY, dated 11/1/2021, revealed .Injury of unknown source means source of injury was not observed by another person or injury could not be explained by the resident. Injury is suspicious because of the extent of the injury, location of injury .injury is located in an area not generally vulnerable to trauma such as facial injuries, bruising of inner thighs, wrap around bruises of arms, legs, or torso, skin tears .When suspicion or reports of abuse, neglect or exploitation occur, as investigation is immediately warranted .Components of the investigation may include .Interview .staff members in the area .Document the entire investigation chronologically .including injuries of unknown source .are reported immediately, but not later than 2 hours after the allegation is made .The Administrator should follow up with the governmental agencies during business hours to confirm the report was received and to report the results of the investigation when final, as required by state agencies .Administrator will review investigational findings to determine appropriate corrective, remedial, or disciplinary actions to occur with accordance with applicable local, state or federal law . Review of the facility's policy titled, INCIDENT REPORT - DOCUMENTATION, INVESTIGATING, AND REPORTING, dated November 2022, revealed .The Charge Nurse at the time of the incident is responsible for documenting the incident in the resident's medical record. The nurses note should contain the following documentation .Clear, objective facts about what occurred .A thorough assessment of the resident's condition at the time of the accident/incident. (This assessment should include a description of the resident, vital signs, and any other physical characteristics apparent as a result of the accident/incident) .Any treatment provided .Any contacts made or attempted with the resident's physician, family .The Administrator/Director of Nursing should obtain signed and dated written statements, from all witnesses with knowledge of the event .Indicate .the follow up interventions put into place to prevent reoccurrences . 2. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure with Hypoxia (when the body's tissue don't have enough oxygen), Tracheostomy (a surgically created hole in the windpipe to provide an alternate airway), Gastrostomy Status (a surgical procedure to insert a tube through the abdomen and into the stomach), Functional Quadriplegia (complete immobility due to severe disability or frailty from medical condition without injury to the brain or spinal cord), Dementia, Cerebral Infarction (stroke), and Contracture Left Hand. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #10 had severe cognitive impairment. The facility was unable to obtain a Brief Interview for Mental Status (BIMS) score as the resident was unable to participate in the test. Review of the Progress Note dated 4/5/2024 at 2:32 PM by Licensed Practical Nurse (LPN) A, documented swelling with nonpitting edema to Resident #10's left arm and placed a note regarding the swelling in the Medical Doctors (MD) book. LPN A failed to notify the practitioner for immediate action and failed to ensure an investigation was immediately started. Review of the Situation, Background, Assessment and Recommendation (SBAR) note dated 4/8/2024 at 10:10, revealed .Recommendations: resident [#10] noted with nonpitting edema to left upper extremity . New orders obtained for Left Shoulder, Humerus, Elbow and Forearm X-ray and Doppler . The facility's investigation consisted of 3 staff interviews with LPN A, certified Nursing Assistant (CNA) N, and CNA O obtained on 4/9/2024, but dated 4/8/2024. The facility's investigation failed to interview staff who cared for Resident #10 back to and before 4/5/2024, when LPN A first documented the swelling in the Resident's left arm. Review of the Care Plan dated 4/9/2024, revealed The resident [#10] has left arm Fracture and is at risk for complications .Monitor limb for swelling and skin changes . The facility X-Rays were obtained on 4/9/2024 and resulted in a comminuted humerus fracture. On 4/10/2024 Resident #10 was sent out to the hospital per family request. Resident #10 was admitted to the hospital from 4/10/2024 - 4/15/2024. Review of the [Named Hospital Progress Note] dated 4/15/2024, by Doctor M revealed .Left humeral fracture - occurred at NH [Nursing Home]. Ortho [Orthopedics] consulted and evaluated the patient. Not a surgical candidate with underlying hemiplegia from CVA [Cerebrovascular Accident] Sling, non-weightbearing in LUE [Left Upper Extremity]. Hx [history] of CVA s/p [status post] trach [tracheostomy], PEG [percutaneous endoscopic gastrostomy tube], nonverbal - Pt [patient] is bed bound; will refer to SW [Social Worker] for APS [Adult Protective Services] referral .Social Determinants of Health that impact treatment or disposition: non-verbal patient with unknown POA [Power of Attorney]. Need to discuss with SW about referral to APS to investigate further nature of this patient's injuries (non-verbal, bedridden patient develops left humeral fracture- how?). Review of the quarterly MDS dated [DATE], revealed Resident #10 had severe cognitive impairment. During an interview on 8/15/2024 at 1:59 PM, LPN A was asked about the injury of unknown origin for Resident #10. LPN A stated, The shower aide [Certified Nursing Assistant (CNA) N], came and got me, they were in the shower on 4/8/2024, to look at her left arm. The whole left side shoulder to her hand were [was] swollen .I let the [Named Medical Director] know and he came to the facility later that day. He advised me to get an x-ray. Got x-ray the next day on 4/9/2024. I'm not sure if results came back that evening or the next day 4/10/2024. It was on 4/10/2024, a Wednesday when got results, it [was] fractured . During an interview on 8/16/2024 at 12:28 PM, the DON was asked should an injury of unknown origin be investigated. The DON stated, Yes. The DON was asked what the process was for injuries of unknown origin. The DON stated, . Receive statements from staff, assess the resident and talk with the resident [if able]. After being readmitted we do initial assessment, and regular body audits. [Named Medical Director] was called by LPN A when swelling was noted. Communicate by report and 24- hour report. Nurses do a huddle with oncoming staff. The DON was asked, do you consider the 3 staff statements were a thorough investigation. The DON stated, All the other staff there had no knowledge of what had happened. X ray was ordered 4/9/2024 and received results on 4/9 [4/9/2024] but I know we didn't get them on 4/9/24 [2024] it was later. The DON was asked, do you have documentation where you interviewed other staff. The DON stated, No, I don't . The DON was asked, why did it take so long to send her out to the hospital. The DON stated, .out to hospital on 4/10/2024. They didn't have an order to send her out sooner. No one knew anything about her arm being injured .First time noted swelling was in shower on 4/9/24. No reason for the fracture. We did not find the reason or cause of fracture. The DON confirmed there was no 72 hour post incident monitoring for Resident #10 on 4/16/2024 one day after she was readmitted and there should have been. During a telephone interview on 8/19/2024 at 1:44 PM, the Medical Director was asked about the humerus fracture of Resident #10. The Medical Director stated, I remember her now, they called me for left arm swelling. She does not move. I ordered a doppler and an x-ray. The x-ray result was a fracture. I got an appointment with Ortho [Orthopedics] but the family was upset and wanted her to go to the hospital. They sent her right back. She is bedridden and it [a comminuted humerus fracture] could happen at any time. Review of the hospital records revealed Resident # 10 was not sent dight back to the nursing home but was admitted to the hospital from 4/10/2024 - 4/15/2024. The facility was unable to provide staff interviews from staff that completed resident care the day prior to finding the swollen arm on 4/5/2024 and 4/8/2024. There was no interview for the staff member who completed the injury of unknown cause report. Resident #10 was an immobile, bedridden resident, who was totally dependent on staff for all her activities of daily living, that sustained a comminuted humerus fracture. Refer to F600.

Based on policy review, medical record review, facility investigation, and interview, the facility failed to ensure a safe environment, adequate supervision/monitoring related to falls, illegal substance use, and elopement for 5 of 9 (Residents #44, #85, #89, #102, and #119) sampled residents reviewed for a safe environment. On 5/27/2024 Resident #44 had a fall, and the facility failed to monitor the resident post fall. On 5/31/2024, 4 days after the fall, Resident #44 complained of rib cage pain and an x-ray revealed a fractured rib, the facility failed to monitor the resident. The Nurse Practitioner was unaware of the resident's fall and fractured rib until 6/3/2024, the resident complained of chest pain on breathing. The facility's failures resulted in Actual Harm for Resident #44. The findings include: 1. Review of the facility's policy titled, Fall Risk-Fall Prevention ., dated 11/28/2017, revealed .Fall refers to unintentionally coming to a rest on the ground floor .when resident is found on the floor, a fall is considered to have occurred .4. After an incident of a fall .complete the Post Fall Risk Assessment .Notify MD [Medical Doctor] and Resident Representative, complete pain assessment after the fall .Fall placed on 24-hour report . Review of the facility's policy titled, Incident Report-Documentation, Investigating, and Reporting . dated 11/2022, revealed .All accidents or incidents involving residents .occurring on our premises shall be investigated and reported to the Administrator .the Charge Nurse at the time of the incident is responsible for documenting the incident in the resident's medical record .The nurses note should contain the following documentation .a. Clear, objective facts that occurred .a thorough assessment of the resident's condition at the time of the accident/incident .all quotes by the resident and/or witness involved or present at the time .any contacts made .resident's physician, family .outcome .Nurse's signature, date and time of charting .All incidents .should be reported to the Administrator .The Administrator/Director of Nursing should obtain signed and dated written statements from all witnesses with knowledge of the event . Review of the facility's policy titled, Unsafe Wandering-Elopement Risk Policy, dated 11/30/2021, revealed .Every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk for elopement .If an elopement occurs, a monitoring schedule will be implemented to ensure resident safety . Review of the facility's policy titled, Resident Rights Policy, dated 10/20/2022, revealed .The facility strives to protect the rights of residents, including .The resident has the right to reside and receives services in the facility with reasonable accommodation of needs .The resident has a right to a safe .environment, including .supports for daily living safely . 2. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE], with diagnoses including Orthopedic Aftercare following Surgical Amputation, Fracture of Rib on Right Side, Pressure Ulcer, and Heart Disease. Review of admission Minimum Data Set (MDS) dated [DATE], revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 14, indicating he was cognitively intact, had impaired mobility to his lower extremity, received set up help for eating, and partial/moderate assist with Activities of Daily Living (ADLs). Review of a Fall Risk Assessment sheet dated 5/27/2024, revealed an effective of date 5/27/2024 and a score of 12, indicating Resident #44 was at high risk for falls. The 5/27/2024 Fall Risk Assessment report was not signed until 8/13/2024. Review of an Incident Report dated 5/27/2024 at 2:20 PM, revealed Resident #44 sustained an unwitnessed fall and was noted to be on the restroom floor beside the toilet, and assisted back onto the toilet. Resident #44 was noted to have no injuries. The Incident Report dated 5/27/2024 was not completed by the Director of Nursing (DON) until 5/31/2024. Record review revealed there were no other progress notes related to Resident #44's fall on 5/27/2024. Review of a Progress Note dated 5/31/2024, revealed, .Resident [#44] c/o [complained of] pain to right rib cage .New order obtained for x-ray . Review of a Radiology Results report dated 5/31/2024, revealed Reviewed by [named person] Nurse Practitioner on 6/3/2024 .CHEST PAIN ON BREATHING .FINDINGS: The bilateral ribs demonstrate an acute right lateral sixth rib fracture . Review of a Physician Progress Note dated 6/3/2024 at 3:08 PM, revealed .He [Resident #44] is being seen for skilled follow up visit. Xray reviewed RIBS Bi-LAT [bilateral sides] .PA [Posteroanterior] CHEST MIN [Minimum] 4V [Views] with acute right lateral sixth, rib fracture. He stated he had a fall last week and he does not have complaints of significant pain . Review of a Progress Note dated 6/3/2024, revealed Resident #44 was transported via stretcher to the emergency room for evaluation due to an abnormal x-ray. Review of the Hospital emergency room Documentation dated 6/3/2024-6/4/2024, revealed .Basic Information .[Resident #44] who presents to the ED [Emergency Department] .for right sixth rib fracture .9 days ago .patient has mild diffuse expiratory wheezing .will order duo-neb given his wheezing .Prescriptions .Azithromycin 5 day Dose Pack .Chest x ray .scattered nodules which may be infectious/inflammatory .will discharge back to rehab center [nursing home] with antibiotic coverage for possible pneumonia and close follow up .Impression and Plan Diagnosis Fall .Pneumonia . Review of the revised Care Plan dated 6/4/2024, revealed .Altercation in musculoskeletal status r/t [related to] fracture of the ribs and gout . Review of a Progress Note dated 6/4/2024, revealed Resident #44 returned to facility with a diagnosis of Pneumonia with antibiotic therapy. Review of a Physician's Order dated 6/4/2024, revealed .Azithromycin Oral Tablet 250 mg [milligrams] .2 tablets by mouth one time a day .and Azithromycin .250 mg 1 tab [tablet] by mouth daily for 4 days .related to MUSCLE WEAKNESS . Review of the revised Care Plan dated 8/13/2024, revealed The resident [#44] has had an actual fall with Poor communication/comprehension. Fall without injury 5/27/2024 .[Revised 8/13/2024] . During an interview on 8/14/2024 at 4:01 PM, the DON confirmed Resident #44 fell on [DATE], however the incident report was not completed until 5/31/2024. The DON stated, .We didn't know he fell till a couple days later .when he complained of pain [on 5/31/2024] . The DON was asked should the nurse have put the incident report in that day (5/27/2024 the day Resident #44 fell ). The DON stated, Yes .I can't tell you why she didn't . The DON was asked, when were you made aware he fell in the bathroom. The DON stated, .not until [Resident #44] complained of rib pain to the unit manager, and the Xray was ordered. The DON confirmed she started her investigation on 5/31/2024. The DON was asked do you know the nurse's name that knows about the fall. The DON stated, Yes, [named Registered Nurse (RN) F]. The DON was asked to look in her computer and show the surveyor where the fall was documented on the 24-hour report on 5/27/2024. The DON confirmed Resident #44 was not listed as having a fall on the 24-hour report on 5/27/2024. During an interview on 8/14/2024 at 4:57 PM, RN F confirmed she did not know Resident #44, and did not know of any fall concerning him. During a telephone interview on 8/15/2024 at 9:58 AM, the Nurse Practitioner (NP) confirmed Resident #44 complained of rib pain on 5/31/2024 and she ordered x-rays. The NP was asked did the facility notify you of the results of the x-ray on 5/31/2024. The NP stated, No. The NP confirmed that the facility did not call her when the facility received the x-ray report of the fractured rib on 5/31/2024. The NP confirmed she was not aware of the fracture until 6/3/2024. The NP confirmed the facility should have called her on 5/31/2024 with results of a fracture. The NP confirmed she assessed Resident #44 on 6/3/2024 and sent him to the emergency room . During an interview on 8/15/2024 at 12:58 PM, the NP was asked if she thought the rib fracture could have contributed to Resident #44's pneumonia. The NP stated.It would take a few days to be acute . The NP was asked if the fall was 7-9 days old could it have contributed to the pneumonia. The NP states, It would be hard to give a definitive answer on that. During an interview on 8/16/2024 at 11:26 AM, the DON confirmed the 5/27/2024 Fall Assessment should have been completed and signed the date of fall. The DON was asked when they were notified that Resident #44 fell . The DON stated, .I would say the day the resident got the x-ray. The DON was asked should the Incident Report have been dated 5/27/2024, when she had no information showing the fall occurred on that date. The DON stated, I don't know, I can't remember why I did that, all my information was 5/31/2024. The DON confirmed the physician and family would have been notified on 5/31/2024, not on 5/27/2024 as documented in the incident report. The DON was asked do you have witness statements. The DON stated, No, just summaries of what they said. The DON was asked was there a pain assessment completed. The DON stated, I cannot confirm or deny it wasn't done on that date. The DON confirmed when she realized Resident #44 had fallen on 5/31/2024, he should have been put on the 24-hour report to be monitored. The DON confirmed there was no documentation of injury following a fall on 5/27/2024 or 5/31/2024 after Resident #44 was diagnosed with a rib fracture. During an interview on 8/16/2024 at 3:05 PM, Licensed Practical Nurse (LPN) H confirmed she assisted Resident #44 from the floor when he fell in the bathroom. LPN H was unable to confirm the date the fall occurred or the names of the 2 Certified Nurses Aides (CNA) that assisted her. LPN H stated, I told his [Resident #44's] [RN F] about his fall, he was not my Resident . During an interview on 8/21/2024 at 11:26 AM, the Administrator was asked, are you aware of Resident #44's fall. The Administrator stated, Yes. The Administrator confirmed she was not made aware the Resident fell , and staff didn't complete an investigation until 5/31/2024. The Administrator confirmed the Incident report should have been completed the day [5/27/2024] of the fall. The Administrator confirmed that the NP or physician should have been notified of the x-ray results showing the rib fracture on 5/31/2024. The Administrator confirmed witness statements are needed for a complete investigation and should have been completed. The facility failed to monitor Resident #44 for injuries following the fall on 5/27/2024, failed to notify appropriate facility staff, and failed to document timely related to the fall. The facility failed to monitor Resident #44 after the fractured rib was identified on 5/31/2024 and failed to monitor the resident's complaints of pain. The Nurse Practitioner was not aware of the resident's fractured rib identified on 5/31/2024 until the NP saw the resident on 6/3/2024, at which time Resident #44 was sent to the hospital ER. These failures resulted in Actual Harm for Resident #44. 3. Review of the medical record revealed Resident #85 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction with Hemiplegia (a condition that causes partial or total paralysis of one side of the body), Sickle-Cell Trait (A genetic blood disorder that occurs when someone inherits one sickle cell gene and one normal gene), Hypertension, History of Falling, and Anxiety. Review of the annual MDS dated [DATE], revealed Resident #85 had a BIMS score of 15, which indicated he was cognitively intact, required moderate/maximum assistance with ADL's and had 2 or more falls. Review of an Incident Report dated 4/20/2024, revealed Resident #85 sustained a fall that was witnessed by another Resident. Review of a Nurse's Note dated 4/20/2024, revealed Resident #85 slid from his chair to the floor, he was placed back in the wheelchair and sat next to the nurse's station. Review of the medical record revealed Resident #85 was not assessed or monitored for injuries for 72 hours following his fall. Review of an Incident Report dated 7/26/2024, revealed Resident #85 was observed half out of the bed with his head on the floor, with no injuries noted. Review of a Nurse's Note dated 7/26/2024, revealed Resident #85 returned from the hospital post fall. During an interview on 8/16/2024 at 12:02 PM, the DON confirmed after a fall a resident should be monitored for 72 hours in his medical record. The DON was asked if Resident #85 was monitored on 4/20/2024 and 7/26/2025 after his falls. The DON stated, No, he was not. Review of the medical record revealed Resident #85 was not assessed or monitored for injuries for 72 hours following his fall, there was no progress note related to his transfer to the hospital, and no assessment or monitoring following the hospital return on 7/26/2024. 4. Review of the medical record revealed Resident #119 was admitted to the facility on [DATE], with diagnoses including Fracture of Thoracic (T) 11-T12 (compression fracture of the thoracic spine usually at the bottom part of the thoracic spine), Respiratory Failure, Urinary Retention, Diabetes, Atrial Fibrillation, and Dysphagia. Review of the Care Plan dated 7/5/2024, The resident [#119] has impaired cognitive function or impaired thought processes r/t [related to] impaired decision making/POISONING BY FENTANYL OR FENTANY . Review of the Fall Risk assessment dated [DATE], revealed Resident #119 scored a 12.0. A score of 10 or higher indicated a high risk for potential falls. Review of the Progress Note dated 7/22/2024 at 8:24 PM, revealed .resident [#119] had an unwitnessed fall outside of her room in the hallway. Resident got up out the bed and walked in the hallway where she fell and hit her head. Resident was assessed, nuerochecks [neuro checks] started and placed back in bed. Resident have [The resident had] no complaints of pain I contacted the NP [Nurse Practitioner] and the DON I attempted to call her RP [Responsible Party] but the phone is disconnected will continue to monitor. Review of the facility's Fall Investigation dated 7/22/2024, revealed Injury Type No injuries observed at time of incident .Injury Report Post Incident No injuries Observed Post Incident .7/23/2024 Assist to nurses station for close supervision .7/24/2024 Resident [#119] remain visible when agitated . Review of the Progress Note dated 7/23/2024 at 5:41 AM, revealed Resident [#119] in bed resting, Resp. [Respirations] even and unlabored, skin w/d [warm/dry] to the touch, no changes in LOC [level of consciousness] noted, neuro checks remain in progress post fall, Resident has swelling noted over right eye, no s/sx [signs/symptoms] of pain or discomfort noted, will continue to monitor . Review of the Progress Note dated 7/23/2024 at 11:15 AM, revealed .Resident [#119] was sent to the hospital due to an unwitnessed fall that occurred last night [7/22/2024]. Resident alert-oriented x [times] 1 . resident has cut on her forehead from the fall. Unable to answer any questions pertaining to the fall . Review of the Fall Risk assessment dated [DATE], revealed Resident #119 scored a 12.0, which indicated the resident was a high fall risk. Review of the Care Plan dated 7/23/2024, revealed The resident [#119] has had an actual fall with injury Poor Balance Unsteady gait 7/22/24 [2024] actual fall with minor injury .Assist to nurses [nurses'] station for close supervision-7/22/24 . Review of the Physician Order Review Report dated 7/15/2024 - 8/15/2024 revealed no order for x-rays for Resident #119. Review of the Care Plan dated 8/12/2024, revealed The resident has a communication problem r/t Expressive Aphasia . Review of the Care Plan dated 8/13/2024, revealed Alteration in musculoskeletal status r/t [related to] fracture of the T11-T12 vertebra [Resident admitted with the diagnosis of T11- T12 fractures] . The fall investigation for Resident #119's fall on 7/22/2024 fall revealed no injuries. The resident was placed back to bed, but she would not stay, so she was put in a wheelchair and placed at the nurses' station. On 7/23/2024, the Resident was noted to have swelling above her right eye. On 7/23/2024 at 11:15 AM, Resident #119 was sent to hospital for a cut on forehead. During an interview on 8/16/2024 at 12:28 PM, the DON was asked about the injury to the forehead for Resident #119. The DON was asked how many falls Resident #119 had. The DON stated, One .put her back to bed but she would not stay so we put her in a wheelchair at the nurses' station. The DON was asked why she went out 9 hours after the fall. The DON stated, Because of the swelling . The DON was asked did you all put her back to bed after the fall. The DON stated, Yes, she wouldn't stay we put [her] in wheelchair at [the] nurses' station. Policy to get neuro checks. 7/23/24 5:41 AM swelling over right eye. Yeah, same cut from fall on 7/22/24. The cut was from that [7/22/2024] fall. The DON was asked was there a fall investigation for the forehead injury, any other injuries, or staff or resident interviews/statements obtained. The DON stated, Yes she only had one fall .We did not have an order to send her out [but due to the cut and swelling noted on 7/23/2024, the resident was sent out on 7/23/2024] .She didn't need sutures . 5. Review of the medical record revealed Resident #89 was admitted to the facility on [DATE], with diagnosis including Paraplegia, Neurogenic Bladder (urinary bladder problems due to disease or injury of the central nervous system .involved in the control of urination), Neurogenic Bowel (loss of normal bowel function) Major Depressive Disorder, Constipation, and Chronic Pain. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status score (BIMS) of 15, indicating intact cognition. Review of the Progress Note dated 7/5/2024 at 11:14 AM, revealed Resident [#89] left facility 7/4/24 [7/4/2024] LOA [Leave of Absence] with family. Family transported resident to hospital on 7/5/24 [7/5/2024] and resident was admitted to the hospital on 7/5/24 . Review of the undated [Named Hospital] Discharge Summary, revealed .ED [Emergency Department] to Hosp [Hospital] Admission .7/5/2024 - 7/11/2024 .Urine drug screen positive for amphetamines and THC [Tetrahydrocannabinol (THC), the main psychoactive ingredient in the cannabis plant] . During an interview on 8/14/2024 at 10:18 AM, the DON confirmed she was aware of Resident #89 having a positive drug test during the 7/5/2024-7/11/2024 hospitalization . The DON stated, He called me from the hospital [unable to recall the date Resident #89 called] .he told me that he does smoke marijuana when he goes home .he said it must have been laced with something . The DON confirmed Resident #89 denied the use of amphetamines, but admitted he does use marijuana when he goes home. Review of the care plan revised on 8/14/2024, a month after the hospital discharge, revealed .Resident [#89] is at risk for substance abuse disorder r/t [related to] potential THC and opioid use Date Initiated: 8/14/2024 .Monitor for s/sx [signs and symptoms] of possible use .changes in resident behavior, increased unexplained drowsiness, lack of coordination, slurred speech, mood changes, and or loss of consciousness .Report any abnormal s/sx . During an interview on 8/14/2024 at 4:16 PM, the Administrator confirmed she was not aware of Resident #89's positive drug test at the time but he smells of marijuana at times. The Administrator confirmed the facility was initiating monitoring of Resident #89 for illegal drug use beginning 8/14/2024 and the monitoring would be documented on the Medication Administration Record (MAR). The Administrator confirmed Resident #89 had not been monitored for illegal drug use since his return from the hospital on 7/11/2024. Review of the [Named Facility] Order History Report dated 8/16/2024, revealed there was no order to monitor Resident #89 for substance abuse. During an interview on 8/16/2024 at 1:24 PM, the DON confirmed the monitoring for illegal substance use order had not been entered into the system as of that time. During an interview on 8/21/2024 at 10:21 AM, the Administrator confirmed Resident #89 should have been assessed and monitored for illegal drug use and interventions should have been put in place in July 2024, when the facility became aware of the drug use, but nothing was initiated until 8/14/2024. 6. Review of the medical record revealed Resident #102 was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety, Chronic Obstructive Pulmonary Disease, Blindness right eye, and Hypertension. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #102 had a BIMS score of 6, which indicated Resident #102 had severely impaired cognition, and had no wandering behaviors. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #102 had a BIMS score of 3, which indicated Resident #102 had severely impaired cognition, required supervision or touching assistance from staff for ambulation, and had no wandering behaviors. Revised of the revised Care Plan dated 5/11/2024, revealed Resident #102 was .an elopement risk/wanderer . with interventions including .Wanderguard bracelet to help prevent elopement . Review of the facility's Incident Investigation Witness Interview Form sheet dated 5/13/2024, revealed Resident #102 exited an East End Hall door alone on 5/11/2024. Review of the facility's Logbook Documentation .Door Security System/Delayed Egress . dated 5/2024, revealed there was no daily interval monitoring of the East End Hall exit door from 5/11/2024 until 5/23/2024. Review of the facility's Securitas Healthcare, invoice dated 5/23/24, revealed .Keypad .Egressable Mag [Magnetic] Lock .Reset Switch .Installation of Locks System . During an interview with the DON on 8/14/2024 at 1:50 PM, the DON was asked about the incident concerning Resident #102 on 5/11/2024. The DON stated, It was a Saturday morning, [Licensed Practical Nurse (LPN C)] called me and stated [Resident #102] got out of the building, he had been agitated all night and would not sleep. She had went [gone] in another resident's room to give medication and heard the back door alarm, looked at [the] nurse's station, and the resident was not there. She looked out the back door and he was outside the back door. He was right outside the back door. The DON was asked what was done for the prevention of the resident being able to exit the door again. The DON stated, I cannot remember, will have to look at computer. During an observation and interview on 8/14/2024 at 3:37 PM, LPN C was asked about Resident #102 exiting the door on the East End Hall. LPN C stated, It was the weekend and one of his behaviors was not going to bed. He was walking around. We sat him at the nurse desk to rest him and keep watch on him. The last time I saw him, before he got out, he was sitting in his wheelchair at the nurse station. I went in a resident [resident's] room to pass medication; he was in the wheelchair when I went into that room. I came out [of] the room, because I heard the alarm, it was coming from the back door alarm. I notice [noticed] he was not at the nurse's desk. I ran to the back door. LPN C was asked to confirm which door [Resident #102] exited. LPN C stated, The hall that room [ROOM NUMBER] is on, went to the door and could see [Resident #102] .[Resident #102] was not far from [the] door I could see [Resident #102]. LPN C pointed to area right out the door. Observation at the East End Hall door revealed a metal gate to the left of the door. LPN C confirmed Resident #102 had no injuries. LPN stated, No, he was standing, stated to me he was trying to get home. I walked him back in arm and arm. The staff heard the alarm, went and found Resident #102 just outside near the door. During an interview on 8/14/2024 at 5:45 PM, LPN D was asked about Resident #102 exiting the East End Door on 5/11/2024. LPN D stated, It was myself and [LPN C] on the East Hall .The last time I saw [Resident #102] he was at the nurse station sitting in a wheelchair .I went to the cart to get medicine and he was still at the nurse station .I went back in the resident's room to give [female resident] her the med and that is when the door alarm sounded. When I came out [of] the room, I saw [Resident #102] and [LPN C] walking back into the facility . During an interview on 8/16/2024 at 10:06 AM, the Maintenance Director was asked how Resident #102 got out of the facility on 5/11/2024. The Maintenance Director confirmed he did not recall the time of day he was called and thought it was a Saturday. The Maintenance Director confirmed it was the East End Hall door, at the end of the hall that contains room [ROOM NUMBER] and 118. The Maintenance Director stated, .the door had malfunction [malfunctioned] due to a power surge . The Maintenance Director was asked how he determined it was a power surge. The Maintenance Director stated, Because immediately the door opened when pushed in on the door handle. The Maintenance Director was asked when the last time, before the incident, had the East End Hall door been checked to see if properly functioning. The Maintenance Director stated, I did it that Friday [5/10/2024], it is part of daily preventive maintenance, make rounds to check all doors Monday thru Friday. The Maintenance Director confirmed the doors are not checked on the weekends to see if they are working properly. The Maintenance Director was asked how he fixed the East End Hall door. The Maintenance Director confirmed the door is a magnet (mag) lock door; he took the Mag Lock apart then to see if it had problems or damage and found nothing with the Mag Lock, then he reset the Mag Lock and the Mag Lock worked. The Maintenance Director confirmed he checked every door after he came in (on 5/11/2024) and found the East End Hall door was unlocked, and the East End Hall door was the only door he found to have malfunctioned. The Maintenance Director was asked to explain a power surge. The Maintenance Director stated, It is when the power may go out, for example, if someone in those apartments behind us hit a pole and the power goes out, and the generator has to kick in for the electricity to come back on. The Maintenance Director was asked if another power outage happens does the nurses know what to do about the doors, to check the doors for malfunction. The Maintenance Director stated, I told them to check the doors to make sure they are locked. The Maintenance Director was asked did the nurses get an in-service about checking the doors to see if they lock if a power surge occurs, and was it documented. The Maintenance Director stated, No, I told them, it was word of mouth on what to do. The Maintenance Director confirmed after he found out the East End Hall door had malfunctioned; he contacted a vendor to have them to check all doors on the East End Hall and the findings were to replace the Mag Lock. The Maintenance Director stated, .a power surge may have caused the door to malfunction . The Maintenance Director was asked if there was anything in place, so that when it happens to be another power surge, staff will check doors' locks to make sure they are working properly. The Maintenance Director stated, If we have a power outage they will, and I will check the doors. The Maintenance Director confirmed before he left on Saturday, it was word of mouth, no documented in-service that nurses were to check the East End Hall door to make sure it is not immediately opening. The Maintenance Director was asked to explain the East End Hall door's Mag Lock. The Maintenance Director stated, It has a 15 second delay, if you hold handle down for 3 seconds, it will beep and within 15 seconds the magnet will release, and the door will open. The Maintenance Director confirmed after Resident #102 exited the East End Hall Door alone on 5/11/2024, there was no documentation the door was monitored and the intervals that the door was monitored, in order to make sure the Mag Lock was working properly and to prevent another resident from being able to exit alone. During an interview on 8/16/2024 at 1:12 PM, the Administrator confirmed it was the East End Hall door that houses rooms [ROOM NUMBERS], that Resident #102 exited alone, and confirmed the Maintenance Director informed her the Mag Lock to that door had malfunctioned and needed to be replaced. The Administrator confirmed the Maintenance Director told her the door needed a new Mag Lock. The Administrator stated, I asked the Maintenance Director do we need someone sitting at the door at all times because of the Mag lock and he reassured me no, to focus on getting the Mag Lock replaced. The Administrator confirmed she was not for sure if there was any documentation of random checks of the East End Hall door for not immediately opening when you push in on the handle. During an interview on 8/19/2024 at 4:28 PM, the DON confirmed the East End Hall exit door is an egress [hold down 15 sec and it will release] door for emergency purposes. The DON confirmed she did not ask the nurses to do anything with the doors. The DON confirmed there are no documented daily checks on the door after the resident got out the East End Hall exit door on 5/11/2024 and until the new Mag Lock was installed.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a resident's missing property was replaced timely after the Social Worker reported they would replace the missing item for 1 of 32 residents (Resident #38) sampled residents. The findings include: 1. Review of the facility's policy titled, Abuse-Investigation Incidents of Theft and/or Misappropriation of Resident Property Policy, dated 11/5/2022, revealed .All reports of theft or misappropriation of resident property shall be promptly and thoroughly investigated .Our facility will exercise reasonable care to protect the resident from property loss or theft, including .Promptly responding to and investigating complaints or misappropriation of property . 2. Review of the medical record revealed Resident #38 was admitted on [DATE], with diagnoses including Bipolar Disorder, Schizoaffective Disorder, and Hypertension. Review of the quarterly Minimum Data Set, dated dated dated [DATE], revealed Resident #38 had a Brief Interview for Mental Status score of 15, which indicated intact cognition. During an observation and interview in the resident's room on 8/13/2024 at 11:01 AM, Resident #38 confirmed she told the Social Worker she had an art pad. The Resident #38 made a verbal grievance to the Social Worker that her art pad was missing. The facility did not do an investigation for the missing art pad. The Social Worker told the resident that she would replace the art pad in 7/2024. During the week of 8/12/2024, the art pad had not yet been replaced. During an interview on 8/13/2024 at 2:37 PM, the Social Worker was asked if she was aware Resident #38 had a missing art pad. The Social Worker stated, Yes .during the residents last care plan meeting and during the month of 7/2024. I told her I would buy her another one. I have to put this on the list. I have so many residents asking me to buy them things. During an interview on 8/16/2024 at 12:36 PM, the Social Worker confirmed she was made aware Resident #38 had a missing art pad during the resident's last care plan meeting on 7/17/2024 and she told the resident in 7/2024 that she would replace the art pad. The Social Worker stated, .I will not make this mistake again. I will not be penalized for something I said I would do. I have to buy a lot of stuff for people. She did not receive the art pad because I do not like Walmart . During an interview on 8/20/2024 at 8:21 AM, the Administrator was asked, what is the process when a staff member is made aware a resident is missing an item. The Administrator stated, .It needs to be put on the 24-hour report and grievance log. The social worker will investigate .will look if the resident had been transferred out of the facility or if a room change occurred. If the resident is alert, will let them know that we are looking for the item. If resident is not alert, will let the family know .will ask the family to keep receipt. If no receipt, will replace or give money .to replace the item. The Administrator was asked, what do you expect the staff member to do if a staff is made aware by the resident that the resident has a missing item, and the staff member tells the resident it will be replaced. The Administrator stated, .first tell us about it, say if the resident told us on a Friday, I would try to get the items replaced within 48 to 72 hours .I want the item to be replaced. I want the resident to be happy. We have to put ourselves in their place . The Administrator was asked, when a staff member is made aware of a resident item missing on 7/17/2024 and replacing the item this past week [week of 8/12/24]; is that in a timely matter. the Administrator stated, No, it is not.

Based on medical record review and interview, the facility failed to ensure assessments were accurately completed to reflect the resident's status related to Hospice services for 1 of 1 (Resident #61) residents reviewed or hospice. The findings include: Review of the medical record revealed Resident #61 was admitted to the facility on [DATE], with diagnoses including Epilepsy, Persistent Vegetative State, Gastrostomy, Hypertension, Dementia, Depression, and Anxiety. Review of the care plan dated 7/3/2020 revealed .The resident has a terminal prognosis r/t [related to] respiratory failure with [Named] Hospice. [Revised 2/27/2024] . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #61 was not coded for receiving Hospice services. Review of the quarterly MDS dated [DATE], revealed Resident #61 was not coded for receiving Hospice services. Review of the Physician's Orders dated 8/15/2024, revealed .Admit to [Named] Hospice .diagnosis Respiratory Failure .[Order Date] 2/5/2024 . During an interview on 8/15/2024 at 4:42 PM, the MDS Coordinator confirmed the MDS assessments dated 4/12/2024 and 7/12/2024, were coded incorrectly and should have been coded to reflect Resident #61 was receiving Hospice services.

Based on policy review, medical record review, and interview, the facility failed to obtain weights in accordance with the facility's policy for 1 of 2 sampled resident (Resident #31) reviewed for nutrition. The findings include: 1.Review of the facility's policy titled, Weight Assessment and Intervention Policy dated 11/2022, revealed .The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .The nursing staff will measure residents on admission and weekly for (4) weeks thereafter .Weights will be recorded in each unit's Weight Record chart .any weight change of 5 % or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will notify the Dietitian The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant' weight change has been met .The threshold for significant unplanned and undesired weight loss will be based on the following criteria .1 month- 5% weight loss is significant; greater than 5% is severe . 2. Review of the medical record revealed #31 was admitted on [DATE], with diagnosis including Psychosis, Dementia, and Diabetes. Review of the Physician Orders dated 4/30/2024, revealed orders for; Offer Snack at Hour of Sleep (HS) one time a day, and Regular diet, Mechanical Soft (Chopped) texture, Thin Liquids consistency, double protein portion, every meal. Review of the facility's Weights and Vitals Summary sheet for Resident #31 revealed on 5/2/2024 Resident #31's weight was 215 lbs (pounds). The facility failed to obtain a weekly weigh for Resident #31 the week of 5/5/2024. On 5/15/24 Resident #31's weight was 200.8 lbs, showing a 14.2 lbs weight loss of 6.6 % (percent) in approximately 2 weeks, indicating a significant and severe weight loss. The facility failed to weigh Resident #31 the week of 5/19/2024, and the week of 5/26/2024. Review of the Physician Order dated 5/21/2024 revealed Resident #31 had an order for 120 milliliters (ml) of Medpass (a nutritional supplement) 2.0 two times a day for 4 Weeks Review of the facility's Weights and Vitals Summary sheet revealed on 6/11/2024, Resident #31's weight was recorded as 201 lbs. Review of the facility's E-Interact Form dated 6/14/2024, revealed Resident #31 was transferred to the hospital with Abscess to Lower [NAME] and diagnosed at hospital with Cellulitis of neck. Review of a Progress Note with dated 6/28/2024, revealed Resident #31 was readmitted into the facility. Review of the facility's Weights and Vitals Summary sheet revealed Resident #31's readmission weight was 194.8 lbs on 6/29/2024. Review of the quarterly Minimum Data Set, dated dated dated [DATE], revealed Resident #31 scored a 5 on the Brief Interview for Mental Status (BIMS), which indicated severely impaired cognition, and required partial/moderate assistance from staff for eating. Review of the Physician Orders dated 7/2/2024 and 7/3/2024, revealed Resident #31 had an order for 240 ml of MedPass 2.0 one time a day for 2 Weeks. On 7/3/2024, orders revealed a Multivitamin with Minerals tablet to give 1 tablet by mouth one time a day, and Fortified foods with breakfast and lunch two times a day for 4 Weeks. Review of the facility's Weights and Vitals Summary sheet revealed on 7/12/2024, Resident #31's weight was 191 lbs. There were no documented weights between the 6/29/2024 weight and the 7/12/2024 weight. Review of a Physician Order dated 7/15/2024 revealed Resident #31 had an order for 240 ml of MedPass 2.0 two times a day for 2 Weeks. The facility failed to follow the Weight Assessment and Intervention Policy, when Resident #31 was not weighed weekly for 4 weeks after his readmission on 6/28/2024. Review of a Progress Note and E-Internet Form dated 8/5/2024, revealed was transfer to the hospital with complaint of stomach pain and heart pain. The resident was admitted to the hospital on 8/5/2024 - 8/20/2024. Review of a Progress Note dated 8/10/2024, revealed Resident #31 was readmitted into the facility. There was no documentation of a readmission weight for Resident #31. Review of the facility's Weights and Vitals Summary dated 8/14/2024 revealed Resident #31's weight was 184.2 lbs, 4 days after the Resident was readmitted . Review of a Physician Order dated 8/16/2024, revealed Resident #31 had an order for Ice cream with lunch and dinner two times a day for Weight Loss, and 120 ml of Med Pass 2.0 twice a day for 4 weeks two times a day. During an interview on 8/16/2024 at 3:34 PM, The DON confirmed the facility failed to weigh Resident #31 weekly for 4 weeks after his admission weights on dates on 4/30/2024 and 6/29/2024. The DON confirmed upon readmission a resident's weight should be obtained within 24 hours. The DON confirmed the facility to weigh Resident #31 within 24 hours of his readmissions.

Based on medical record review, observation, and interview, the facility failed to provide care and services for residents with enteral feedings when staff failed to check residual as ordered, failed to follow physician orders for water flushes, and failed to administer medications with gravity through a percutaneous endoscopic gastrostomy (PEG) tube (plastic tube inserted into the stomach to administer medications, supplements and liquid food) syringe for 2 of 2 (Resident #8 and #10) residents reviewed for enteral feedings, and failed to ensure the enteral feedings and the flush solutions were properly labeled for 1 of 3 sampled residents (Resident #90) reviewed PEG tube feedings. The findings include: 1.Review of the Facility's policy titled, Gastrostomy Enteral Feeding and Nutrition Medication Administration Management dated 12/7/2017, revealed .Hang the prescribed feeding .Ensure resident's name, date, rate, and time hung is on the feeding solution . Review of the facility's policy titled, MEDICATION ADMINISTRATION-ENTERAL TUBES dated 11/2022, revealed, This facility assures the safe and effective administration of enteral formulas and medications .Crushed medications are not mixed together. The powder from each medication is mixed with water before administration .Each medication is administered separately to avoid interaction and clumping. The enteral tubing is flushed with water between each medication to avoid interaction of the medications .Remove plunger from syringe and insert syringe into tubing .Allow medication to flow down tube via gravity . Review of the facility's policy titled, ADMINISTRATION OF MEDICATIONS dated 11/15/2022, revealed, .Medications must be administered in accordance with the orders, including any required time frame . 3. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Aneurysm, Dysphagia, Gastrostomy Status, Dementia, Cerebral Infarction, and Gastrointestinal Hemorrhage. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed there was no Brief Interview for Mental Status (BIMS) score, Resident #8 was severely cognitively impaired, dependent on staff for Activities of Daily Living (ADLS), active diagnosis of Gastrostomy, and the use of a feeding tube. Review of the facility's Order Review History Report dated 7/16/2024 to 8/16/2024, revealed, .Ativan [also known as Lorazepam - a medication used for anxiety] .1 MG [milligram] .via PEG .Baclofen [medication used for muscle spasms] .5 MG .via PEG-Tube .Glycopyrrolate [medication used to dry secretions] .2 MG .via PEG-Tube .Enteral Feed Order .every shift FLUSH TUBE WITH 60CC [cubic centimeters] WATER BEFORE AND AFTER MEDS [medications] . Review of Resident #8's Care Plan dated 7/21/2024, revealed .at risk for alterations in nutritional status r/t [related to] .NPO [nothing by mouth] with 100% [symbol for percent] nutrition/hydration via [by way of] PEG .The resident is dependent with tube feeding and water flushes administration. See MD [Medical Doctor] orders for current tube flushes and medication administration orders .Enhanced Barrier precautions . Observation during medication administration on the [NAME] Hall at Medication cart #1 on 8/15/2024 at 1:45 PM, revealed Licensed Practical Nurse (LPN) B, removed 1 Lorazepam 1 mg tablet, 1 Baclofen 5 mg tablet, and 1 Glycopyrrolate 2 mg tablet for Resident #8. LPN B placed all 3 of the medications into a plastic sleeve and crushed all 3 medications together and then placed the mixed medications into a plastic cup. LPN B sanitized her hands, knocked and entered Resident #8's room, donned a clean pair of gloves, checked placement of the PEG. LPN B mixed the medications together with 10 milliliters (ml) of water, flushed the PEG feeding tube with 30 ml of water by pushing the water with a plunger, administered the mixed medications by pushing the medications into the PEG tube with a plunger, flushed the PEG feeding tube with 30 ml of water by pushing the water with a plunger. LPN B placed the enteral feeding syringe into the trash and reconnected the enteral feeding tube and restarted the enteral feeding. LPN B failed to follow the facility's policy and administer the medications separately and failed to allow the medications to flow down the PEG tube via gravity. LPN B failed to flush the PEG feeding tube with 60 cc of water before and after medication administration per physician orders. 4. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses including Tracheostomy, Gastrostomy, Quadriplegia, Dysphagia, Dementia, and Aphasia. Review of the quarterly MDS dated [DATE], revealed there was no BIMS score, Resident #10 was severely cognitively impaired, Range of Motion Limitations to both upper and lower extremities, dependent on staff for all ADLs, incontinent of both bowel and bladder, and had active diagnoses of Aphasia, Cerebrovascular Accident, Non Alzheimer's Disease, and Hemiplegia and Hemiparesis, Tracheostomy and Gastrostomy, and the use of a feeding tube. Review of the Care Plan dated 6/19/2024, revealed .Tracheostomy . ADL Self Care Performance Deficit .impaired cognitive and communication function .at nutritional risk r/t receiving 100% nutrition/hydration via PEG r/t dx [diagnoses] of dysphagia. trach [tracheostomy] .dependent with tube feeding and water flushes. See MD orders for current feeding orders . Review of the facility's Order Review History Report, dated 7/14/2024-8/14/2024, revealed .Glycopyrrolate .1 MG .via PEG-Tube .Enteral Feed Order every shift .to GASTROSTOMY STATUS .flush peg tube with 60cc water before and after meds . Observation on the East Hall at Medication cart #2 on 8/14/24 at 1:35 PM, revealed LPN A, removed 1 Glycopyrrolate 1 mg tablet, crushed the medications and placed it into a plastic cup. LPN A knocked and entered Resident #10's room, exited the room and walked across the hall and returned back to Resident 310's room with an over the bed table from a room across the hall. LPN A washed her hands, donned a clean pair of gloves, mixed the medications with water, removed her gloves, went to the medication cart for plastic cups, returned to the sink, and washed her hands. LPN A checked placement of Resident #10's PEG feeding tube and failed to check the PEG's residual. LPN A flushed the PEG feeding tube with 30 cc of water by pushing the water in with a plunger, administered the medications by pushing the medications in with a plunger, and then flushed the PRG feeding tube with 30 cc of water by pushing water with a plunger. LPN A rinsed the plunger and the syringe and placed both back into the plastic bag and hung on the enteral feeding pole with visible water particles in the plastic bag. LPN A removed her gloves and exited the room. LPN A failed to follow the facility's policy and allow the medication to flow down the PEG tube via gravity. LPN A failed to follow the physician's orders and flush the PEG with 60 cc of water before and after the administration of the medication. During an interview on 8/16/2024 at 12:14 PM, the Director of Nursing (DON) was asked, what was the process for administering medications through a PEG tube. The DON stated staff should make sure the resident was comfortable, check placement of the PEG tube, check residual of the PEG, use 5-10 cc of water to mix with the medications, and flush the PEG tube before and after with the physician prescribed amount of water. The DON stated staff should rinse the syringe and the plunger that was used with the medication administration, to air dry the syringe and plunger separately on a clean barrier and ensure the syringe and plunger were completely dry before returning them to the plastic bag for storage. The DON confirmed that is should not be returned to the plastic bag undried and with water particles present. The DON confirmed no medications should be crushed and administered together unless there was a physician order, and medications should be administered by way of gravity unless there was a physician order otherwise. 5. Review of the medical record revealed Resident #90 was admitted to the facility on [DATE], with diagnoses including Aphasia, Dysphasia, Percutaneous Endoscopic Gastrostomy (PEG), and Cerebral Infraction. Review of the quarterly Minimum Data Set, dated dated dated [DATE], revealed there was no BIMS score, and Resident #90 had severely impaired cognitive skills for making decisions and had a PEG feeding. Review of the Physician's Order dated 7/18/2024, revealed .Enteral Feed Order two times a day Jevity [a high calorie nutritional formula] 1.5 at 65 cc/hr [cubic centimeters per hour] x [times] 22h [hour] off 11am on 1p [pm] via peg /pump .Enteral Feed Order every 6 hours h20 [water] flush 250cc q6h [every 6 hours] via peg . Observation in Resident #90's room revealed the following: On 8/12/2024 at 11:53 AM, the Jevity container was not labeled with a rate to be administered or the time. The Jevity had been started. On 8/12/2024 at 4:28 PM, the Jevity container was not labeled with a date the Jevity had been started and the rate it should be administered. On 8/13/2024 at 10:21 AM, the Jevity container was not labeled with a time the Jevity was started or the rate for the Jevity to be administered. There was no date or rate on the water container hanging. On 8/14/2024 at 8:22 AM, the water container hanging with the Jevity was not labeled with a rate to be administered. On 8/14/2024 at 3:53 PM, the water container was not labeled with a rate to be administered. On 8/15/2024 at 8:42 AM, the water container was not labeled with a rate to be administered. During 8/16/24 at 8:48 AM, the DON confirmed the Jevity feeding should be labeled with the resident's name, flow rate to be administered, and the resident's room number. The DON confirmed the water container used for PEG flushes should be labeled with the amount/volume of water and rate of flush.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure assistance was provided with grooming and dressing for a Resident with a scheduled physician's appointment in order to ensure the Resident was ready and available when transportation services arrived to take the Resident to the physician's appointment for 1 of 1 resident (Resident #67) sampled residents who missed a scheduled physician's appointment. The findings include: 1.Review of the facility's policy titled, Resident Rights Policy dated 10/20/2022, revealed .The resident has a right to a dignified existence, self determination and communication with and access to persons and services inside and outside the facility .The facility strives to protect the rights of residents, including .All activities and interacting with residents by staff .must focus an assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident's goals, preferences and choices .The resident has the right to reside and receives services in the facility with reasonable accommodation of needs . Review of the facility's policy titled, Activity of Daily Living (483.24). dated 11/2022, revealed .Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices this facility will provide the necessary care and services .Each resident shall receive, and this facility will provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being . 2.Review of the medical record revealed Resident #67 was admitted to the facility on [DATE], with diagnoses including Osteomyelitis of right ankle and foot, Peripheral Vascular Disease, Diabetes, Pain, and Calculus of Kidney. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #67 scored a 15 on the Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition, was dependent upon staff for dressing and bathing, and required substantial to maximum assistance from staff for personal hygiene. Review of the Care Plan dated 5/21/2024, revealed Resident #67 required assist of one for bathing personal hygiene and dressing. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #67 scored a 15 on the BIMS, which indicated intact cognition, required substantial to maximum assistance from staff for dressing and putting on/taking off footwear. During an interview on 8/14/2024 at 8:26 AM, Resident #67 was asked to tell the surveyor about the bandage on her right foot. Resident #67 stated, .Infection down to the bone .going to doctor appoint [appointment] today . During an interview in the Resident's room on 8/14/2024 at 11:40 AM, Resident #67 stated, .The driver left me this morning. I needed to be at a doctor's appointment for infection. During an interview on 8/14/2024 at 11:48 AM, the Director of Nursing (DON) was asked if she was aware Resident #67 missed her doctor's appointment due to the bus driver leaving her. The DON stated, Yes she told me she was sore and could not move as fast. During an interview on 8/19/2024 at 11:24 AM, Certified Nurse Assistant (CNA) L confirmed Resident #67 required assistance from staff for lower and upper body dressing. During an interview on 8/20/2024 at 2:45 PM, Resident #67 confirmed she would not have missed her appointment on 8/14/2024 if a staff member had helped her to get ready and get to the door in enough time to catch the ride on the transportation service. During an interview on 8/21/2024 at 8:29 AM, the DON confirmed Resident #67 does not move fast and staff should have assisted Resident #67 in a timely matter with dressing and grooming in order to ensure the Resident was available for the transportation services.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were administered in a safe and sanitary manner during Percutaneous Endoscopic Gastrostomy (PEG) - a plastic tube inserted into the stomach for the administration of medications and feedings) administration for 2 of 2 (Resident #8 and #10) sampled residents observed during medication administration, and the facility failed to ensure hazardous, and infectious waste was properly stored for the prevention of infectious diseases in 2 of 2 soiled linen rooms (West End Hall Soiled Linen Room and East End Hall Soiled Linen Room). The findings include: 1.Review of the facility's policy titled, ADMINISTRATION OF MEDICATIONS dated 11/15/2022, revealed .Staff shall follow established facility infection procedures .handwashing .antiseptic technique, gloves, isolation precautions .when these apply to the administration of medications . Review of the Facility's policy titled, Infection Control/Medical Waste Handling dated 11/2022, revealed .Medical waste will be handled and disposed of safely and in accordance with regulatory requirements .For the purpose of this policy, medical waste include human blood and blood soiled articles contaminated items .soiled dressing .disposable sharps .needles .Disposable items contaminated with excretions or secretions from residents believed to be infectious must be placed in plastic bags and sealed, and either decontaminated with .or stored in appropriate container until removal from the premises .Disposable items soiled with blood or other potentially infectious materials must be placed in plastic bags or containers .place in appropriate containers and handled as medical waste . Review of the facility's policy titled, Infection Prevention and Control CLEANING AND DISINFECTION OF RESIDENT-CARE ITEMS AND EQUIPMENT dated 11/29/2022, revealed .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to CDC [Centers for Disease recommendations for disinfection and the OSHA [Occupational Safety and Health Administration] Bloodborne Pathogens Standards .Durable medical equipment [DME] must be cleaned and disinfected before reuse by another resident . Review of the facility's policy titled, MEDICATION ADMINISTRATION-ENTERAL TUBES dated 11/2022, revealed .Crushed medications are not mixed together. The powder from each medication is mixed with water before administration .Enteral tubes are flushed with at least 15 ml of water before administering any medications and after all medications after all medications have been administered .Each medication is administered separately to avoid interaction and clumping. The enteral tubing is flushed with water between each medication to avoid physical interaction of the medications .Remove plunger from syringe and insert syringe into tubing .Allow medication to flow down tube via gravity . Review of the facility's policy titled, Enhanced Barrier Precautions, dated 3/30/2024, revealed .Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities .EBP are used in conjunction with standard precautions and expand the use of PPE [personal protective equipment] to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs [multidrug-resistant organism] to staff hands and clothing .EBP are indicated for residents with any of the following as long as they reside in the facility .Wounds and/or indwelling medical devices .Chronic wounds .pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers .Indwelling medical devices examples include central lines, urinary catheters, feeding tubes, and tracheostomies .Resident Status .has a wound or indwelling medical device .Use EBP .Yes .for Residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities .Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use .central line, urinary catheter, feeding tube, tracheostomy, Wound care any skin opening requiring a dressing .EBP are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device . 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including of Aneurysm, Dysphagia, Gastrostomy Status, Dementia, Cerebral Infarction, and Gastrointestinal Hemorrhage. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #8 was severely cognitively impaired, and the use of a feeding tube. Review of the facility's Order Review History Report dated 7/16/2024 to 8/16/2024, revealed .Ativan [also known as Lorazepam - medication used for anxiety] .1 MG [milligram] .via PEG .Baclofen [medication used for muscle spasms] .5 MG .via PEG-Tube .Glycopyrrolate [medication used to dry secretions] .2 MG .via PEG-Tube .Enteral Feed Order .every shift FLUSH TUBE WITH 60CC WATER BEFORE AND AFTER MEDS [medications] . Review of the Care Plan dated 7/21/2024, revealed .at risk for alterations in nutritional status r/t [related to] .NPO [nothing by mouth] with 100% [symbol for percent] nutrition/hydration via [by way of] PEG .The resident is dependent with tube feeding and water flushes administration .Enhanced Barrier precautions . Observation during medication administration on the [NAME] Hall at Medication cart #1 on 8/15/2024 at 1:45 PM, revealed Licensed Practical Nurse (LPN) B, removed 1 Lorazepam 1 mg tablet, 1 Baclofen 5 mg tablet, and 1 Glycopyrrolate 2 mg tablet for Resident #8. LPN B placed all 3 of the medications into a plastic sleeve and crushed all 3 medications together and placed the mixed medications into a plastic cup. LPN B sanitized her hands, knocked and entered Resident #8's room, donned a clean pair of gloves, checked placement with air and residual, mixed the medications with 10 ml (milliliters) of water, flushed the PEG feeding tube with 30 ml of water by pushing the water with the plunger, administered the mixed medications by pushing the medications with the plunger, flushed the PEG feeding tube with 30 ml of water by pushing with the plunger. LPN B placed the enteral feeding syringe into the trash and reconnected the enteral feeding tube and restarted the enteral feeding. LPN B failed to use enhanced barrier precautions when administering Resident #8's medications through the PEG tube. 3. Review of the medical record revealed Resident #10 was admitted to the facility with diagnoses including Cellulitis, Tracheostomy, Gastrostomy, Quadriplegia, Dysphagia, Dementia, and Aphasia. Review of the quarterly MDS dated [DATE], revealed Resident #10 was severely cognitively impaired, Range of Motion Limitations to both upper and lower extremities, dependent on staff for all ADLs, incontinent of both bowel and bladder, and had active diagnoses of Aphasia, Cerebrovascular Accident, Non Alzheimer's Disease, and Hemiplegia and Hemiparesis, Tracheostomy and Gastrostomy, and the use of a feeding tube. Review of the Care Plan dated 6/19/20 revealed, .at nutritional risk r/t receiving 100% nutrition/hydration via PEG r/t dx [diagnoses] of dysphagia. trach [tracheostomy] .dependent with tube feeding and water flushes .Enhanced Barrier Precautions . Review of the facility's Order Review History Report, dated 7/14/2024-8/14/2024, revealed .Glycopyrrolate .1 MG . via PEG Tube .Enteral Feed Order every shift .to GASTROSTOMY STATUS .flush peg tube with 60cc water before and after meds . Observation on the East Hall at Medication cart #2 on 8/14/2024 at 1:35 PM, revealed LPN A, removed 1 Glycopyrrolate 1 mg tablet, crushed the medication and placed it into a plastic cup. LPN A knocked and entered Resident #10's room, exited the room and walked across the hall and obtained an over the bed table and returned to Resident #10's room. LPN A cleaned the over the bed table with a water moistened paper towel. LPN A washed her hands, donned a clean pair of gloves, mixed the medications with water, removed her gloves, went to the medication cart for plastic cups, returned to the sink, washed and dried her hands, turned off the faucet, and cleaned the vanity top with the same paper towel. LPN A administered the medication. LPN A rinsed the plunger and the syringe and placed both back into the plastic bag and hung on the PEG feeding pole with visible water particles in the plastic bag. LPN A failed to clean the over the bed table with the proper disinfectant wipes, failed to use Enhanced Barrier Precautions while administering the PEG tube medications, and failed to properly store the PEG tube syringe after cleaning. During an interview on 8/14/2024 at 2:25 PM, LPN A confirmed that enhanced barrier precautions are used when a resident has a tracheostomy, PEG feeding tube, and a wound. LPN A confirmed that Resident #10 was on enhanced barrier precautions for her PEG feeding tube and all residents on enhanced barrier precautions has a red dot by their name on the outside of the door. LPN A confirmed that Resident #10 has a red dot by her name on the outside of the room door. LPN A confirmed that she should have used enhanced barrier precautions when administering Resident #10 her medications. During an interview on 8/16/2024 at 12:14 PM, the Director of Nursing (DON) confirmed that staff are to use enhanced barrier precautions when they are in close contact with residents, and they should wear a gown and gloves. The DON confirmed staff should use enhanced barrier precautions when administering PEG medications. The DON confirmed when staff are conducting proper hand hygiene, they should use soap and wash their hands for 20-30 seconds, rinse and use a clean paper towel to dry their hands, use a separate paper towel to turn off the faucet. The DON was asked, what should staff use to clean an over the bed table. The DON stated staff should use a bleach micro kill cloth when cleaning any reusable equipment including an over the bed table and should not use a water moistened paper towel. The DON was asked, what was the process for administering medications through a PEG tube. The DON stated staff should make sure the resident was comfortable, check placement of the PEG, check PEG residual, use 5-10 cc of water with the medications, and flush the PEG before and after with the physician prescribed amount of water. The DON stated staff should rinse the syringe and plunger used for the administration of medications via the PEG, and air dry them separately on a clean barrier. The DON stated the syringe and plunger should be completely dry before returning them to the plastic bag for storage. The DON confirmed there should not be observations of water particles present when placing them back in the plastic storage bag. 4. Observation and interview on the [NAME] End Wing Soiled Linen Room on 8/20/2024 at 4:14 PM, revealed 8 filled sharp containers on the counter. The Infection Control Preventionist stated the filled sharp containers should be in a biohazard box lined with a red biohazard bag and not on the counter. Observation and interview in the East End Wing Soiled Room on 8/20/2024 at 4:21 PM, revealed a biohazard box overflowing with red bags filled with biohazard waste. The Infection Control Preventionist verified the biohazard box was overflowing with red bags full of biohazard waste and that the biohazard box should not be stacked and overflowing like that. The Infection Control Preventionist stated a biohazard box full of bags containing biohazard waste should be contained and the biohazard box with the waste should be placed in a plastic biohazard container located in a room that is outside of the facility. The Infection Control Preventionist stated, .The box [biohazard box] should have been removed and a new box should have been put in there .prevents odor .prevents contamination . The Infection Control Preventionist confirmed the red bags full of biohazard waste should not have been stacked above what the biohazard box could contain.

Based on policy review, observation, and interview, the facility failed to provide a functioning call light for 1 of 114 (Resident #108) sampled residents which had the potential to result in unmet care needs. The findings include: 1. Review of the facility's policy titled Call Light Policy, dated October 20, 2022, revealed .The purpose for the call light is to provide a system for the resident to call for assistance .STANDARD OF PRACTICE Equipment: Bedside call light in functioning order .Emergency call light in working order .Report any defective call lights to charge nurse and the maintenance department immediately . 2. Observation of the resident's room on 8/12/2024 at 11:44 AM, revealed Resident #108 had activated his call light, but the hall light above his door was not on to alert staff the call light was on. During an interview in the conference room, on 8/12/2024 at 1:46 PM, the Maintenance Director, was told that Resident #108's call light was not working. The Maintenance Director stated, I will check it out . Observation in the resident's room on 8/13/2024 at 9:48 AM and 4:08 PM, revealed Resident #108 activated his call light, but the hall light over his door was still not working. Resident #108 confirmed maintenance did come in to check the call light, but he had not fixed the call light. Observation in the resident's room on 8/15/2024 at 1:55 PM, revealed Resident #108 activated the call light, but the hall light over the door was not working. Observation in the resident's room on 8/16/2024 at 2:24 PM, revealed Resident #108 pushed the call light and the surveyor went to the hallway to check the light over the door and the light was working. During an interview on 8/16/2024 at 3:20 PM, the Maintenance Director, was asked what was wrong with Resident #108's call light. He stated, I had to replace the board and both cords in the room. During an interview on 8/21/2024 at 7:53 AM, the Administrator was asked whether the East Hall call light system was fixed. The Administrator stated, That is correct. The Administrator was asked, what is an acceptable timeframe for a call light to be fixed when it is not functioning. The Administrator stated, I would say 1-2 hours. I have told them a call light is something important. The Administrator was asked, so would fixing it in 3-4 days be acceptable. The Administrator stated, No Ma'am. The Administrator was asked, so if that section needed to be fixed should they have gotten to it sooner than 3-4 days. The Administrator stated, I would say 1-2 hours.

Based on policy review, medical record review, and interview, the facility failed to provide an accurate Baseline Care Plan for 1 of 9 sampled residents (Resident #309) reviewed for with Baseline Care Plans. The findings include: 1. Review of the facility's policy titled CARE PLAN POLICY . dated 11/15/2022, revealed .A baseline plan of care will be developed by the interdisciplinary team (with resident input) for each resident within forty-eight (48) hours of the resident's admission to the facility. The baseline plan of care will consist of information that will provide effective and person-centered care that meets professional standards of quality care . 2. Medical record review revealed Resident #309 was admitted to the facility on [DATE], with diagnoses of Metabolic Encephalopathy, Chronic Obstructive Pulmonary Disease, Human Immunodeficiency Virus [HIV], and Respiratory Failure. Review of the 48-hour Care Plan dated 2/5/2024, revealed dialysis was not included in the 48-hour Baseline Care Plan. During an interview on 2/29/2024 at 9:40 AM, the Minimum Data Set (MDS) Coordinator was asked should Resident #309's baseline care plan have dialysis included. The MDS Coordinator stated, .It should have .I don't see it .

Based on policy review, Director of Maintenance job description, User's Operational Manual, maintenance supervisor's log documentation, observation, interview, and medical record review, the facility failed to ensure the environment was free from accident hazards when dangerously hot water temperatures were measured from 126.1 degrees Fahrenheit (F) to 130.6 degrees in 10 of 60 resident rooms (room [ROOM NUMBER], #110, #111, #112, #115, #119, #126, #129, #200 and #210) and a sink in the East Hall shower room. The dangerously hot water placed 9 physically and/or cognitively impaired residents (Resident #15, #17, #23, #24, #27, #48, #67, #72, and #241) that resided in the affected rooms and able to access the hot water, and 10 residents assessed for wandering (Resident #3, #18, #30, #53, #57, #65, #66, #69, #71 and #76) at risk of serious bodily injury, harm, burns, or death. The failure of the facility to maintain safe hot water temperatures placed all residents with access to these rooms in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance has caused, or has potential to cause serious injury, harm, impairment, or death to a resident). The facility's census was 92. The Administrator and Director of Nurses were notified of the Immediate Jeopardy for F-689 on 6/29/2023 at 9:29 AM, in the Omega Room. The facility was cited F-689 at a scope and severity of K which is Substandard Quality of Care. The extended survey was conducted on 6/29/2023 through 7/5/2023. The Immediate Jeopardy began on 6/26/2023 through 7/1/2023. An acceptable Removal Plan, which removed immediacy of the jeopardy, was received on 7/3/2023 at 10:31 AM. The corrective actions were validated onsite by the surveyors on 7/3/2023 - 7/5/2023. The findings include: 1. Review of the facility policy titled, WATER TEMPERATURES, SAFETY OF, revision date 11/2022, revealed .Tap water in the facility shall be kept within a temperature range to prevent scalding of residents . Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110 degrees F .or the maximum allowable temperature per state regulation .Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log .Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log .If at any time water temperatures feel excessive to the touch .staff will report this finding .exposure to warm or hot water .to certain temperatures will cause scalding or burns .Nursing staff will be educated about the signs and symptoms of burns . 2. Review of the undated and unsigned Director of Maintenance job description revealed .The primary purpose of your job is to plan, organize, develop, and direct the overall operation of the Maintenance Department in accordance with current federal, state and local standards, guidelines, and regulations governing our facility .to assure that our facility is maintained in a safe and comfortable manner .maintain written maintenance policies and procedures .Interpret the department's policies and procedures to employees, residents, visitors, government agencies .Assume the administrative authority, responsibility, and accountability of directing the Maintenance Department .Assist in establishing a preventative maintenance program .Make daily rounds to assure that maintenance personnel are performing required duties and to assure that appropriate procedures are being rendered to meet the needs of the facility .Assume the responsibility for maintaining your professional competence .Ensure that .equipment .are maintained to provide a safe and comfortable environment .Maintain inventory and records according to established policies .Must be knowledgeable in building codes and safety regulations .Must be knowledgeable of maintenance practices and procedures, as well as the laws, regulations and guidelines governing maintenance functions in nursing care facilities .must perform regular inspections of resident rooms . 3. The manufacturer Tankless Water Heater (Commercial) Installation and Operation Manual, dated 6/2020, page 4, .Temperature setting .Maximum: Default: 140 F .page 74, Water temperatures over 125 F (52C) can cause severe burns or scalding resulting in death .Hot water can cause first degree burns with exposure .3 seconds at 140 F .20 seconds at 130 F .and 8 minutes at 120 F . disabled, or elderly are the highest risk of being scalded .check local codes for the maximum water temperature setting allowed when used in nursing homes . 4. Review of the facility's maintenance log revealed no documentation of water temperature checks were performed in residents' rooms from 5/2/2023 - 6/25/2023. The surveyors thermometers were calibrated (a procedure using ice water to ensure the thermometer is measuring correctly) before water temperature checks were obtained. The surveyor's hot water temperature checks in residents' rooms on 6/26/2023 beginning at 3:30 PM, revealed the following: room [ROOM NUMBER] was 120 degrees F. room [ROOM NUMBER] was 122 degrees F. The Director of Maintenance and the surveyor's hot water temperature checks, using a calibrated thermometer, in residents' rooms on 6/26/2023 beginning at 4:04 PM, revealed the following: room [ROOM NUMBER] was 126.3 degrees F. room [ROOM NUMBER] was 124.8 degrees F. The Director of Maintenance and the surveyor's hot water temperature checks, using a calibrated thermometer, in residents' rooms on 6/26/2023 beginning at 4:55 PM, revealed the following: room [ROOM NUMBER] was 126.8 degrees F. room [ROOM NUMBER] was 127.9 degrees F. room [ROOM NUMBER] was 130.2 degrees F. room [ROOM NUMBER] was 130.6 degrees F. room [ROOM NUMBER] was 126.1 degrees F. room [ROOM NUMBER] was 128.1 degrees F. room [ROOM NUMBER] was 128.3 degrees F. room [ROOM NUMBER] was 128.3 degrees F. room [ROOM NUMBER] was 126. degrees F. room [ROOM NUMBER] was 124.8 degrees F. East Hall shower sink was 129.7 degrees F. During an observation and interview on 6/26/2023 at 5:29 PM, in the Mechanical Room, The Director of Maintenance showed the 6 tankless water heaters on the wall, all 6 tankless water heaters were set at 140 F. The Director of Maintenance was asked what temperature should these tanks be set. The Director of Maintenance confirmed he really didn't know however he stated that the water heaters have been set at 140 since he was hired on April 24, 2023 and that he was told to leave them alone. The Director of Maintenance was asked who told you to leave the tankless water tanks alone. The Director of Maintenance stated, They did. The Director of Maintenance would not answer who they were. 5. Residents #15, #17, #23, #24, #27, #48, #67, #72, and #241 were cognitively and/or physically impaired, resided in the rooms with the dangerously hot water temperatures and had access to the hot water. Residents #3, #18, #30, #48, #53, #57, #65, #66, #69, #71, and #76 had cognitive impairment and identified by the facility as residents with wandering behaviors (random, repetitive, or aimless locomotion/movement throughout an area) and had the potential to be affected by the dangerously hot water temperatures. 6. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnosis of Heart Failure, Dementia, Schizophrenia, Bipolar and Hypertension. Review of the annual MDS dated [DATE] revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident was severely cognitively impaired, requiring extensive assist with transfers, and was independent with set up for locomotion in her room. Observation on 6/26/2023 at 12:16 PM, revealed Resident #15 sitting in a wheelchair in her room. The resident resided in a room with the dangerously hot water and had the ability to access the hot water. 7. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE], with diagnoses of End Stage Renal Disease, Dependence on Renal Dialysis, Diabetes Mellitus and Hypertension. Review of the annual MDS dated [DATE], revealed a BIMS score of 13 which indicated the resident was cognitively intact, required limited assistance with transfers and was independent with setup for locomotion in the room. The resident resided in a room with the dangerously hot water and had the ability to access the hot water. 8. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE], with diagnoses of End Stage Renal Disease, Diverticulosis, Hypertension and Dementia. Review of the annual MDS dated [DATE], revealed a BIMS score of 9, which indicated the resident was moderately cognitively impaired, required supervision with transfers and independent with set up for locomotion in room. The resident resided in a room with the dangerously hot water and had the ability to access the hot water. 9. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE], with diagnosis of Diabetes, Osteoarthritis, and Venous Hypertension. Review of the admission MDS dated [DATE], revealed Resident #24 had a BIMS score of 15 which indicated the resident was cognitively intact and required assist of one for personal hygiene. Observation on 6/26/2023 at 3:02 PM, revealed Resident #24 sitting up in her bed, wearing glasses, and was alert, and oriented. The resident resided in a room with the dangerously hot water and had the ability to access the hot water. 10. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], with diagnoses of Intracranial Hemorrhage, Chronic Kidney Disease, Diabetes, Bipolar, Insomnia, and Hypertension. Review of the quarterly MDS dated [DATE], revealed Resident #27 had a BIMS score of 15 which indicated the resident was cognitively intact, and independent with locomotion in a wheelchair. Observation on 6/28/2023 at 10:03 AM, revealed Resident #27 wearing a smoking apron, sitting outside in her wheelchair, and smoking a cigarette on the patio area. The resident resided in a room with the dangerously hot water and had the ability to access the hot water. 11. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of Alzheimer's, Diabetes, and Dementia. Review of the quarterly MDS dated [DATE], revealed Resident #48 had a BIMS score of 6, which indicated the resident was severely cognitively impaired, required assist of one for personal hygiene, and independently used a wheelchair for locomotion/mobility. Observation on 6/26/2023 at 3:06 PM, revealed Resident #48 propelled herself in a wheel chair in the facility hallway. Resident #48 had wandering behaviors, resided in a room with the dangerously hot water, and had the ability to access the hot water. 12. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE], with diagnoses of Peripheral Vascular Disease, Below Left Knee Amputation, Dementia, Schizoaffective Disorder, and Anxiety. Review of the quarterly MDS dated [DATE], revealed Resident #67 had BIMS score of 15, which indicated the resident was cognitively intact, required limited assistance with transfers and independent with locomotion. Observation on 6/26/2023 at 1:10 PM, revealed Resident #67 sitting in a wheelchair in his room. The resident resided in a room with the dangerously hot water and had the ability to access the hot water. 13. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE], with diagnoses of End Stage Renal Disease, Schizophrenia, Dysphagia, and Atherosclerotic Heart Disease. Review of the quarterly MDS dated [DATE], revealed Resident #72 had a BIMS score of 13 which indicated the resident was cognitively intact, required supervision with one person assist with transfers, and was independent with walking in room. Observation on 6/28/2023 at 2:18 PM, revealed Resident #72 sitting in a wheelchair in the dining room. The resident resided in a room with the dangerously hot water and had the ability to access the hot water. 14. Review of the medical record revealed Resident #241 was admitted to the facility on [DATE], with diagnoses of Diabetes Mellitus, Congestive Heart Failure, Dysphagia, and Acute Kidney Failure. Resident #241's admission MDS was currently in progress at the time of the survey. Observation on 6/26/2023 at 2:42 PM, revealed Resident #241 was sitting in a wheelchair in her room. The resident resided in a room with the dangerously hot water and had the ability to access the hot water. 15. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], was readmitted on [DATE], with diagnosis of Diabetes, Dementia, and Bilateral Cataract. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #3 was severely impaired for daily decision making, required one person assist for transfers was totally dependent upon staff for showers, and independently wheeled self in wheelchair. Resident #3 had wandering behaviors and had the ability to access the rooms identified with the dangerously hot water. 16. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE], with diagnoses of Psychosis, Anxiety, Insomnia, Bipolar Disorder, and Muscle Weakness. Review of the quarterly MDS dated [DATE] revealed Resident #18 was assessed with a BIMS score of 5, which indicated the resident was severely cognitively impaired, independent with walking in room. Observation on 6/29/23 at 12:18 PM, revealed Resident #18 self-ambulating on the 200 Hall, stopping and peering into other resident's rooms. Resident #18 had wandering behaviors and had the ability to access the rooms identified with the dangerously hot water. 17. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE], with diagnoses of Atrial Fibrillation, Aphasia, Diabetes Mellitus, Adult Failure to Thrive, Alzheimer's Disease, and Psychotic Disorder with Delusions. Review of the annual MDS dated [DATE], revealed Resident #30 had a BIMS score of 5, which indicated the resident was severely cognitively impaired, and required extensive assistance from staff for ADLs and was independent with locomotion in room. Resident #30 had wandering behaviors and had the ability to access the rooms identified with the dangerously hot water. 18. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE], with diagnosis of Cerebral Infarction, Hypertension, Cocaine Abuse, and Major Depressive Disorder. Review of the annual MDS dated [DATE], revealed Resident #53 had a BIMS score of 10, which indicated the resident was moderately cognitively impaired, required supervision with transfers, independent with set up for locomotion in the room, required extensive assistance with personal hygiene. Resident #53 had wandering behaviors and had the ability to access the rooms identified with the dangerously hot water. 19. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE], with diagnoses of Schizophrenia, Traumatic Brain Injury, Bipolar Disorder, Insomnia, Anxiety, and Dementia. Review of the quarterly MDS dated [DATE], revealed Resident #57 had a BIMS score of 12, which indicated the resident was moderately cognitively impaired, required supervision for walking in room, and required a wheelchair for mobility. Resident #57 had wandering behaviors and had the ability to access the rooms identified with the dangerously hot water. 20. Review of the medical record revealed Resident #65 was admitted to the facility on [DATE], with diagnoses of Dementia, Anxiety, Dysphagia, and Insomnia. Review of the quarterly MDS dated [DATE], revealed Resident #65 had a BIMS score of 6, which indicated the resident was severely cognitively impaired, required limited assistance with transfers, and was independent up in a wheelchair. Resident #65 had wandering behaviors and had the ability to access the rooms identified with the dangerously hot water. 21. Review of the medical record revealed Resident #66 was admitted to the facility on [DATE], with diagnosis of Cerebrovascular Disease, Vascular Dementia, Hypertension, and Anxiety. Review of the admission MDS dated [DATE], revealed a BIMS score of 8 which indicated the resident was moderately cognitively impaired, required limited assistance with transfers, and supervision to walk in her room. Resident #66 had wandering behaviors and had the ability to access the rooms identified with the dangerously hot water. 22. Review of the medical record revealed Resident #69 was admitted to the facility on [DATE], with diagnoses of Dementia, Congestive Heart Failure, Atrial Fibrillation, and Anxiety. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 9, which indicated resident was moderately cognitively impaired, required extensive assistance with two persons assist for transfers and independent with set up for locomotion in room. Observation on 6/26/2023 at 2:44 PM, revealed Resident #69 sitting in a wheelchair in the dining room. Resident #69 had wandering behaviors and had the ability to access the rooms identified with the dangerously hot water. 23. Review of the medical record revealed the Resident #71 was admitted to the facility on [DATE], with a diagnoses of Psychosis, Schizophrenia, Dysphagia, Cognitive Communication Deficit, Muscle Weakness, and Insomnia. Review of the quarterly MDS dated [DATE], revealed Resident #71 had a BIMS score of 7, which indicated the resident was severely cognitively impaired, required extensive assistance for transfers, and was independent with set up for locomotion in his room. Observation on 6/28/2023 at 12:45 PM, revealed Resident #71 self-propelling in a wheelchair in the hallway by the nurses desk and down to the vending machine. Resident #71 had wandering behaviors and had the ability to access the rooms identified with the dangerously hot water. 24. Review of the medical record revealed Resident #76 was admitted to the facility on [DATE], with diagnoses of Diabetes Mellitus, Peripheral Vascular Disease, Schizophrenia, Seizures and Anxiety. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 8, which indicated the resident was moderately cognitively impaired, required extensive assistance for transfers, and was independent for locomotion. Observation on 6/26/2023 at 12:55 PM, revealed Resident #76 was dressed and sitting in wheelchair in her room. Resident #76 had wandering behaviors and had the ability to access the rooms identified with the dangerously hot water. 25. During an interview on 6/26/2023 at 4:23 PM, the Director of Maintenance was asked if they kept a log of the residents' rooms checked. The Director of Maintenance stated, I do not, I check them randomly. The Director of Maintenance was asked when he first started who told you what the water temperature for residents should be. The Director of Maintenance stated, I cannot remember exactly who it was .I myself think the tankless units are set too high .I begged them to let me turn it down .I was told the ranges were set to where they needed to be. The Director of Maintenance who not say who them were. When asked what the water temperatures should be in resident rooms, the Maintenance Director stated, I would like it myself to be around 105-120, scalding water is at 120. The Director of Maintenance asked .Can you tell me what the regulation water temperature is? . During an interview on 6/26/2023 at 4:53 PM, the Administrator confirmed the Director of Maintenance had one week of training, maintenance background, but not a long-term care background. The Administrator confirmed maintenance should be checking the water temperatures in all areas including resident's rooms and documenting the results. The Administrator confirmed she has not reviewed water temperature logs from the Maintenance department, and stated the water temperatures should be 105 F-120 F. The Administrator confirmed she is responsible for ensuring the Director of Maintenance is following state and federal regulations. The Administrator was asked if water temperatures of 124 F and 130 F degrees was acceptable. The Administrator stated, No Ma'am. During an interview on 6/26/2023 at 5:00 PM, the Director of Maintenance confirmed there were no documented water temperature logs for resident rooms. The Director of Maintenance was asked if he checked the residents' rooms for water temperatures. The Director of Maintenance stated, Yes. The Director of Maintenance was asked where he logs this information. I don't . During an interview on 6/28/2023 at 2:21 PM, the Master Plumber of [Named Company] was asked what temperature should the tankless water heaters be set. The Master Plumber stated, All installed water heaters are installed at 140 [degrees F], then the nursing home should adjust them to what they need. During an interview on 7/3/2023 at 2:35 PM, the [NAME] President (VP) of Clinical Services confirmed the Director of Maintenance failed to document the water temperatures in the logbook. During an interview on 7/5/2023 at 4:28 PM, with the Administrator, VP of Clinical Services, and the Director of Nursing (DON) all confirmed the water temperatures had the potential to affect all the residents (Residents #15, #17, #23, #24, #27, #48, #67, #72, and #241) that were cognitively and/or physically impaired and resided in the affected rooms, along with (Residents #3, #18, #30, #48, #53, #57, #65, #66, #69, #71, and #76) who were wandering residents and had the mobile ability to wander into the affected rooms. During an interview on 7/5/2023 at 5:14 PM, the Director of Maintenance confirmed the water temperature in rooms were elevated and not within regulation. He confirmed he knew the temperatures were high, but he was told the leave it like it was. He confirmed he now knows what the regulation water temperature should be. The Facility's IJ removal plan, received on 7/3/2023 at 10:31 AM, was validated onsite 7/3/2023 - 7/5/2023 through policy reviews, review of temperature logs, review of education, sign-in sheets, observations, and interviews as follows: 6/28/23, a root cause analysis was completed. From the root cause analysis, a concern was identified that required an action plan to correct deficient practices that included the immediate return visit of (Name of Plumbing, Air and Electric Company) on 6/27/23 and 6/28/23. From this assessment, it was recommended that the preventative maintenance needed to be conducted annually which would include descaling and flushing of the tankless water systems. 6/29/23, water temperatures are obtained and documented throughout the facility twice daily. Water temperatures remain and are within state and federal regulatory guidelines since 6/28/23. 6/29/23, the root cause analysis was presented to the Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee. The Administrator, Chief Clinical Operations (CCO), Medical Director and Regional Director of Clinical Operations, Maintenance Director and QAPI Committee for discussion of identified issue, interventions, and immediate resolution. The following actions were recommended by the QAPI committee. The policy for Safety of Water Temperatures was reviewed by the Administrator, Chief Clinical Operations, Medical Director, and Regional Director of Clinical Operations, with no revisions made. Reviewed the new hire on-boarding trainings with the Maintenance Director that were conducted on 5/1/23, by the Regional Director Clinical Operations in attendance virtually with the Administrator, Maintenance Director and Regional Director of Clinical Operations. Areas in-serviced and materials reviewed during this training consisted of . Facility software Preventative and Daily Maintenance Program including safe temperatures for water and water . Emergency Preparedness (generator, disaster drills and risk assessment) . on 4/25/23 - 4/26/23 with a tenured Maintenance Director that included time management, use of computer software, processes for notifying contractors, i.e. electricians, plumbers, ect . 6/29/23, Administrator re-educated the Maintenance Director on regulatory guidelines related to hot water temperatures in the nursing home setting. Topics reviewed with return verbalization consist of frequency of temperature monitoring, recording and trouble shooting. 6/29/23- Maintenance Director in-serviced all Department Heads how to obtain water temperature readings, recording temperatures correctly, and actions to take for unsafe temperatures. A return demonstration was approved by the Maintenance Director and Administrator to validate skill performance during in-service meetings. Plumber was on site on 6/30/2023, and completed the manufacture recommended preventative maintenance which consisted of diagnosing tankless water heaters through tech support. Reset number 2 tankless water heater through tech support and is now operational. Possible contributing factors also reviewed were that the facility was unable to locate annual preventative maintenance of tankless water heater. 6/30/23- Facility Maintenance Director obtained the manufacturer's manual (Rinnai) that included preventative maintenance, upkeep and appropriate temperatures for the tankless water system. The tankless water heaters are factory pre-set at 140 degrees Fahrenheit and adjusted to 120 degrees Fahrenheit at the facility (to ensure water at resident site is not greater than 115 degrees F). It is recommended temperatures are monitored due to water flow distribution of tankless water systems. 6/30/23- Representative with Name of Plumbing Air and Electric Company completed the tankless water heating training with the Maintenance Director. Training conducted on 6/30/23 consisted of basic preventative maintenance, flushing, trouble shooting and descaling techniques along with hands on demonstration with return verbal and demonstration performance conducted by the representative. Additional, trainings recommended by the representative including a (4) hour training program with the named Tankless Water System representative in the future. Attempted to schedule training for the Maintenance Director, and messages have been left for the person who does the training for [NAME] Plumbing Air and Electric. The Maintenance Director will check the six tankless water heaters twice weekly (Tuesdays and Fridays) and record water temperature settings and documented in a log maintained in a binder to be in the Administrator's office. The Maintenance Director on 6/27/23 initiated monitoring and documenting water temperature readings at least twice daily (in the morning and evening hours) for the original 10 resident rooms and East Wing Shower Room that were discovered in non-compliant range on 6/29/23. Temperature logs were placed above each sink in resident rooms, visitor bathrooms, soiled utility rooms, shower rooms, medication rooms, rehab gym, nutrition kitchens, and oxygen storage rooms. All rooms will be checked twice daily beginning 6/30/23 by a dedicated staff member until July 31, 2023, between the hours of 7:00 am to 11:00 am and 1:00 pm to 5:00 pm seven days per week. Facility guidance for water temperature duties will consist of: After 7/31/2023, temperature recordings will return to the regular preventative maintenance schedule. All obtained temperatures will be documented on a temperature log for all rooms listed above until 7/31/2023. temperatures outside of the required range (105 degrees F - 115 degrees F). If unacceptable range is detected, Administrator is to be notified immediately, and the staff member is to remain at the sink until water is shut off and Maintenance is present. The dedicated staff member will be responsible for removing and replacing the daily log forms, and these logs will be kept in a binder and maintained by the Administrator. The logs will be reviewed Monday-Friday by the Administrator and Saturday and Sunday by the Manager on Duty. All managers have been trained on how to use the temperature probe to obtain water temperature readings and the action to take if temperatures are found to be out of acceptable range. If unacceptable range is detected, Administrator is to be notified immediately and the staff member is to remain at the sink until water is shut off and Maintenance is present. 6/29/23, Treatment Nurse performed skin assessments for all residents in room [ROOM NUMBER], #110, #111, #112, #115, #119, #126, #129, #200, #210 identified as rooms with unsafe water temperatures on 6/26/23. No new skin concerns were identified. Skin Assessments are documented in the resident's medical records. The Medical Director reviewed skin assessments completed 6/29/23 on residents identified in rooms with unsafe water temperatures on 6/26/23 and updated the progress notes accordingly. No new skin concerns were identified. Progress notes are documented in the resident's medical records. On 6/27-6/29/23, The Staff Development Coordinator began education for all staff regarding actions to take if water temperatures are discovered in an unsafe range below 105 degrees Fahrenheit and above 115 degrees Fahrenheit. If unacceptable range is detected, the Administrator is to be notified immediately and the staff member is to remain at the sink until water is shut off and Maintenance is present. As of 6/29/23, the SDC, in-serviced 95 of 110 all staff regarding actions to take if water temps are discovered in an unsafe range. Those not in-serviced will not be placed on the schedule and/or will not be allowed to return to work until in-services are completed. 6/29/23, Cliniconex (system that provides automated messaging for families) utilized for family notification and Onshift (system that provides automated messaging for staff ) utilized for staff notification for actions to take if water temps are an unsafe range. Census for today is 90 and 90 families were contacted through our system. The Administrator will review all temperature readings Monday-Friday and the temperature readings from the weekend will be reviewed by the Administrator on Monday. This information will be discussed during morning stand-up meetings until July 31, 2023. Beginning August 1, 2023 water temperatures will be monitored according to regular preventative maintenance schedule which is once daily, two locations. Administrator will review water temperature documentation daily x two weeks, weekly x two weeks and monthly x four months. All findings will be brought to the monthly QA committee for review. Monitoring will continuing until Administrator has stated compliance has been achieved.

Based on policy review, job description review, Quality Assurance Performance Improvement (QAPI) Root Cause Analysis (RCA) Worksheet, and interview, Administration failed to provide oversight to ensure systems and processes were developed and consistently followed, failed to provide oversight of nursing staff, failed to identify the root cause for incidents identified in the facility, and failed to ensure systems and processes were developed and consistently followed by facility staff. Administration failed to provide oversight that established and implemented policies and procedures to ensure a safe and secure environment when Resident #2 a exited the facility unsupervised and without staff knowledge, got in the security guard's vehicle, and was left unsupervised in the vehicle while the security guard entered the facility to notify facility staff. The facility failed to conduct a thorough investigation of incidents and obtain statements from all direct care staff. Administration failed to ensure an incident report was completed when Resident #2 exited the facility unsupervised and without staff knowledge. Administration failed to investigate an incident of Resident #1 a confused, vulnerable resident that was found in a locked lobby bathroom for an undetermined amount of time. These failures resulted in Immediate Jeopardy for Resident #2 and Resident #1. The Administration's failure to ensure a safe environment resulted in Immediate Jeopardy (IJ) when the front entrance/exit door push pressure emergency opening was reprogrammed from 15 seconds to 50 seconds, having the potential to affect all residents and facility staff. Reprograming the emergency delayed release (door exit bar) greater than 30 seconds without prior authorization is in violation of Life Safety Codes National Fire Protection Association. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Director of Nursing (DON), and the Chief Operating Officer (COO) by phone, were notified of the Immediate Jeopardy (IJ) for F-610 on 10/13/2022 at 5:10 PM. The Administrator, the Director of Nursing (DON) and the Chief Operating Officer (COO) by phone, were notified of the Immediate Jeopardy (IJ) for F-689 on 10/13/2022 at 5:10 PM. The Administrator, the Director of Nursing (DON), and the Chief Operating Officer (COO) by phone, were notified of the Immediate Jeopardy (IJ) for F-835 on 10/13/2022 at 5:10 PM. The facility was cited Immediate Jeopardy at F-610, F-689, and F-835. The facility was cited at F-610 and F-689 at a scope and severity of J which is Substandard Quality of Care. The Immediate Jeopardy existed from 9/13/2022 and is ongoing. The findings include: The facility's signed Administrator job description date of 9/4/2022, revealed .Administration .The primary purpose of your job is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality of care can be provided to our residents at all times .you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties .Ensure that all employees, residents, visitors and the general public follow the facility's established policies and procedures .make written and oral reports/recommendations to the governing board concerning the operation of the facility .Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed .Assume the administrative authority, responsibility and accountability of directing the activities and programs of the facility .Serve on various committees of the facility .Quality Assurance [QA] .and provide written/oral reports .to the governing board as directed .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies .Consult with department directors concerning the operation of their department to assist in eliminating/correcting problem areas, and/or improvement of services .Ensure that an adequate number of appropriately trained licensed professional and non-licensed personnel are on duty at all times to meet the needs of the residents .Ensure that appropriate staffing level information is posted on a daily basis .Schedule and participate in departmental meetings to ensure that appropriate information sharing is provided on a continuous basis .Inform the Medical Director of all suspected or known incidents of resident abuse .assure the facility is maintained in a clean, safe and sanitary manner .Ensure that the facility is maintained in a clean and safe manner for resident comfort and convenience . The facility's signed Director of Nursing job description dated 9/7/2022, revealed, .The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times .you are delegated that administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. In the absence of the Medical Director, you are charged with carrying out the resident care policies established by this facility .Plan, develop, organize, implement, evaluate, and direct the nursing service department .in accordance with current rules, regulations, and guidelines that govern the nursing care facilities .Make written and oral reports/recommendations to the Administrator, as necessary/required concerning the operation of the nursing service department .Develop, implement, and maintain an ongoing quality assurance program for the nursing service department .Assist the Quality Assessment & Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies . The facility's QAPI RCA WORKSHEET dated 10/3/2022 documented .Front/entry push pressure emergency opening reprogramed to 50 seconds from 15 seconds 10.3.2022 . During an interview with the Interim Administrator during an entrance conference on 9/16/2022 at 9:30 AM, The Interim Administrator was asked if there was any elopements, Dr. Finds or any incidents that should be looked at by the State Agency since the survey exit date on 8/30/2022. The Interim Administrator stated, .no . During an interview on 10/6/2022 at 3:19 PM, with the Maintenance Director and Interim Administrator. The Maintenance Director stated .egress time is still 50 seconds changed that Monday [10/3] . Maintenance Director was asked if front door exit alarm could be heard at both nursing stations. The Maintenance Director stated .depends on where you are in the facility as to whether you can hear the alarms or not . The Interim Administrator stated, .it's that 15 second egress on that door . The Maintenance Director was asked was if the time was reset on the front entrance exit door from 15 seconds to 50 seconds. The Maintenance Director and Interim Administrator looked at each other when the Maintenance Director stated .no it wasn't changed . The Administrator stated .I might have made a typo [mistake typing], I will change that on the summary if that's okay .I have sent paperwork in, but I haven't heard from them yet . During an interview on 10/6/2022 at 4:30 PM, the Interim Administrator was asked why the front entrance door did not open in 15 seconds when the door was tested by the surveyor. The Interim Administrator stated, .I don't know .please .we have worked so hard to get this place back in shape .trying to get the facility new doors that will be locked all the time 24/7 . The Interim Administrator acknowledged the door release was greater than 1 minute and did not open and did not alarm in 15 seconds. During an interview on 9/28/2022 at 10:30 AM, the Interim Administrator confirmed there was no reportable incidents or investigations to be reviewed by the State Agency. During an interview on 9/28/2022 at 12:40 PM, with the Interim Administrator, the Interim DON and the DON, the DON stated, .there was an incident of a missing resident being found in the lobby bathroom of the facility .there were no concerns because the resident was only gone 5 or 10 minutes before she was found . During an interview on 9/28/2022 at 1:15 pm, the Interim Administrator confirmed there were no incidents of a missing resident to report. During an interview on 10/7/2022 at 1:51 PM, the DON stated, .the psychiatric NP said something else was going on with [Resident #1] .uncertain if she would be able to use the call light, she was confused that night when they found her . During an interview on 10/13/2022 at 11:05 AM, the Administrator confirmed incidents should be thoroughly investigated. During the exit conference on 10/13/2022 at beginning at 5:10 PM the COO (who was present via telephone) stated, .it was reported to me that the wander guard door monitor was malfunctioning .the delayed egress was changed from 15 seconds to 50 seconds . Refer to F-610 and F-689.

Based on policy review, facility investigation review, Quality Assurance and Performance Improvement (QAPI) Root Cause Analysis (RCA) Worksheet review, Life Safety Code, medical record review, observation, and interview, the facility failed to ensure appropriate supervision and a safe environment to prevent an incident of elopement for 1 of 5 (Resident #2) sampled residents reviewed for elopement and wandering behaviors. The facility failed to provide adequate supervision for a safe environment to prevent a missing resident incidents for 1 of 6 (Resident #1) sampled residents reviewed for incidents. The facility failed to ensure a safe environment that had the potential to affect all staff and all residents by re-programming the front entrance/exit door emergency delay egress (door exit bar) from 15 seconds to 50 seconds. The facility's failure to ensure a safe environment to prevent elopements resulted in Immediate Jeopardy (IJ) when Resident #2 a vulnerable cognitively impaired resident at risk for elopement and wandering was left unsupervised in the front lobby, exited the facility without authorization or staff supervision through the facility's front door. Resident #2 was discovered approximately 44 feet from the front door, sitting in a security guard truck. The facility's staff was unaware Resident #2 had exited the building until a security guard went back into the building to notify the staff, leaving Resident #2 in the truck unattended and unsupervised. Resident #2 was wearing a wander guard bracelet (a monitoring device to alert staff of a resident attempting to exit the facility unattended), exited the facility without authorization or staff supervision by applying pressure to the front entrance/exit door until it opened. The facility's failure to ensure appropriate supervision and a safe environment resulted in Immediate Jeopardy (IJ) when Resident #1, a vulnerable cognitively impaired resident was missing for an undetermined amount of time and was later found in a locked lobby bathroom. The facility's failure to ensure a safe environment resulted in Immediate Jeopardy (IJ) when the front entrance/exit door push pressure emergency opening was reprogrammed from the approved 15 seconds to an unapproved 50 seconds, this had the potential to affect all staff and residents. Reprograming a delayed release (door exit bar) from greater than 30 seconds without prior approval is a violation of Life Safety Codes National Fire Protection Association (NFPA )101, 19.2.2.2.4 (2) 2012 Edition and NFPA 101, 7.2.1.6.1.1 (3) 2012 Edition. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON) and Chief Operating Officer (COO) were notified of the Immediate Jeopardy on 10/13/2022 at 5:10 PM. The facility was cited Immediate Jeopardy at F-689. The facility was cited F-689 at a scope and severity of J which is Substandard Quality of Care. The IJ existed 9/13/2022 and is ongoing. The findings include: 1. Review of the facility's policy titled, Abuse Prevention Policy, revised 3/1/2018, revealed .the resident has a right to a safe .environment . Review of the facility's policy titled, ELOPEMENT OF RESIDENT POLICY, dated August 2017, revealed .It is standard of this Health Care center that appropriate procedures exists in the case of a missing resident .Determine time and location when last seen .The Charge Nurse will complete an Incident report .the Administrator /director of Nurses Services will notify the Department of Health per State Regulations .If an elopement occurs, a monitoring schedule will be implemented to ensure resident's safety . Review of the facility's policy titled, Alarms Policy, dated September 1, 2018, revealed, .An alarm is any physical device or electronic device that monitors resident movement and alerts the staff by either audible or inaudible means, when movement is detected and may include .door alarms, or elopement/wandering devices .alarms do not replace necessary supervision .Wander/Elopement alarms include such devices as bracelets .building/unit exit sensors worn or attached to the resident that alert the staff when the resident nears or exits the building . Review of the facility's policy titled, ACCIDENTS AND INCIDENTS-INVESTIGATING AND REPORTING, reviewed/revised November 2021, revealed, .All accidents and incidents involving residents .occurring on our premises shall be investigated .The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident .The following .shall be included on the Report of Incident/Accident form .the date and time the accident or incident took place . Review of the facility's UNSAFE WANDERING-ELOPEMENT RISK POLICY, reviewed November 25, 2021, revealed .every effort will be made to prevent unsafe wandering episodes .should an elopement episode occur, an incident report will be completed providing explanation of how the event occurred and contributing factors . Review of the Life Safety Codes NFPA 101, 19.2.2.2.4 (2) (2012 Edition), NFPA 101, 7.2.1.6.1.1 (3) (2012 Edition) documented an irreversible process shall release the lock in the direction of egress within 15 seconds or 30 seconds where approved by the authority having jurisdiction. 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of Dementia, Hypertension, Anxiety, Major Depressive Disorder, Insomnia, Lack of Coordination and Unsteadiness on Feet. Review of the care plan dated 7/27/2022, revealed Resident #2 is an elopement risk/wanderer with a history of attempts to leave the facility unattended, impaired safety awareness with the updated intervention on 10/2/2022 (after the resident eloped), one (1) on one (1) at this time, monitor location every shift, maintain wander guard bracelet per MD (Medical Doctor) orders, and check wander guard placement every shift. Review of a Physician's order dated 8/31/2022 revealed, wander guard due to exhibiting elopement behaviors, check placement of wander guard every shift, if not intact replace, and document in progress note every shift. Review of the Minimum Data Set (MDS) dated [DATE], revealed Resident #2 was assessed with a Brief Interview for Mental Status (BIMS) score of 4, indicating she was severely cognitively impaired, required limited assessment to extensive assistance with ADL's, always incontinent of bowel and bladder and uses wheelchair for mobility. Review of the Elopement Evaluation dated 10/2/2022, revealed risk for elopement score of 3, which indicated Resident #2 exhibits wandering behavior, has a pattern, and is goal directed, utilizes exit alarm (wander guard). Review of a Nurses Notes dated 10/2/2022 documented .Resident being observed being escorted to room .resident was found outside in the security guard's truck .resident walked to the security's guard truck and ask for a ride home .security guard reported he had resident sitting in front seat of truck . Review of the facility's timeline summary and investigation dated 10/2/2022 revealed, .10/2/2022 .[Resident #2] sitting at front lobby screening table with [Resident #6] .[Resident #2] rolls wheelchair to front lobby entry/exit .stands up at the front door entry exit and begins rocking and attempting to force the door nearest to the temperature machine open .5:12pm [Resident #2] exits the facility front/exit door and walks directly to the security officer's gray pick-up truck and sits in the passenger side of the truck .5:16 Security Guard enters facility using keypad to enter code for door access to alert staff for assistance .5:19pm [Resident #2] is escorted back in facility with staff .6:00pm Maintenance Director notified .8:17pm Maintenance Director Notified the Administrator that all doors/wander guards are working properly .10/3/2022 at 11:00am-Administrator and Maintenance Director (programed) 15 second release function was changed to 50 second release function (exit bar) . Review of the QAPI Root cause analysis dated 10/3/2022 revealed, .Root Cause Analysis .Why .doors automatically open after 15seconds of push pressure .Why resident BIMS 4, elopement risk and even though cognitive impairment resident was able to push on door to open .instructions to Coaches .elopement and wandering procedures for identifying, reporting and interventions . Observation on 10/6/22 at 4:17 PM revealed, the Maintenance Director and surveyor measured distance from the door threshold to the passenger side of the security guards' truck passenger side was 44 feet. The distance from the passenger side of the truck to a street by the facility, a busy and highly traveled street, measured 75 feet. During an telephone interview on 10/5/2022 at 4:15 PM, CNA #3 stated, .I am agency staff and I worked a double that day .I left to go on break .[Resident #2] was sitting at the front entrance near the entrance door beside where they take temperatures .I went out the door she was still sitting there .when I came back from across the street staff was outside at the security guard's truck taking her back in the facility .I have worked with her before .I knew she was a wanderer .I told the nurse earlier that day [Resident #2's] wander guard bracelet was on the wheelchair .the nurse looked at me as if I didn't need to say anything and the nurse didn't do anything about it . During an interview on 10/5/2022 at 4:55 PM, the Security Guard stated, .she [Resident #2] was pushing on the entrance door to get out, the door opened, and came to the truck and said I want you to take me home. I told her to hop in .she got in the truck, put the seat belt on and I locked the truck .the front windows were down .told her I was going to tell the nurses I was going to take her home .went in the building to get assistance and they came and got her . During an interview on 10/6/22 at 3:19 PM, the Interim Administrator stated, .she got up from the wheelchair .pushed on the door and it opened .went straight to the security guard's truck that was parked at the front entrance .got in on the passenger side .security guard secured her in the truck with the seat belt .security guard came in the building about 3-minutes .he [Security Guard] returned to the truck .3 staff came out and brought the resident back in .she was not unsupervised because he was with her . The Interim Administrator was asked if the security guard a facility staff member. The Interim Administrator stated, .no, he is contracted .no, he is not our staff . The Interim Administrator confirmed Resident #2 was unsupervised while the security guard went into the building to get assistance. The Interim Administrator stated .yes .but it was only a few minutes . The Interim Administrator confirmed Resident #2 was sitting in the lobby unsupervised and staff were unaware. The Interim Administrator confirmed Resident #6 (at risk for wandering, elopement, and had a wander guard) was in the lobby unsupervised and staff were unaware. The Interim Administrator stated, .yes, the other resident [Resident #6] sitting in the lobby near the receptionist window, then she left the area leaving [Resident #2] sitting by the temperature stand at the table near the front entrance door .no staff was in the lobby . The Interim Administrator was asked if facility staff were aware that Resident #2 and Resident #6 were at risk for wandering, elopement and had a wander guard. The Interim Administrator stated, .yes, and staff did not take [Resident #2] back to her room .no .this is their home and it's their right to sit in the lobby and watch TV . The Interim Administrator was asked should 2 wandering elopement risk residents wearing wander guards be sitting in the lobby unsupervised and without staff. The Interim Administrator did not answer. During a telephone interview on 10/7/2022 at 1:30 PM, CNA #4 stated .I am agency staff .have only worked at facility a few times .My assignment was changed an hour and half into the shift .did not get report from anyone .I checked my room assignment and [Resident #2] was not in the bed or room .I assumed she was gone to the hospital .did not see [Resident #2] until she was being escorted to her room .the nurse informed me that was [Resident #2] was my resident. I took her in her room and to the bathroom, it was around supper time .Did not get any orientation or information about [Resident #2] or any other residents being wanderers .I did not provide 1 to 1 observation after the incident. I did not provide 15-30 minutes checks for [Resident #2] .I checked on during my rounds that night but not 15-30-minute checks .no one told me to do any safety checks .I left when shift ended .I did not write a statement, and none has called me from the facility about writing a statement . During an interview on 10/5/2022 at 4:15 PM revealed the Interim Administrator stated she reviewed the video footage for Resident #2's elopement but stated she did not save the video as part of an investigation. The Interim Administrator provided the survey team with a documented timeline based on her recollection of the video. The facility was unable to provide the team with video footage of the incident. During the exit conference on 10/13/2022 beginning at 5:10 PM, The COO (who was present via telephone) stated .It was reported to me that the wander guard door monitor on the door was malfunctioning .the delayed egress was changed from 15 seconds to 50 seconds . The facility failed to conduct a thorough investigation that identified the root cause(s) for Resident #2's elopement, failed to preserve sources of information obtained, and failed to implement interventions to provide a safe and secure environment for all residents. The facility failed to ensure facility staff and contract agency staff were knowledgeable of the residents' needs and could demonstrate the monitoring and supervision required for wandering residents with an elopement risk. 3. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Schizophrenia, Dementia, Traumatic Brain Injury, and Anxiety. Review of the care plan revised 6/22/2022, revealed Resident #1 has an Activities of Daily Living (ADL) self-care performance deficit that requires cues, encouragement, and supervision related to Dementia and delusions. The interventions included supervision/assistance with all decision making. Resident #1 has impaired cognitive function and impaired thought processes related to dementia. Resident #1 had communication problems related to a head injury and is usually understood, usually understands, and has delusions. Interventions included ensure/provide a safe environment avoid isolation. Review of a BIMS assessment completed on 8/22/2022, revealed Resident #1 was assessed with a BIMS of 4 indicating severe cognitive impairment for daily decision making. Review of the quarterly MDS dated [DATE], revealed a staff assessment of mental status Resident #1 had modified independence with difficulty in new situation. Resident #1 was independent for dressing, requires supervision for locomotion on and off the unit, eating and personal hygiene. Resident #1 required extensive one person assistance for bed mobility, transfer, and toilet use. Resident #1 was occasionally incontinent of urine and frequently incontinent of bowel. Review of the nurses progress note Draft dated 9/14/2022 documented, .1220 [AM] during 1st round staff was alert by CNA [Certified Nurse Assistant], Resident was not in her bed or bathroom. Staff directed to look for resident while this nurse searched West 1 [unit] after 5-10 minutes of direct searching Dr. Find [emergency code called for a missing resident] was call overhead AT 12:20 [AM], Staff continued to search. Approx. [approximately] 5 min [minutes] after Dr. Find was announced, Resident was located by [Licensed Practical Nurse (LPN) #1] in the employee bathroom in the Front Lobby @ [at] 12:30 [AM] .with noted confusion . Review of an elopement risk assessment dated [DATE] revealed Resident #1 was not assessed at risk for elopement. Review of a Psychiatric Nurse Practitioner progress note dated 9/15/2022 revealed, .asked to see ahead of scheduled visit due to new problem. Staff reports she wandered off unit .could not be found for some time . found .in employee bathroom .says she went in to use the bathroom and could not get the door open .3 [NAME] Carters locked me in .poor grip on reality and incorporates delusional fantasy world into everyday interactions .delusional ideas are expressed .reasoning is illogical .associations are loose .insight into problems appears to be poor . Observation on 9/28/2022 at 10:54 AM revealed, the lobby bathroom door is unlocked, a call light is located on the wall to the right of the toilet, the bathroom door has lever with a push button lock on the inside of the bathroom. Observation on 10/4/2022 at 4:59 PM, the lobby bathroom door is locked, appears to be a new lever handle on the door, a key is hanging on the door approximately 6 feet to the right of the door with sign below the key with instructions to use key to enter the bathroom. On the inside of the bathroom another sign instructing to return the key to the hook outside the door. Call light noted on the wall beside commode. Observation on 10/06/2022 at 12:33 PM, revealed the front entrance exit door did not open or alarm when constant pressure was applied for over 60 seconds. Observation on 10/6/2022 at 4:09 PM, revealed one side of front entrance exit door did not open or alarm when constant pressure was applied for over 50 seconds. The observation was verified by the Maintenance Director and the Administrator. During an Allegation of Compliance (AoC) validation revisit on 9/16/2022 to remove Immediate Jeopardy from the previous 8/30/2022 recertification survey an entrance conference interview was conducted with the Interim Administrator. On 9/16/2022 at 9:30 AM, The Interim Administrator was asked if there were any elopements, Dr. Find for missing resident, or any incidents since the exit on 8/30/2022. The Interim Administrator stated, .no . During an interview on 10/6/2022 at 3:19 PM, the [Interim] Administrator and Maintenance Director was asked if the front exit entry door push pressure emergency opening was reprogrammed from 15 seconds to 50 seconds. The [Interim]Administrator stated, .that was a typo .can I change that . The Maintenance Director stated, .no .it was not changed . During an interview on 10/6/2022 at 4:17 PM, the Maintenance Director confirmed the front exit entry door push pressure emergency opening was reprogrammed from 15 seconds to 50 seconds. During a telephone interview on 9/29/2022 at 10:03 AM, CNA #5 stated, .I don't remember anything about that resident or her being missing. CNA #5 was asked if she was Resident #1's CNA that night. CNA #5 stated, .yes, I worked 3p-11p that night . During a telephone interview on 9/29/2022 at 10:23 AM, LPN #4 stated, .I was at the med cart the aide [CNA #1] came and asked if we knew where [Resident #1] was .Resident #1's dinner tray was in the room and hadn't been touched .everyone looked around on the unit for about 5 minutes .called a Dr. Find (code for a missing resident) looked about 5-10 more minutes .[LPN #1] found her in the employee bathroom up front [by dining room] .since her tray wasn't touched we didn't know how long she'd been gone .she normally eats .she said herself she was gone a while . During a telephone interview on 9/29/2022 at 2:09 PM the housekeeping supervisor, stated, .yes I was working came in around 8 pm that night to strip the floors .ladies bathroom [lobby] was locked, it's normally unlocked .after shift change (11:00 PM shift change) staff was looking for a resident .I told them the bathroom door .had been locked for a while told them to check in there .I didn't see anyone going in and out of the bathroom .I had checked it several times that evening and it was locked .knocked but no one would answer .saw the staff looking for someone .they went in the bathroom a female resident was in there .I was not interviewed about it until you called today . During a telephone interview on 9/29/2022 at 2:58 PM, housekeeping staff #1 stated, .got to work about 9:00 PM .we were stripping and waxing the floors in the area around the restrooms [across from dining room] .tried to get into the women's bathroom to do the floor but the door was locked .knocked but there wasn't an answer .tried several times .about 12 or so the staff said a resident was missing .my supervisor told them to check that bathroom .the resident was in there and they brought her out . During a telephone interview on 9/29/2022 at 4:00 PM, housekeeping staff #2 stated, .yes worked the night they were looking for a resident .told them to look in the ladies bathroom (by the dining room) .it had been locked a while .she [Resident #1] was in there they brought her out . During a telephone on 9/30/2022 at 3:38 PM, LPN #2 stated, .in her bed asleep or in the bathroom in her room .I can't say for sure how long she was gone .the aide [CNA#1] went to her room between 11:30 PM and 12 AM, she came and asked me if I knew where [Resident #1] was .I looked in the computer to see if she was out .started looking .didn't find her .called a missing person code [Dr. Find] so everyone could look .she was in the bathroom by the dining room .found her about 15 minutes after the aide [CNA #1] asked where she was .[Resident #1] had some noted confusion .said people were knocking on the door .she thought [NAME] had sent someone to get her .I think she was scared to come out because of the floor machines running .[LPN #1] found her in the bathroom .scared to come out because of the machines and the people knocking on the door .she stays in her room .I talked to the [Interim] Administrator and [Interim] DON that night about it . During a telephone interview on 9/30/2022 at 9:31 PM, CNA #1 stated, .I worked that night .it was close to midnight [Resident #1] wasn't in her room .her meal tray [supper] had not been touched .silverware not opened or anything .I told LPN #2 she was not in her room .they called a Dr Find .she was found in the bathroom across from the dining room laying on the floor in the dark .she was scared .she'd been gone since before supper .the noise from the buffer scared her .I hadn't seen [Resident#1] since I come on shift at 11pm .they brought her out of the bathroom .her dinner was served around 5 or so she didn't eat .[Resident #1] told me she was in there a long time .said she went for a walk before supper .had to use the bathroom she said it was about 4:30 pm. I asked her how she knew what time it was, and she said because she looked at the clock .I walked her to her room and when we went in the room she started crying and said you see [looking at her meal tray] that's how long I was gone. She was upset . I did not write a statement and I was not interviewed about this incident .Resident #1 mostly eat her meals in her room . During an telephone interview on 10/3/2022 at 9:01 AM, LPN #1 stated, .paged Dr. Find .looking for the resident .went up the hall toward the lobby .I knocked on the [lobby bathroom ] door, no one said anything the door was locked .I used a credit card to pop the lock on the door .I opened the door and she was standing in the bathroom .I don't know if she went in there and it was hard for her to pull the door open .there were floor techs doing the floors that night .I think they mentioned after she was found that the door had been locked for a while .no I did not write a statement and I was not interviewed .Resident #1 is pleasantly confused . During an telephone interview on 10/3/2022 at 10:07 AM, the Psych Nurse Practitioner (NP) stated, .[Resident #1] refuses medications and is very guarded .I saw her that Thursday [9/15/2022] .the staff didn't say how long she was gone .just that they looked for a while .[Resident #1] has no grip on reality .incorporates things seen on tv into her life .she told me her daughter was married to the prince of England .she told me she went to the bathroom and couldn't open the door said that 3 [NAME] Carters locked her in . During an interview 10/4/2022 at 5:25 PM, Resident #1 stated, .I've got a good appetite .my sons do not visit much they're really busy .my sons are doctors .I've been here 4 months .I'm not supposed to be here .if I'm not out of here tonight .if I can't drive, I'll talk to you tomorrow . During an interview on 10/5/2022 at 10:45 AM, CNA #6 stated, .Resident #1 is always confused very paranoid when it comes to noise and loud sounds .confused not very oriented .she eats in her room .I don't think she would put it together to unlock the door or to use the call light in the [lobby] bathroom, it's a different call light than the one in her room . During a telephone interview on 10/5/2022 at 3:40 PM, CNA #2 stated, .I worked a double (3p-11p and 11p-7a) that day .I ended up sitting with her that night .I hadn't seen her during the shift .she was pretty shook up she said she was on the floor, she [Resident #1] said water coming in so she [Resident #1] put paper towels down on the floor she said she heard a man say he didn't have a key .I tried to use that bathroom [lobby] that night several times and the door was locked .unusual for her [Resident #1] to be up that late .she's always in her room .she [Resident #1] was pretty shook up she didn't want to be alone .she [Resident #1] said she was in there for a while . During an interview on 10/6/2022 at 2:25 PM, LPN #4 stated, .we were about to go outside and start looking for [Resident #1], when we were walking up the hall to go outside, we met [LPN #1] and [Resident #1] .the [CNA #5] that was assigned [Resident #1] on the 3P-11P shift was already left .[Resident #1] was scared, frantic, and didn't want to be alone in her room .I would think this was an incident .it's a different call light than what is in her room, not sure she would know how to use it .she [Resident #1] said she heard people knocking .they had tried to get in the bathroom door but the door was locked .she said I've been gone so long I didn't get my meal and I'm hungry .so hungry she ate her meal cold .I feel like it was an elopement . During an interview on 10/6/2022 at 6:05 PM, LPN #5 stated, .not sure she would use the call light in that bathroom .she [Resident #1] doesn't like loud noises because when her roommate makes noise she comes to the desk and tells us .doesn't ever use the call light in her room . she comes out and comes to the desk .I was not asked and did not write a statement . During an interview on 10/7/2022 at 10:37AM, LPN #3 stated, .when I came in [LPN #2] told me about the Dr. Find code on her shift .discussed in the morning meeting .[Interim] Administrator wasn't in the meeting .I can't remember if any statement were given to me .this didn't meet the criteria for an incident .she refused the UA [urinalysis] .she refused to put on the wander guard because she said she went to the bathroom and it [wander guard] was a tracking device .went by what was in the nurse note .no monitoring other than looking in on her . During an interview on 10/7/2022 at 1:51 PM, the DON (ADON at the time of incident) stated, .[Resident #1] walks from her room to the dining room .that morning in the clinical meeting someone said they were looking for her and called a Dr. Find Code .the Psych NP [Nurse Practitioner] said something else was going on with her [Resident #1] .a Dr. Find code is called after 15 minutes of looking for them .I did not think it was a true Dr. Find .we do not use a Dr. Find Code often to find residents . During an telephone interview on 10/10/2022 at 9:35 AM, LPN #2 stated, .Resident #1 was fully dressed the night she was found in the bathroom .she had a sitter that night to keep an eye on her .[LPN #1] said she was standing in the bathroom when she opened the door .the door was locked on the inside she had to use a credit card to get into the bathroom .I hadn't seen her since I came in that night .she was having delusions that [NAME] or [NAME] had sent their men to get her because someone kept knocking on the door and those floor machines were running . in the state of mind she was in I don't think she knew how to use the call light in the [lobby] bathroom . The facility staff failed to monitor and provide proper supervision to ensure a resident with known delusional and paranoid behavior was in safe environment. The facility failed to monitor and ensure a safe environment free of accident hazards for a vulnerable cognitively impaired resident with delusions and paranoid behaviors.

Based on policy review, review of the Director of Nursing (DON) job description, facility investigation review, medical record review, observation, and interview, the facility failed to complete a thorough investigation of an elopement incident for 1 of 6 (Resident #2) sampled residents reviewed for accidents and elopement risk, when Resident #2 exited the facility without staff knowledge or supervision. The facility failed to initiate a thorough investigation of a missing resident incident for 1 of 6 (Resident #1) sampled residents reviewed for accidents, when Resident #1 was missing for an undetermined amount of time and was found in a locked lobby bathroom of the facility. The facility's failure to thoroughly investigate incidents resulted in Immediate Jeopardy when the facility failed to thoroughly investigate the elopement of Resident #2 and the missing person of Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON) and the Clinical Operating Officer (COO) were notified of the Immediate Jeopardy for F-610 on 10/13/2022 at 5:10 PM. The facility was cited at F-610 at a scope and a severity of J which is Substandard Quality of Care. The Immediate Jeopardy existed from 9/13/2022 and is ongoing. The findings include: 1. Review of the facility's ELOPEMENT OF RESIDENT POLICY, reviewed 11/21/2021, revealed, .standard of this Health Care Center that appropriate procedures exist in the case of a missing resident .should an employee discover that a resident is missing .Determine time and location when last seen .Once the Resident is Located .the charge nurse will document the incident in the resident's medical record including times (time discovered, time of contacts) .The resident will be assessed by the M.D. [Medical Director] .The charge nurse will complete an Incident Report .The Administrator/Director of Nursing Services will notify the Department of Health .A complete and thorough root-cause analysis .should be done to prevent recurrences, to ensure policies, and procedures and systems are effective, and to protect other residents . Review of the facility's policy titled, REPORTING OF ACCIDENT/INCIDENTS, reviewed November 2, 2021, revealed, .each incident involving a resident shall be documented on a standard Incident Report Form .All incidents are treated in the same manner .Accidents/Incidents will be investigated .Incidents are identified as any event or occurrence out of the ordinary .Incident Reports .Completed by the licensed nurse assigned to the resident .The nurse will complete a narrative notation in the medical record describing the accident/incident .The supervisor and nurse will initiate the investigation process and begin interviewing witnesses .interviews will be documented on the Witness Interview Form .Resident will be the first individual interviewed .interview as soon as possible after the incident .report shall be filed with specific state agency .investigation process for all incidents that require investigations .as soon as the following situations are identified .Resident left in a harmful or dangerous situation . Review of the facility's policy titled, ACCIDENTS AND INCIDENTS-INVESTIGATING AND REPORTING, reviewed November 2021, revealed, .All accidents and incidents involving residents .occurring on our premises shall be investigated .The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident .The following .shall be included on the Report of Incident/Accident form .the date and time the accident or incident took place . Review of the facility's UNSAFE WANDERING-ELOPEMENT RISK POLICY, reviewed November 25, 2021, revealed, .every effort will be made to prevent unsafe wandering episodes while maintaining the least restrictive environment for residents .should an elopement episode occur, an incident report will be completed providing explanation of how the event occurred and contributing factors . Review of the facility's signed (Interim) Director of Nursing job description dated 9/7/2022, revealed, .The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medial Director, to ensure that the highest degree of quality care is maintained at all times . 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of Dementia, Hypertension, Anxiety, Major Depressive Disorder, Insomnia, Lack of Coordination and Unsteadiness on Feet. Review of the care plan dated 7/27/2022, revealed Resident #2 was an elopement risk/wanderer with a history of attempts to leave the facility. Review of a physician order dated 8/31/2022 revealed, Wander guard due to behaviors exhibiting elopement. Check placement of Wander guard every shift, if not intact replace. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #2 was assessed with a Brief Interview for Mental Status (BIMS) score of 4, indicating she was severely cognitively impaired, required limited assessment to extensive assistance with ADLs, always incontinent of bowel and bladder and uses wheelchair for mobility. Review of the facility's timeline summary and investigation revealed, .10/2/2022 at 4:43 pm Resident #2 was sitting at front lobby screening table with Resident #6 (wander, elopement risk, wander guard resident) unsupervised and not monitored .Resident #2 stands up at the front door entry exit and begins rocking and attempting to force the door nearest to the temperature machine open .Resident #2 exits the facility front/exit door and walks directly to the security officer's gray pick-up truck and sits in the passenger side of the truck. The Security Guard leaves Resident #2 in the truck unsupervised to go into building to get assistance. Review of the Elopement Evaluation dated 10/2/2022, revealed Resident #2 was assessed at a score of 3 indicating at risk for elopement. Resident #2 exhibits wandering behavior and utilizes an exit alarm (wander guard). Review of the revised care plan dated for Resident #2 dated 10/2/2022 revealed, resident one (1) on one (1) at this time, monitor location every shift, maintain wander guard bracelet per physician's orders and check placement every shift. There was missing documentation after 10/2/2022 that the wander guard bracelet was intact. During a telephone interview on 10/5/2022 at 4:15 PM, CNA #3 (agency staff) stated they had worked a double shift the day that Resident #2 eloped. CNA #3 stated when they exited the front door to go on break that Resident #2 was sitting near the front entrance door. CNA #3 stated when they came back to the facility from across the street the facility staff was at the security guard's truck taking Resident #2 back into the facility. CNA #3 stated, .I knew she [Resident #2] was a wanderer .I told the nurse earlier that day [Resident #2's] wander guard bracelet was on the wheelchair .the nurse looked at me as if I didn't need to say anything and the nurse didn't do anything about it . During an interview on 10/5/2022 at 4:15 PM revealed the Interim Administrator stated she reviewed the video footage for Resident #2's elopement but stated she did not save the video as part of an investigation. The Interim Administrator provided the survey team with a documented timeline based on her recollection of the video. The facility was unable to provide the team with video footage of the incident. During an interview on 10/5/2022 at 4:55 PM, the Security Guard stated, .she [Resident #2] was pushing on the entrance door to get out, the door opened, and came to the truck and said I want you to take me home .she got in the truck, put the seat belt on and I locked the truck .the front windows were down .told her I was going to tell the nurses I was going to take her home .went in the building to get assistance and they came and got her . During an interview on 10/6/22 at 3:19 PM, the Interim Administrator stated, .she got up from the wheelchair .pushed on the door and it opened .went straight to the security guard's truck that was parked at the front entrance . security guard secured her in the truck with the seat belt .security guard came in the building about 3-minutes .he returned to the truck .3 staff came out and brought the resident back in .she was not unsupervised because he was with her . The Interim Administrator was asked if the security guard a facility staff member. The Interim Administrator stated, .no, he is contracted .no, he is not our staff . The Interim Administrator confirmed Resident #2 was unsupervised while the security guard went into the building to get assistance. The Interim Administrator stated .yes .but it was only a few minutes . The Interim Administrator confirmed Resident #2 was sitting in the lobby unsupervised and staff was unaware. The Interim Administrator confirmed when Resident #2 exited the building and .no staff was in the lobby .and staff did not take [Resident #2] back to her room .no .this is their home and it's their right to sit in the lobby and watch TV . The Interim Administrator was asked should wandering elopement risk residents wearing wander guards be sitting in the lobby unsupervised and without staff. The Interim Administrator did not answer. During a telephone interview on 10/7/2022 at 1:30 PM, CNA #4 stated .I am agency staff .have only worked at facility a few times . I checked my room assignment and [Resident #2] was not in the bed or room .I assumed she was gone to the hospital .did not see [Resident #2] until she was being escorted to her room .the nurse informed me that was [Resident #2] was my resident. I took her in her room and to the bathroom, it was around supper time .I did not provide 1 to 1 observation after the incident. I did not provide 15-30 minutes checks for [Resident #2] .no one told me to do any safety checks .I did not write a statement, and none has called me from the facility about writing a statement . 3. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Schizophrenia, Dementia, Traumatic Brain Injury, and Anxiety. Review of the care plan revised 6/22/2022, revealed Resident #1 had an Activities of Daily Living (ADL) self-care performance deficit that required cues, encouragement, and supervision related to Dementia and delusions. The interventions included supervision/assistance with all decision making. Resident #1 had impaired cognitive function and impaired thought processes related to dementia. Communication problem related to head injury, is usually understood, usually understands, and had delusions. Interventions included ensure/provide a safe environment avoid isolation. Review of a BIMS assessment completed on 8/22/2022, revealed Resident #1 was assessed with a BIMS of 4 indicating severe cognitive impairment for daily decision making. Review of the quarterly MDS mental assessment dated [DATE], revealed Resident #1 had modified independence with difficulty in a new situation. Resident #1 was independent for dressing, requires supervision for locomotion on and off the unit, eating and personal hygiene. Resident #1 required extensive one person assistance for bed mobility, transfer, and toilet use. Resident #1 was occasionally incontinent of urine and frequently incontinent of bowel. Review of an elopement risk assessment dated [DATE] revealed Resident #1 was not assessed at risk for elopement. Review of a nurse's progress note marked as Draft and dated 9/14/2022 documented, .1220 [AM] during 1st round staff was alert [alerted] by CNA [Certified Nurse Assistant], Resident was not in her bed or bathroom. Staff directed to look for resident while this nurse searched West 1 [unit] after 5-10 minutes of direct searching Dr. Find [emergency code called for a missing resident] was call overhead AT 12:20 [AM], Staff continued to search. Approx. [approximately] 5 min [minutes] after Dr. Find was announced, Resident was located by [Licensed Practical Nurse (LPN) #1] in the employee bathroom in the Front Lobby @ [at] 12:30 [AM] .with noted confusion . Review of a Psychiatric Nurse Practitioner progress note dated 9/15/2022 revealed, .asked to see ahead of scheduled visit due to new problem. Staff reports she wandered off unit .could not be found for some time . found .in employee bathroom .says she went in to use the bathroom and could not get the door open .3 [NAME] Carters locked me in .poor grip on reality and incorporates delusional fantasy world into everyday interactions .delusional ideas are expressed .reasoning is illogical .associations are loose .insight into problems appears to be poor . During an Allegation of Compliance (AoC) validation revisit on 9/16/2022 to remove Immediate Jeopardy from the previous 8/30/2022 recertification survey an entrance conference interview was conducted with the Interim Administrator. On 9/16/2022 at 9:30 AM, the Interim Administrator was asked if there were any elopements, Dr. Find for missing residents, or any incidents since the exit on 8/30/2022. The Interim Administrator stated, .no . During an interview on 9/28/2022 at 12:40 PM, the Interim Administrator, the Interim DON and DON was asked if there had been any incidents of a missing resident, or any incidents of a resident being found in a bathroom? The Interim Administrator stated, .no . The DON stated, .a resident was found in the [employee/lobby bathroom] .wasn't gone but 5 or 10 minutes . During an interview on 9/28/2022 at 1:15 PM, the Interim Administrator stated, .I talked to the nurse [Licensed Practical Nurse (LPN) #2] on the phone that night [night the resident was missing], she said during the 1st round staff identified she was not in her room . The Interim Administrator was asked how long had she been gone from her room? The Interim Administrator stated, .I assumed LPN #2 had seen her that night at shift change [11pm] .the staff called a Dr Find .did what they were supposed to do .I didn't have a reason to start an investigation .she wasn't gone that long, she was found in the bathroom .I don't have any interviews . The Interim Administrator was asked do you know how long she was missing and how long she was in the lobby bathroom? The Interim Administrator stated, .no . During a telephone interview on 9/29/2022 at 2:58 PM housekeeping staff #1 stated, .got to work about 9:00 PM .we were stripping and waxing the floors in the area around the restrooms [across from dining room] .tried to get into the women's bathroom to do the floor but the door was locked .knocked but there wasn't an answer .tried several times .about 12 or so the staff said a resident was missing .my supervisor told them to check that bathroom .the resident was in there and they brought her out .I was not asked to write a statement about this and no one has called me for an interview . During a telephone interview on 10/3/2022 at 9:01 AM, LPN #1 stated, .[Resident #1] missing about 2-3 weeks ago .they paged a Dr Find .I started looking .I went up the hall toward the lobby .I knocked on the [lobby/employee] bathroom door, no one said anything, I checked the door, it was locked .I used a credit card to unlock the door, I opened the door and she was standing in the bathroom .I didn't know how long she had been there .I don't know if it was hard for her to pull the door open .did not write a statement .wasn't interviewed about it . During a telephone interview on 10/5/2022 at 3:30 PM, CNA #2 stated, .I worked a double that day I was assigned rooms down from her [Resident #1] .hadn't see her that night walking in the hall .noticed the tray [supper] was still in the room and hadn't been touched .they checked to see if she was out to the hospital or signed out .called the Dr. Find code and everyone started looking for her .I looked around on the hall .I think a nurse found her .she [Resident #1] was pretty shook up she said she [Resident #1] was on the floor, she said water was coming in so she [Resident #1] put paper towels down on the floor, she [Resident #1] said she heard a man say he didn't have a key she [Resident #1] said she was in there for a while .the lobby bathroom door had been locked that night .unusual for her to be up .she's always in her room .she was pretty shook up she didn't want to be alone, I ended up sitting with her that night .she finally went to sleep .I did not write a statement . During an interview on 10/7/2022 at 10:37 AM, LPN #3 Unit Manager (UM) confirmed she was aware of a Dr Find code being called to find Resident #1 who was missing. LPN #3 UM stated, .discussed it in the morning meeting didn't consider it an incident .did not investigate . [Resident #1] refused to put on the wander guard .she said it was a tracking device .refused the UA [urinalysis] .and there was not a sitter with her that morning when I came to work .and was not monitored . During an interview on 10/7/2022 at 1:51 PM, with the Director of Nursing ((DON) previously the Assistant Director of Nursing) stated we talked about it [Resident #1] they were looking for her and they had called a Dr Find .[LPN #2] had told the [LPN #3 UM] what had happened .that she [Resident #1] had went to the [lobby] bathroom .under normal circumstances she could open the door .the Psychiatric Nurse Practitioner said something else was going on with her .uncertain if she could use the call light in that bathroom . The DON was asked when is a Dr Find code utilized and how often is it used to find residents? The DON stated, .is called after 15 minutes of looking for a resident .I did not think it was a true Dr Find . because of the time of what was reported . The facility was unable to provide documentation that an investigation was conducted for the incident of Resident #1, a vulnerable resident with a history of delusional thinking, Schizophrenia and bizarre thoughts, being found in a locked bathroom for an undetermined amount of time. The facility failed to determine the last time Resident #1 was seen in the facility prior to the resident becoming missing and failed to ensure Resident #1 was provided care in a safe environment.

Based on policy review, review of the facility's staffing documents, review of time detail reports, facility investigation review, medical record review, observation, and interview, the facility failed to maintain sufficient staffing to ensure the safety and supervision of wandering residents and failed to ensure sufficient staff to provide care to residents on 3 of 16 days (7/27/2022, 7/30/2022, and 8/22/2022) reviewed, which had the potential to affect all 94 residents in the facility. The facility's failure to ensure staffing levels were adequate to maintain the safety and supervision of wandering residents placed Resident #549 in Immediate Jeopardy when he exited the building without staff knowledge or supervision, was found outside the facility approximately 45 minutes later, and then exited the building without staff knowledge or supervision 3 days later and was located at an autobody shop approximately 21 miles from the facility approximately 4 hours later. The facility's failure had the potential to affect all 94 residents residing in the facility when 1 Licensed Practical Nurse (LPN) #15 worked in the building providing licensed nursing care for all 94 residents from 1:15 AM until 6:44 AM. Immediate Jeopardy (IJ) is a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, severe injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON), and [NAME] President of Clinical Operations were notified of the Immediate Jeopardy at on 8/26/2022 at 5:48 PM, in the Omega Room. The facility was cited Immediate Jeopardy at F-725. The facility was cited at F-725 at a scope and severity of L, which is Substandard Quality of Care. The IJ was effective on 3/29/2022 and is ongoing. The findings include: Review of the facility's undated policy titled, POSTING DIRECT CARE DAILY STAFFING NUMBERS, revealed .The facility will provide sufficient staff to provide care as needed . Review of a closed medical record, revealed Resident #549 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Clinical Admission Evaluation dated 7/22/2022, revealed Resident #549 had disorganized thinking, walked with an unsteady gait and poor balance, and wandered at night. Review of the Brief Interview for Mental Status (BIMS) assessment dated [DATE], revealed Resident #549 had a score of 14, indicating he was cognitively intact. Review of a facility investigation dated 7/27/2022, revealed Resident #549 was found sitting outside in front of the building without staff supervision between 7:45 AM and 7:50 AM, on 7/27/2022, and brought back inside the facility. He was last seen by staff at 7:05 AM. Resident #549 exited the building without staff knowledge and was unsupervised for approximately 45 minutes. Review of the Elopement Risk assessment dated [DATE], revealed Resident #549 was assessed as high risk for elopement. Review of a facility investigation dated 7/30/2022, revealed staff observed Resident #549 at 6:40 AM on 7/30/2022. At 7:05 AM, staff entered Resident #549's room but was unable to locate him until approximately 10:59 AM, when he was located at an autobody shop approximately 21 miles from the facility. Resident #549 exited the building without staff knowledge or supervision and was not located for approximately 4 hours. During an interview on 8/8/2022 at 12:15 PM, the Staffing Coordinator reviewed time detail reports and the assignment sheets for 7/27/2022 and confirmed that there was 1 nurse and 1 Certified Nursing Assistant (CNA) on the East Hall when Resident #549 eloped. During an interview on 8/8/2022 at 12:15 PM, the DON was asked if she was aware there was 1 nurse and 1 CNA on the East Hall when Resident #549 eloped on 7/27/2022. The DON stated .no I was not aware of that .we are having problems with call ins and staff not getting to work on time . The DON was asked if staffing was changed on the East Hall after the elopement on 7/27/2022. The DON stated .no I did not check the staffing . During an interview on 8/10/2022 at 9:30 AM, the Human Resources Director compared time detail reports with the monthly schedule, handwritten assignment sheets, and daily census sheets for dates including 7/26/2022-7/30/2022 and confirmed there was 1 CNA and 1 Nurse on the East Hall on 7/27/2022 when Resident #549 eloped. During an interview on 8/10/2022 at 12:00 PM, CNA #9 stated .when I got to work, I started my rounds down by room [number] .I did not know if any other CNAs were here .I did not know he [Resident #549] had got [gotten] out until he was back, and I heard the nurses at the desk talking . The facility failed to ensure sufficient staffing to maintain the safety and security of wandering residents. Review of the staff assignment sheets, and time detail reports dated 8/21/2022 and 8/22/2022, revealed LPN #15 was the only nurse in the building between 1:15 AM and 6:44 AM on 8/22/2022. The census on 8/21/2022 was 94. During an interview on 8/24/2022 at 10:00 AM, LPN #15 confirmed he was the only nurse in the building on 8/22/2022 between 1:15 AM and 6:44 AM. LPN #15 stated, I had to pass meds [medications], I had to hang [enteral] feedings .I did the best I could, there was supposed to be a nurse that came in at 11 [11:00 PM on 8/21/2022] but she never showed. LPN #15 was asked how many nurses are usually scheduled on night shift on the weekend. LPN #15 stated, There are usually 2 nurses on each unit .The other nurse called staffing and asked where the one who was supposed to show up at 11 was . LPN #15 was asked if he felt it was safe to be the only nurse in the building for 94 residents. LPN #15 stated, Like I said, I did the best I could. During an interview on 8/24/2022 at 11:06 AM, the Staffing Coordinator was asked how many nurses usually work the night shift. The staffing Coordinator stated, 3. The Staffing Coordinator was asked if there are ever less than 3 nurses working night shift. The Staffing Coordinator stated, Yes .1 or 2 days a week . The Staffing Coordinator was asked how many nurses usually work the night shift on the weekends. The Staffing Coordinator stated, .I try to keep 4 .I don't want anybody to be overwhelmed . The Staffing Coordinator was asked how many CNAs usually work on the day shift. The Staffing Coordinator stated, .6. The Staffing Coordinator was asked how many CNAs usually work on the night shift. The staffing Coordinator stated, .5. The Staffing Coordinator confirmed she attempts to cover call ins and makes the DON aware of staffing shortages. The Staffing Coordinator was asked who covers for licensed staff if someone calls in. The Staffing Coordinator stated, .you are supposed to have backup nurses and managers and everything. I am supposed to call the DON and she is supposed to call them .I keep calling. I do not stop at her [the DON] .I call, and I beg, and I put it on on-shift [an employee messaging system] .some nurses will be like, they need more [a larger bonus] and I go to [Named DON] .2 nurses called in today and they [the nurses called and asked to come in] laughed . The Staffing Coordinator was asked does the DON come in if you are not able to find coverage for a nurse. The Staffing Coordinator stated, .No, she does not . The Staffing Coordinator confirmed that one nurse worked in the building from 1:15 AM-6:44 AM on the morning of 8/22/2022. The staffing coordinator confirmed that she sent a message to the DON about the staffing issue, and she asked the nurse leaving at 1:15 AM [LPN #9], to message the Assistant Director of Nursing (ADON) and the Unit Managers about the situation. The Staffing Coordinator was asked if she thought it was safe to have 1 nurse in the building to provide care for 94 residents. The Staffing Coordinator stated, No .nobody answered [when calls were made to staff] . During an interview on 8/24/2022 at 5:43 PM, the DON was asked if she was aware that there was only 1 nurse in the building from 1:15 AM-6:44 AM on the morning of 8/22/2022. The DON stated, No, I didn't get that until the next morning. I was traveling .I was out of town, so my phone did not show any call ins and I didn't have any messages. The DON was asked if she thought it was safe for 1 nurse to care for 94 residents. The DON stated, No . The DON was asked who was ultimately responsible for making sure there are enough nurses and CNAs in the building to care for the residents. The DON stated, I am. During an interview on 8/28/2022 at 4:52 PM, LPN #9 confirmed that she came in at 7:00 AM on 8/21/2022 and worked until 1:15 AM on 8/22/2022, leaving 1 nurse in the building. LPN #9 stated, The nurse that was supposed to be here was not here yet .[Named person] .said she would try to call the nurse and see where she was. She told me to send out a group text to the 2 Unit Managers, the Assistant Director of Nursing [ADON], the DON, and include her in the text, and let them know that she [the nurse scheduled to come in at 11:00 PM] hadn't come in and that I had been here since 7 [7:00 AM] that morning. LPN #9 was asked if anyone responded to the text. LPN #9 stated, Only the Staffing Coordinator. LPN #9 was asked how were staffing problems handled. LPN #9 stated, We call the staffing Coordinator and notify the DON .In the past, they have had nurses that were on call should a situation occur. LPN #9 was asked when the on-call system stopped. LPN #9 stated, About a year ago. LPN #9 was asked how many nurses usually come in on weekends on the 7:00 PM to 7:00 AM shift. LPN #3 stated, Usually at least 3. LPN #9 was asked if it was safe to only have 1 nurse in the building at night. LPN #9 stated, No, not at all. During an interview on 8/29/2022 at 5:37 PM, the ADON confirmed she received a text between 5:00 PM or 6:00 PM stating that the facility needed a nurse to come in at 7:00 PM but did not get a text about the nurse not coming in at 11:00 PM. The ADON was asked who was responsible for covering for the DON if she is not available. The ADON stated, Technically it would be me. The ADON was asked if she knew the DON was going to be unavailable on 8/21/2022. The ADON stated, No ma'am. During an interview on 8/30/2022 at 5:48 PM, LPN #13 confirmed she received a text message from LPN #9 on 8/22/2022 at 12:12 AM, stating that her relief had not shown up and she had been at the facility since 7:00 AM the morning before. LPN #13 confirmed she did not reply to the text message because she did not see it until she woke up on 8/22/2022.

Based on policy review, job description review, and interview, Administration failed to provide oversight to ensure systems and processes were developed and consistently followed, failed to provide oversight of nursing staff, failed to identify the root cause of concerns identified in the facility, and failed to ensure systems and processes were developed and consistently followed by facility staff. Administration failed to provide oversight that established and implemented policies and procedures to ensure residents were free from verbal, physical, sexual abuse, and misappropriation of property. Administration failed to provide oversight that established and implemented policies and procedures to ensure resident behaviors were monitored, assessed, and identified. Administration failed to provide oversight that established and implemented policies and procedures to ensure facility staff investigated abuse allegations thoroughly. Administration failed to provide oversight that established and implemented policies and procedures to ensure abuse allegations were reported timely to all respective entities. Administration failed to provide oversight that established and implemented policies and procedures to ensure a safe and secure environment when Resident #549 exited from the facility on 2 separate occasions, 3 days apart through the same malfunctioning door without staff knowledge. Administration failed to provide oversight that established and implemented policies and procedures to ensure the facility had sufficient numbers of staff to provide care and services to residents when 1 newly hired Licensed Practical Nurse (LPN) #15 was left to work alone in the facility with 94 residents. Administration failed to provide oversight that established and implemented policies and procedures to ensure the facility provided effective housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment. Administration failed to provide oversight that established and implemented policies and procedures to ensure foot care was provided for Resident #25 who had foot pain and Resident #93 who stopped wearing shoes and walked with difficulty and pain due to long toenails. These failures resulted in Immediate Jeopardy for Resident #5, #14, #25, #29, #30, #50, #72, #549, #550, and #551, actual Harm for Resident #25 and Resident #93, and Substandard Quality of Care in environment. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-689 during the complaint investigation on 8/9/2022 at 6:20 PM, in the Omega Room. The Administrator and the Director of Nursing were notified of the Immediate Jeopardy (IJ) for F-600 and F-610 during the complaint investigation on 8/12/2022 at 2:50 PM, in the Omega Room. The Administrator and the Director of Nursing were notified of the Immediate Jeopardy (IJ) for F-609 and F-725 on 8/24/2022 at 7:03 PM, in the Omega Room. The [NAME] President of Clinical Operations, the Administrator, and the Director of Nursing were notified of the Immediate Jeopardy (IJ) for F-744, F-835, and F-867 on 8/26/2022 at 5:48 PM, in the Omega Room. The [NAME] President of Clinical Operations and the Regional Director of Clinical Operations were notified of the Immediate Jeopardy (IJ) for F-837 on 8/30/2022 at 12:04 PM, in the Omega Room. The facility was cited Immediate Jeopardy at F-600, F-609, F-610, F-689, F-725, F-744, F-835, F-837, and F-867. The facility was cited at F-725, F-835, F-837 and F-867 at a scope and severity of L. The facility was cited at F-600, F-609, F-610, and F744 at a scope and severity of K, at F-584 at a scope and severity of F, and at F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 3/29/2022 and is ongoing. The findings include: The facility's signed Administrator job description date of 3/1/2022, revealed .Administration .The primary purpose of your job is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality of care can be provided to our residents at all times .you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties .Ensure that all employees, residents, visitors and the general public follow the facility's established policies and procedures .make written and oral reports/recommendations to the governing board concerning the operation of the facility .Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed .Assume the administrative authority, responsibility and accountability of directing the activities and programs of the facility .Serve on various committees of the facility .Quality Assurance [QA] .and provide written/oral reports .to the governing board as directed .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies .Consult with department directors concerning the operation of their department to assist in eliminating/correcting problem areas, and/or improvement of services .Ensure that an adequate number of appropriately trained licensed professional and non-licensed personnel are on duty at all times to meet the needs of the residents .Ensure that appropriate staffing level information is posted on a daily basis .Schedule and participate in departmental meetings to ensure that appropriate information sharing is provided on a continuous basis .Inform the Medical Director of all suspected or known incidents of resident abuse .assure the facility is maintained in a clean, safe and sanitary manner .Ensure that the facility is maintained in a clean and safe manner for resident comfort and convenience . The facility's signed Director of Nursing job description dated 7/13/2021, revealed .The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times .you are delegated that administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. In the absence of the Medical Director, you are charged with carrying out the resident care policies established by this facility .Plan, develop, organize, implement, evaluate, and direct the nursing service department .in accordance with current rules, regulations, and guidelines that govern the nursing care facilities .Make written and oral reports/recommendations to the Administrator, as necessary/required concerning the operation of the nursing service department .Develop, implement, and maintain an ongoing quality assurance program for the nursing service department .Assist the Quality Assessment & Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies .Assist in calculating the number of direct nursing care personnel on duty each shift. Report such information to the Administrator his/her designee to ensure that accurate staffing information is posted .Ensure that all resident care rooms .are maintained in a clean, safe and sanitary manner .Review complaints and grievances made by the resident and make a written/oral report to the Administration indicating what action(s) were taken to resolve the complaint or grievance .Report and investigate all allegations of resident abuse and/or misappropriation of resident property . During an interview on 8/26/2022 at 4:58 PM, the Administrator and the Director of Nursing (DON) were asked if the facility's QA/Quality Assurance Performance Improvement (QAPI) program was effective since the last survey, less than 11 months ago when the facility was cited for the same deficiencies at an Immediate Jeopardy level. The Administrator shrugged her shoulders in an up and down motion and did not answer the question. The Administrator was asked who was responsible for the behavior monitoring program. The Administrator confirmed the DON was responsible. The Administrator was asked if the facility had an effective behavior monitoring program in the event vulnerable residents are at risk for abuse and abuse allegations are made. The Administrator did not respond. The Administrator confirmed that there should be sufficient staff in the facility to meet residents' highest practicable well-being and no staff member should be left in the building alone with 94 residents. The Administrator was asked should allegations of physical, verbal, sexual abuse and misappropriation of property be reported and thoroughly investigated. The Administrator confirmed that all abuse should be thoroughly investigated, and the facility policy should be followed. The Administrator was asked who was ultimately responsible for the residents' highest practicable well-being, to ensure there was sufficient staffing in the facility, ensure procedures were followed, to monitor resident behaviors, to ensure allegations of verbal, sexual, physical abuse, and misappropriation of resident property was identified, reported, and thoroughly investigated, and to ensure residents resided in a safe, secure, and sanitary environment. The Administrator confirmed she was ultimately responsible for the well-being of all residents along with the DON who was responsible for ensuring all medical needs of the residents were met. During an interview on 8/27/2022 at 8:00 AM, the [NAME] President (VP) of Clinical Operations confirmed administration was ineffective. During a telephone interview on 8/30/2022 at 8:01 AM, the Chief Operating Officer (COO) was asked who reports directly to her. The COO confirmed the VP of Clinical Operations and the Regional Director of Clinical Operations along with the Administrators report directly to her in some instances. The COO was asked what things they report to her. The COO confirmed any risk management issues are reported directly from the Administrator to both the VP and the COO in an ongoing email communication system. The COO stated, Those are mandatory things that have to be reported along with any elopements . The COO was asked if allegations of physical, sexual, verbal abuse, and misappropriation of resident's property, and elopement were reported to her. The COO confirmed these are circumstances that would be reported directly to the COO and the VP from the Administrator. The COO stated, .we (VP and COO) were not (informed) this is where administratively the process failed . The COO confirmed the Administrator should have reported any allegation of abuse, misappropriation of property and elopement. The COO was asked if she was made aware of the allegation of misappropriation of property for Resident #25 that was reported to the Director of Nursing (DON) on 8/27/2022. The COO confirmed that all allegations of abuse and misappropriation should be reported to both the Regional Director of Clinical Operations and to the VP and the COO immediately, and it should be investigated when it occurs. The COO confirmed she was made aware of the allegation on 8/29/2022 on the date that the VP was made aware of the allegation, and it should have been investigated and reported the day it occurred on 8/27/2022. She confirmed administration failed to do so. The COO was asked if she believed the building was in disrepair and needed repairs. The COO confirmed the environment had significantly deteriorated, was not up to appropriate standards, and needed repairs and preventative maintenance. She confirmed it needed some improvements and was not acceptable. The COO confirmed this was information that should have been reported by the Administrator. The COO confirmed department managers were responsible for reporting anything significant that has occurred, and the Administrator should follow up. The COO stated, The facility failed to report and to seek help to be guided through those things .because of that the step was missed and that is why we are where we are now . The COO was asked was the Administration in the building effective. The COO stated, Absolutely not . The Administration failed to maintain oversight, establish, and implement policies and procedures to ensure allegations of abuse are thoroughly investigated, and reported. Refer to F-600, F-609 and F-610. The Administration failed to maintain oversight, establish, and implement policies and procedures to ensure adequate staffing. Refer to F-725. The Administration failed to maintain oversight, establish and implement policies and procedures to ensure behavior monitoring for residents. Refer to F-744. The Administration failed to maintain oversight, establish, and implement policies and procedures to ensure an effective QAPI program was in established in the facility. Refer to F-867.

Based on policy review, job description review, and interview, the Governing Body failed to provide oversight to ensure systems and processes were developed and consistently followed by facility staff and failed to provide oversight of administration and nursing staff, failed to identify the root cause of concerns identified in the facility. The Governing Body failed to provide oversight that established and implemented policies and procedures to ensure residents were free from verbal, physical, sexual abuse, and misappropriation of property. The Governing Body failed to provide oversight that established and implemented policies and procedures to ensure facility staff investigated abuse allegations thoroughly. The Governing Body failed to provide oversight that established and implemented policies and procedures to ensure abuse allegations are reported or reported timely to the respective entities. The Governing Body failed to provide oversight that established and implemented policies and procedures to ensure Resident #549 was assessed for exit seeking behaviors and monitored when he exited from the facility on 2 separate occasions, 3 day apart through the same malfunctioning door. The Governing Body failed to provide oversight that established and implemented policies and procedures to ensure facility had sufficient numbers of staff to provide care and services to residents when 1 newly hired Licensed Practical Nurse (LPN) #15 was left to work alone in the facility with 94 residents. The Governing Body failed to provide oversight that established and implemented policies and procedures to ensure residents behaviors were monitored, assessed, and identified. The Governing Body failed to provide oversight that established and implemented policies and procedures to ensure the facility provided effective housekeeping services and maintenance services to maintain a sanitary, orderly, and comfortable environment. The Governing Body failed to provide oversight that established and implemented policies and procedures to ensure foot care was provided for Resident #25 who had foot pain and Resident #93 who stopped wearing shoes and walked with difficulty and pain due to long toenails. These failures resulted in Immediate Jeopardy for Resident #5 #14, #25, #29, #30, #50, #72, #549, #550, and #551, actual Harm for Resident #25 and Resident #93, and Substandard Quality of Care in environment. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-689 during the complaint investigation on 8/9/2022 at 6:20 PM, in the Omega Room. The Administrator and the Director of Nursing were notified of the Immediate Jeopardy (IJ) for F-600 and F-610 during the complaint investigation on 8/12/2022 at 2:50 PM, in the Omega Room. The Administrator and the Director of Nursing were notified of the Immediate Jeopardy (IJ) for F-609 and F-725 on 8/24/2022 at 7:03 PM, in the Omega Room. The [NAME] President of Clinical Operations, the Administrator, and the Director of Nursing were notified of the Immediate Jeopardy (IJ) for F-744, F-835, and F-867 on 8/26/2022 at 5:48 PM, in the Omega Room. The [NAME] President of Clinical Operations and the Regional Director of Clinical Operations were notified of the Immediate Jeopardy (IJ) for F-837 on 8/30/2022 at 12:04 PM, in the Omega Room. The facility was cited Immediate Jeopardy at F-600, F-609, F-610, F-689, F-725, F-744, F-835, F-837, and F-867. The facility was cited at F-600, F-609, F-610, and F-744 at a scope and severity of K, at F-584 at a scope and severity of F, and at F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 3/29/2022 and is ongoing. The findings include: Review of the facility's policy titled, Governing Body Policy F837 . dated 9/19/2021, revealed .The Governing Body assumes full legal responsibility for the overall conduct of the facility and shall be responsible for compliance with applicable laws and regulations pertaining to the facility .will include, but not be limited to .Licensed Administrator .Director of Nursing .Director of Quality Assurance .Medical Director .the Governing shall meet as needed but no less frequently than annually and shall record minutes .The Governing Body has the authority to appoint .responsible for the interpretation, implementation, and proper application of policies and programs .The administrator reports and is accountable to the Governing Body regarding the day-to-day operations and management of the facility .The Governing Body will ensure that policies and procedures .including such operational matters as .Regulatory Survey results .Allegations of Abuse and Neglect .Internal Quality Audits .Budget .Staffing levels . Review of the facility's signed Administrator job description dated of 3/1/2022, revealed .Administration .The primary purpose of your job is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality of care can be provided to our residents at all times .you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties .Ensure that all employees, residents, visitors and the general public follow the facility's established policies and procedures .make written and oral reports/recommendations to the governing board concerning the operation of the facility .Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed .Assume the administrative authority, responsibility and accountability of directing the activities and programs of the facility .Serve on various committees of the facility ( .Quality Assurance .and provide written/oral reports .to the governing board as directed .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies .Consult with department directors concerning the operation of their department to assist in eliminating/correcting problem areas, and/or improvement of services .Ensure that an adequate number of appropriately trained licensed professional and non-licensed personnel are on duty at all times to meet the needs of the residents .Ensure that appropriate staffing level information is posted on a daily basis .Schedule and participate in departmental meetings to ensure that appropriate information sharing is provided on a continuous basis .Inform the Medical Director of all suspected or known incidents of resident abuse .assure the facility is maintained in a clean, safe and sanitary manner .Ensure that the facility is maintained in a clean and safe manner for resident comfort and convenience . Review of the facility's signed Director of Nursing job description dated 7/13/2021, revealed .The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medial Director, to ensure that the highest degree of quality care is maintained at all times .you are delegated that administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. In the absence of the Medical Director, you are charged with carrying out the resident care policies established by this facility .Plan, develop, organize, implement, evaluate, and direct the nursing service department .in accordance with current rules, regulations, and guidelines that govern the nursing care facilities .Make written and oral reports/recommendations to the Administrator, as necessary/required concerning the operation of the nursing service department .Develop, implement, and maintain an ongoing quality assurance program for the nursing service department .Assist the Quality Assessment & Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies .Assist in calculating the number of direct nursing care personnel on duty each shift. Report such information to the Administrator his/her designee to ensure that accurate staffing information is posted .Ensure that all resident care rooms .are maintained in a clean, safe and sanitary manner .Review complaints and grievances made by the resident and make a written/oral report to the Administration indicating what action(s) were taken to resolve the complaint or grievance .Report and investigate all allegations of resident abuse and/or misappropriation of resident property . During an interview on 8/26/2022 at 4:58 PM, the Administrator and the DON confirmed the Administrator is ultimately responsible for the well-being of all residents along with the DON who is responsible for ensuring all medical needs of the resident are met. During an interview on 8/27/2022 at 8:00 AM, the [NAME] President of Clinical Operations confirmed the administration was ineffective. During a telephone interview on 8/29/2022 at 3:53 PM, the Medical Director was asked how she communicates with the Administrator and DON. The Medical Director stated, Usually I will talk to the DON every time I come in .the Administrator I really haven't had much dealings with her. The Medical Director was asked if she thought the facility had an effective Quality Assurance and Performance Improvement (QAPI) program and if she had been part of the decision making for the facility. The Medical Director stated, I think it's a work in process. The Medical Director was asked if she had been made aware of the environmental issues, and if the facility had a homelike environment. The Medical Director stated, It's a work in progress. During a telephone interview on 8/30/2022 at 8:01 AM, the Chief Operating Officer (COO) was asked what her job duties consisted of. The COO stated, I oversee the operations of 14 nursing homes .I have an operation team that reports to me .the Regionals report to the [NAME] President (VP), and the VP reports to me .I report to the President of the company. The COO was asked what type of things does the VP report. The COO stated, .QAPI mock surveys, plan of corrections .reports all regulatory violations .elopements .falls with injuries .emergent staffing issues . The COO was asked if she was made aware that a resident exited the building on 7/27/2022. The COO stated, We were not, this is where administratively, they failed. The COO was asked should she have been made aware. The COO stated, Yes that is a requirement . The COO was asked if she was made aware of the abuse allegations. The COO stated, No Ma'am .I can't say if they were reported to the [Named Regional] at the time .those situations are a potential for harm and should have been reported .we were not made aware of the grievances related to misappropriations of funds . The COO was asked when there was an allegation of abuse, should it be investigated and reported immediately. The COO stated, Yes. The COO was asked if there was a report of misappropriation that was reported on Saturday, would she expect the investigation to start on a Monday. The COO stated, No .it should have been investigated immediately. The COO was asked who makes up the Governing Body. The COO stated, The Director of Nursing, the Administrator, the Medical Director, the Regional and the management team. The COO was asked if she thought the facility was a home like environment for the residents. The COO stated, I feel like the environment has digressed .preventable maintenance needed .and it was not acceptable at all . The COO was asked if she had been notified of the events that have happened in the last 4-5 weeks. The COO stated, No, not of the things you have identified. They did not follow procedure . The COO was asked how she provided oversite and ensure the facility is effective in providing care and services. The COO stated, My oversight is to ensure the VP has the Regional trained on policies and procedures. The COO was asked does the facility report to her and how often. The COO stated, Directly to me, No, the Regional reports to the VP .we have a group email .the facility has failed to report those issues .this is why we are where we are right now. The COO was asked if she thought your administration has been effective. The COO stated, No . The COO was asked did she think her Regional was very effective. The COO stated, No he wasn't, I think we failed in giving him proper oversight. The Governing Body failed to maintain oversight to provide consistent Administrative staff including an Administrator and Director or Nursing. Refer to F-835 The Governing Body failed to maintain oversight, establish, and implement policies and procedures to ensure allegations of abuse are thoroughly investigated and reported. Refer to F-600, F-609, and F-610. The Governing Body failed to maintain oversight, establish, and implement policies and procedures to ensure adequate staffing. Refer to F-725. The Governing Body failed to maintain oversight, establish, and implement policies and procedures to ensure behavior monitoring for residents. Refer to F-744. The Governing Body failed to maintain oversight, establish, and implement policies and procedures to ensure an effective QAPI program was in established in the facility. Refer to F-835 and F-867.

Based on policy review, review job description review, and interview, the facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) program that recognized ongoing problems with resident safety to prevent, identify, report, and thoroughly investigate, allegations of abuse, neglect, and misappropriation. The QAPI committee failed to assure the facility was administered in a manner to use its resources effectively and efficiently, and that the [NAME] President of Clinical Operations assisted the facility with identifying, evaluating, addressing clinical concerns, coordinating the care, and providing clinical guidance and oversight. Failure of the facility to implement and/or provide interventions to maintain safety of the residents and ensure the residents highest quality of care resulted in the likelihood of a serious event when Resident #549 exited the facility without staff knowledge or supervision on 2 separate occasions, 3 days apart, through a malfunctioning exit door. The QAPI committee program failed to identify the root cause of elopement. The facility failed to report and thoroughly investigate allegations of resident-to-resident abuse, verbal and sexual abuse, and misappropriation of resident property. The QAPI committee failed to monitor ongoing behaviors for sexual abuse and failed to implement safety measures for residents related to abuse. The facility failed to provide sufficient staffing to provide care and services, promote the residents' highest practicable well-being when 1 Licensed Practical Nurse (LPN) #15 was assigned to 94 residents during his shift. The facility QAPI program failed to ensure residents were provided care and services to meet a resident's highest practicable well-being for foot care and services causing pain for Resident #25 and #93. The facility QAPI program failed to provide oversight that established and implemented policies and procedures to ensure the facility provided effective housekeeping services and maintenance services to maintain a sanitary, orderly, and comfortable environment. These failures resulted in Immediate Jeopardy for Resident #5 #14, #25, #29, #30, #50, #72, #549, #550, and #551, actual Harm for Resident #25 and Resident #93, and Substandard Quality of Care in environment. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-689 during the complaint investigation on 8/9/2022 at 6:20 PM, in the Omega Room. The Administrator and the Director of Nursing were notified of the Immediate Jeopardy (IJ) for F-600 and F-610 during the complaint investigation on 8/12/2022 at 2:50 PM, in the Omega Room. The Administrator and the Director of Nursing were notified of the Immediate Jeopardy (IJ) for F-609 and F-725 on 8/24/2022 at 7:03 PM, in the Omega Room. The [NAME] President of Clinical Operations, the Administrator, and the Director of Nursing were notified of the Immediate Jeopardy (IJ) for F-744, F-835, and F-867 on 8/26/2022 at 5:48 PM, in the Omega Room. The [NAME] President of Clinical Operations and the Regional Director of Clinical Operations were notified of the Immediate Jeopardy (IJ) for F-837 on 8/30/2022 at 12:04 PM, in the Omega Room. The facility was cited Immediate Jeopardy at F-600, F-609, F-610, F-689, F-725, F-744, F-835, F-837, and F-867. The facility was cited at F-600, F-609, F-610, and F744 at a scope and severity of K, at F-584 at a scope and severity of F, and at F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 3/29/2022 and is ongoing. The findings include: Review of the facility's undated policy titled Quality Assurance Performance Improvement Plan, revealed .it is the intent of this facility to conduct an on-going quality assurance/performance improvement program designed to systematically monitor and evaluate the quality and appropriateness of resident care, pursue opportunities to improve resident care, resolve identified problems and identify opportunities for improvement. Performance improvement supports the overall goals of the facility and examines both outcomes and processes relevant to these outcomes with the objective of improving the organization's overall performance .The program will be a coordinated effort among all department and services within the organization .The Quality Assurance and Performance Improvement committee will meet at a minimum on a monthly basis and as needed .The Quality Assurance and Performance Improvement Committee is set up to provide structure and direction for the Performance Improvement Program and Risk Management. The Quality Assurance and Performance Improvement Committee is responsible for establishing priorities, approving key quality indicators and assigning project team/s if deemed appropriate .Composition of the Performance Improvement Committee shall include but not limited to .Administrator .Director of Nursing .Medical Director .Nurse Practitioner .Consulting Pharmacist .Registered Dietitian .Medical Record .at least two other facility persons .RAI [Resident Assessment Instrument] Coordinator .The facility will identify areas for Quality Assurance/Performance Improvement monitoring and tools/resources to be used. These monitoring activities should focus on those processes that significantly affect resident outcomes .The following sources of data will be used .Resident electronic health record .Direct observation .Departmental logs .24-hour report .Clinical rounds check list .Accident/incident log/trending .Resident/family grievance log .PIP [Performance Improvement Project] committee minutes .Survey results .Compliance survey .ABAQIS [a complete quality management system] .Risk Management Reports .Safety Committee .QI/QM [Quality Indicators/Quality Measures] .The QAPI committee will review and coordinate all the proposed activities and identify the priorities .Once an aspect of care has been selected the committee .Decide if this is to be a concurrent or retrospective study .PIP will be established for the purpose of finding the root cause of the identified areas of concern .Identify the goal .These goals must be objective, measurable and based on current knowledge and/or clinical experience .It is expected that each department at any given time will generally be involved in one intensive Performance Improvement Project activity and one facility wide Quality Assurance Performance Improvement activity while continuing to perform routine monitoring at their respective areas .The department/committee will document findings, initiate corrective actions as directed and present results to the Quality Assurance Performance Improvement Committee .The Quality Assurance Performance Improvement committee will advise individual services and Performance Improvement Project Teams on methodology, data collection and data analysis and will review all final reports and recommendations .The goals, plans and results of the facility's Quality Assurance Performance Improvement activities will be communicated to all staff by means of staff meetings, changes in policy and procedures, and in-service training .The Quality assurance Performance Improvement Committee has the responsibility for designing and implementing corrective action plans as needed to resolve resident aspects of care/service problems. Improvement plans and effectiveness of actions will be documented in the committee minutes . Review of the undated Nursing Home Administrator job description revealed .The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality of care can be provided .As Administrator, you are delegated the administrative authority, responsibility and accountability necessary for carrying out your assigned duties .Serve on various committees of the facility .and provide written/oral reports of such committee meetings to the governing board as directed .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies . The facility's signed Director of Nursing job description dated 7/13/2021, revealed .The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medial Director, to ensure that the highest degree of quality care is maintained at all times .you are delegated that administrative authority, responsibility, and accountability necessary for carrying out your assigned duties .Develop, implement, and maintain an ongoing quality assurance program for the nursing service department .Assist the Quality Assessment & Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies . During an interview on 8/26/2022 at 4:56 PM, the Administrator, DON, and [NAME] President of Clinical Operations confirmed the process of collecting data to bring to the QAPI to review would be anything that is under review. The [NAME] President of Clinical Operations stated, .we bring a spreadsheet, anything that is negative, we do a Root Cause Analysis . The Administrator, DON, and [NAME] President of Clinical Operations confirmed they look at the last survey results and stated, .working on elopement, we added a key-pad lock to restricted areas, wander guard system (a monitoring device to alert staff of a resident attempting to exit the facility unattended) .we identified the high-risk residents .new residents with the possibility of wandering .wander guards are placed on them .the doors were changed . The [NAME] President of Clinical Operations stated, .we changed elopement focus to unsafe areas, we had to look at our system processes. Qualitative and Quantitative measures in the facility behavior meeting, we go over the behavior meeting data, pharmacy reviews, Root Cause Analysis is brought to the behavior meeting . The DON confirmed behaviors are reviewed in QAPI once a month. The Administrator was asked if her Quality Assurance (QA) had been effective in the facility. The Administrator stated, for the most part, we have identified things that have been missed or are not adequate . The DON stated, .there was a lot y'all saw . The [NAME] President of Clinical Operations stated, .we have a tracking sheet now, it is more formal. The Administrator, Director of Nursing, and [NAME] President of Clinical Operations were asked how they monitor and ensure the facility and resident rooms are kept in good condition. The DON confirmed they do spot checks. The Administrator stated, .no designated time, it's random . During a telephone interview on 8/30/2022 at 8:00 AM, the Chief Operating Officer (COO) confirmed the [NAME] President of Clinical Operations reported to her on the regular reports of QA, Patients at Risk (PAR), falls, weights and accidents. The COO confirmed she was not made aware of a resident exiting the building on 7/27/2022, and she confirmed it was a requirement that they notify her of any incident. She confirmed the facility determined the Root Cause Analysis for the first elopement was the resident did not have a wander guard on. She confirmed the facility determined the Root Cause Analysis for the second elopement was because the wander guard batteries were dead (the door the resident exited did not have a wander guard system). She confirmed she was not made aware of sexual abuse. She stated, It should have been reported, we have a procedure in place. Most oversite comes from policy and procedures. My oversite is to ensure the [NAME] President of Clinical Operations is trained and educated She confirmed she reviews the policies after they are written to make any needed changes. She confirmed she last attended a QA meeting before COVID (Coronavirus). The QAPI committee failed to ensure Administration developed and implemented policies and procedures, had a system in place to monitor nursing services and facility staff, and had a system to ensure allegations of abuse were thoroughly reported and investigated. Refer to F-600, F-609, F-610, and F-689 The QAPI committee failed to have a QAPI program that was ongoing, comprehensive, and addressed the full range of care and services provided by the facility and utilized the best available evidence to define and measure indicators of facility goals that reflected processes of care for residents with allegations of abuse. Refer to F-600, F-744, and F-835 The QAPI failed to establish, monitor, and implement policies and procedures to ensure adequate staffing. F-725 The QAPI committee failed to ensure behaviors were monitored. Refer to F-744 The QAPI committee failed to provide ongoing communication between the facility and the Governing Body, Administrative staff, including the Administrator, and the Director or Nursing to ensure identified concerns were addressed in a timely manner. Refer to F-837

Based on policy review, job description review, review of facility investigations, review of Grievance Logs, medical record review, observation, and interview, the facility failed to ensure a resident's right to be free from abuse, neglect, and misappropriation for 9 of 13 sampled residents (Resident #5, #14, #25, #29, #30, #50, #549, #550, and #551) reviewed for abuse. The facility's failure to ensure a resident's right to be free from abuse, neglect, and misappropriation resulted in Immediate Jeopardy when the facility failed to identify an incident of resident to resident verbal abuse between Resident #14 and Resident #25, an incident of resident to resident sexual abuse between Resident #14 and Resident #29, an incident of sexual abuse involving Resident #5 and a facility staff member (Certified Nurse Assistant (CNA) #8), incidents of misappropriation of residents' money for Resident #30 and #25 and Resident #50's missing debit card, allegations of neglect for Resident #551, and an allegation of verbal abuse and neglect for Resident #550 by Licensed Practical Nurse (LPN) #6 and LPN #3. The facility failed to ensure a resident was free from neglect when the facility staff neglected to provide adequate supervision for a vulnerable resident (Resident #549) who exited the facility unsupervised and without staff knowledge on 2 separate occasions, 3 days apart. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy during the complaint investigation on 8/12/2022 at 2:50 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-600. The facility was cited at F-600 at a scope and a severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 3/29/2022 and is ongoing. The findings include: Review of the facility's Abuse Prevention Policy, reviewed 11/1/2021, revealed .the resident had the right to be free from verbal, sexual, physical, and mental abuse .resident has the right to be free from .neglect and misappropriation of property .The abuse coordinator in the facility is the administrator. Reports of allegations or suspected abuse, neglect, or exploitation .Abuse means the willful infliction of injury .intimidation .depravation .of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Abuse may be resident to resident, staff to resident .Verbal abuse .use of oral .language that .includes disparaging and derogatory terms .Sexual abuse includes but not limited to sexual harassment, sexual coercion, or sexual assault .Physical abuse includes hitting, slapping, pinching, kicking .Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness .misappropriation of resident property .misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money .When abuse, neglect or exploitation is suspected the Licensed Nurse should .respond to the needs of the resident, and protect them from further abuse .notify the Director of Nursing and Administrator .complete an incident report and initiate an immediate investigation to prevent further potential abuse .obtain witness statements following incident policies; suspend the accused employee .monitor and document the resident's condition, including the response to medical treatment or nursing interventions. Provide initial and follow-up counseling for the resident/s .document actions taken .All facility staff including contractors and volunteers will be educated on abuse, neglect, and exploitation . Review of the facility's policy titled, Resident Grievances, revised 8/22/2017, revealed .resident's right to voice grievances of any nature with the assurance that the facility actively seeks a resolution and keep the resident appropriately apprised of its progress towards resolution .facility is responsible in taking appropriate corrective action . The facility's signed Administrator job description dated 3/1/2022, revealed .Administration .The primary purpose of your job is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality of care can be provided to our residents at all times .you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties .Ensure that all employees, residents, visitors and the general public follow the facility's established policies and procedures .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies .improvement of services .Ensure that an adequate number of appropriately trained licensed professional and non-licensed personnel are on duty at all times to meet the needs of the residents . The facility's signed Director of Nursing job description dated 7/13/2021, revealed .The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medial Director, to ensure that the highest degree of quality care is maintained at all times .Review complaints and grievances made by the resident and make a written/oral report to the Administration indicating what action(s) were taken to resolve the complaint or grievance .Report and investigate all allegations of resident abuse and/or misappropriation of resident property . Review of the medical record review, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Incident Report dated 7/13/2022, revealed .he [Resident #5] had given a staff member [CNA #8] $187.50 . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 12, indicating Resident #5 was moderately impaired cognition. There was no documentation of interviews with Resident #5's roommate or other interviewable residents regarding any unreported allegations of misappropriation by CNA #8. There were no additional staff interviews documented to attempt to identify if the staff had noticed any unreported inappropriate behaviors or statements regarding CNA #8 related to misappropriation. The facility failed to thoroughly investigate the incident of misappropriation to ensure no other residents were victims of misappropriation by CNA #8. Observations from 8/2/2022 through 8/30/2022, revealed Resident #5 was up daily participating in activities and appeared calm. Review of an incident reported by Adult Protective Services (APS) on 8/4/2022, revealed an allegation of sexual relationship involving Resident #5 and CNA #8. During an interview on 8/8/2022 at 4:02 PM, the DON was asked if there had been allegations of a sexual relationship and misappropriation concerning Resident #5. The DON stated, .no reports of a sexual relationship between a staff member and a resident until Adult Protective Services came .to investigate an allegation for [Named Resident #5] .I didn't .start an investigation because APS had already came [come] and you [State Survey Agency] were here . The DON confirmed APS came to interview Resident #5 about a sexual relationship with a CNA #8. During an interview on 8/10/2022 at 4:55 PM, Resident #5 stated, .she [CNA #8] asked me to borrow money to get back and forth to work on .she needed to get an apartment .her purse had gotten stolen .she borrowed money and was supposed to pay me back .then she started dodging me .I took a picture of her with my phone she knew I was taking a picture .she performed oral sex one time here in this room .I didn't report it .it was consensual . During an interview on 8/17/2022 at 11:31 AM, CNA #5 stated, .[Named Resident #5] told me that he thought someone had taken his debit card .I told him I would have to report it .I told [Named Social Worker] .[Named CNA #8] suddenly started staying over on nights and always wanted that hall assigned to her .in May [Named Resident #5] told me he was getting ready to move out into the apartments behind the facility with [Named CNA #8] .he told me he gave her [CNA #8] some money to pay down on an apartment .he told me she gave him oral sex and some of her panties .I told him [Resident #5] he needed to report it when he said he was giving her money for stuff . The facility failed to investigate the incident of alleged sexual misconduct to ensure no other residents were victims of sexual misconduct by CNA #8. Review of the medical record, revealed Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Progress Note dated 3/29/2022, revealed .resident [#14] has been displaying inappropriate sexual behavior. Resident [#14] grabbing at staff members and descriptively describing their body parts. Resident [#14] stated, 'I'm going [Explicit Word] the [Explicit Word] out of them'. Resident [#14] then stated to niece on phone im [I'm] just [Explicit Word] with them and asking about their [Explicit Word] resident [#14] stated 'I want one of yall [y'all] to hit me so I can slap the[OBSCENITY]out of yall [y'all], put me out.' Resident [#14] cursing staff . Review of Resident #14's Progress Note dated 3/30/2022, revealed .On 3/29/22 [2022], the SW [Social Worker] was informed that the resident grabbed the buttocks of a housekeeper and then attempted to grab the activities assistant vaginal [the Activity Assistant's vagina]. The resident was making [NAME] and inappropriate comments and offer the staff money for sex. The SW talked to the resident who then admitted to the behaviors and then attempted the grab the SW. The SW went to the DON's office to report the incident. The resident was asked to come into the DON's office to talk about the incident. The resident admitted what he was accused of and then proceeded to call the staff [Explicit Word] . Review of Progress Note dated 3/31/2022, revealed, .new problem. Staff reports he [Resident #14] has been grossly verbally and physically inappropriate with female staff including threats of physical harm . The facility failed to identify an incident of verbal abuse. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #14 had BIMS score of 6, indicating severely impaired cognition, impaired decision making, and displayed physical and verbal behaviors directed toward others. Review of the quarterly MDS dated [DATE], revealed Resident #14 had a BIMS of 10, indicating moderately impaired cognition. Review of the Care Plan initiated on 6/16/2022, revealed Resident #14 had a behavior problem related to inappropriate sexual behaviors. Observations 8/3/2022 through 8/16/2022 revealed, Resident #14 was up daily, participated in activities, and appeared clean and neat. Observation in the resident's room on 8/17/2022, revealed Resident #14 was in bed and a female staff member was in the room supervising. Review of the medical record, revealed Resident #14 discharged to an acute care hospital on 8/19/2022 due to increased sexual behavior. Review of the medical record, revealed Resident #25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #25 had a BIMS of 15, which indicated intact cognition. Review of Resident #14's Progress Note dated 6/17/2022, revealed, .On yesterday, the resident [#14] rolled up behind a female resident [Resident #25] and threatened her by stating, I am going to beat your [explicit]. The female resident [Resident #25] notified this SW who then talked to the DON and psych [psychiatric] services . The facility failed identify the incident as verbal abuse and was unable to provide an investigation of this incident to protect to ensure no other residents were victims of abuse from Resident #14. Observations 8/2/2022 through 8/30/2022 revealed Resident #25 was up and participated in activities daily. During an interview on 8/17/2022 at 2:00 PM, the [NAME] President of Clinical Operations confirmed the behaviors would be considered an incident of abuse. During an interview on 8/29/2022 at 9:26 AM, Resident #25 was asked if she was fearful of Resident #14 after he threatened her. Resident #25 stated, .no . During an interview on 8/23/2022 at 8:32 AM, Resident #25 stated, .I had money come up missing in March .I told the [former] Social Worker .I haven't heard anything about the missing money . Review of the 3/2022 Grievance Log, revealed there were no grievances related to Resident #25's missing money. The surveyor informed the DON of Resident #25's report of missing money on 8/27/2022 at 9:50 AM. During an interview on 8/30/2022 at 10:44 AM, the DON stated, .she said the money was misplaced she didn't say it had been taken .just misplaced . During an interview on 8/30/2022 at 10:50 AM, the Administrator stated, .a grievance was filed on 8/22/2022 that the money was misplaced not missing .when I talked to her about it yesterday [8/29/2022] she said the money was missing and she thought someone took it .that's when it became an allegation .doesn't normally take a week to resolve a grievance but she said the money was misplaced . The facility failed to start the investigation until 8/27/2022, 5 days after the Grievance and failed to resolve the allegation of misappropriation until 8/29/2022. Review of the medical record, revealed Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident #14's Psychiatric Nurse Practitioner Progress Note dated 7/14/2022, revealed, .asked to see ahead of scheduled visit due to same problems staff reports he [Resident #14] touched a female resident [Resident #29] inappropriately on her breasts today. This is a pattern of behavior for this resident . The facility failed to identify this incident of sexual abuse. The facility failed to implement interventions to protect residents from further abuse by Resident #14 until 8/17/2022 when Resident #14 was placed on one to one (1:1) supervision. Observations of Resident #29 throughout the onsite visit from 8/2/2022 to 8/17/2022, revealed Resident #29 wandered throughout the facility without a bra, wearing a light-colored t-shirt, and her nipples were noticeable through her clothing. Observations of Resident #29 beginning on 8/18/2022, revealed Resident #29 was wearing a bra and 2 shirts to ensure nipples were not noticeable. Review of the medical record, revealed Resident #30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE] revealed Resident #30 was assessed as having a BIMS of 15, indicating he was cognitively intact. Review of the Nurses' Note dated 7/28/2022, revealed Resident #30 reported he had $40.00 missing and his roommate knew where he kept his money. During an interview on 8/12/2022 at 1:02 PM, the DON was asked if she had reported the allegation of missing money for Resident #30. The DON stated, .no, I did not . During an interview on 8/12/2022 at 1:05 PM, the Administrator was asked about the allegation of missing money for Resident #30. The Administrator stated, .this is the first time I've heard about this . The facility was unable to provide an investigation of this incident of misappropriation to ensure no other residents were victims of misappropriation. Review of the medical record revealed, Resident #50 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #50 was assessed as having a BIMS of 14, indicating he was cognitively intact. Observations of during the onsite visit 8/2/2022 through 8/23/2022, revealed Resident #50 was up daily, very cheerful, talkative, and participated in activities. During an interview on 8/16/2022 at 3:20 PM, Resident #50 stated, .my debit card came up missing .it was here in my [book] .[Named CNA #8] came in the room to take care of my roommate .I left the room. When I came back the debit card wasn't in my book .I think the CNA took my card .I didn't know to report it .one of the CNAs told me I needed to report it .I went down to the Social Worker's office and left a note on the door .went back down there and the Social Worker was gone .I told [Named Interim Social Worker] that the CNA [Unknown CNA] told me to report it .I cancelled the card myself and ordered a new one .when it didn't show up I contacted [Named Interim Social Worker] to help me get another card . During an interview on 8/17/2022 at 9:39 AM, the Interim Social Worker was asked about the incident related to Resident #50's debit card. The Interim Social Worker stated, .[I] helped him get his debit card he said he misplaced it .he had the card in a [book] when the CNA [CNA #8] left out of the room he said he came back and didn't see his debit card .I suggested putting a hold on the card and requested a statement .I don't have any documentation about this, am I supposed to .I didn't look for the card .I thought it had already been reported since a CNA or a nurse knew about it . Review of the facility's investigation dated 8/19/2022, revealed Resident #50 notified the former Social Worker that his debit card was missing on or around 7/17/2022. The Social Worker notified the Administrator of the missing/alleged theft. The allegations related to misappropriation were not thoroughly investigated or investigated timely. The allegation of misappropriation was not identified until the surveyor questioned the facility about the misappropriation. Review of a closed medical record, revealed Resident #549 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #549 signed Against Medical Advice (AMA) on 7/30/2022 and was discharged . Review of the Brief Interview of Mental Status (BIMS) dated 7/23/2022 revealed Resident #549 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's investigation dated 7/27/2022, revealed .Resident last seen by nurse at 7:05 AM .was seen by another resident walking past her window .Speech Therapist saw resident sitting in front of the building [approximately 372 feet from the PUI Hall (Patient Under Investigation hall is an area designated in the facility for residents who have not received the covid vaccination are monitored for a number of days after hospitalization to ensure they do not show Covid symptoms) exit door] and was brought back into the building .30-minute checks .wander guard applied to resident .instructed maintenance to check all exit doors . Review of the Elopement Risk assessment dated [DATE] revealed, Resident #549 was assessed as high risk for elopement. The intervention of a Wander guard bracelet (a monitoring device to alert staff of a resident attempting to exit the facility unattended) was initiated and every 30 minutes safety checks. Review of the Quality Assurance Performance Improvement (QAPI) Root Cause Analysis (RCA) dated 7/27/2022, revealed .[Director of Nursing [DON] not notified of incidences in timely manner .facility failed to complete through investigation of elopement .facility failed to obtain signed and dated written statements from staff with knowledge of the incident . Review of the facility's investigation dated 7/30/2022, revealed .6:40 AM last seeing the resident .Dr. Wander [code for a missing resident] initiated .staff out in cars and on foot .police notified of possible address resident may be located .10:59 AM found resident at [Named] Autobody and Body Panel Shop [approximately 21 miles from facility] .11:30 AM Resident refused to return to facility .signed AMA [Against Medical Advice] papers . Resident #549 was not located for approximately 4 hours. Review of the facility's investigation revealed the facility did not complete a thorough investigation for the incidents of elopement, there were no written statements from nurses providing care to the resident on the previous shifts. During an interview on 8/8/2022 at 12:15 PM, the DON was asked would the wander guard monitor alarm if a resident exited the PUI exit door. The DON stated .no it would not, only the front and back entrance doors are equipped with the wander guard system. The DON was asked if staffing was adjusted to monitor Resident #549 with 30 minutes safety checks and other wandering residents on the East Hall. The DON stated .I did not check the staffing after the elopement . The facility neglected to adequately supervise Resident #549 to prevent incidents of elopement. Review of the medical record, revealed Resident #550 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 8/18/2022, revealed interventions related to anxiety and depression that included monitoring for signs and symptoms of a worsening condition. During an interview on 8/19/2022 at 11:00 AM, Resident #550 stated, .last night the nurse [Named Licensed Practical Nurse (LPN) #3] was rude to me .told me to shut up .I had a bowel movement in the floor because no one would come help me to the bathroom .would not give me my medicine .I've fell 4 times since I've been here . During an interview on 8/20/2022 at 8:30 AM, The [NAME] President of Clinical Operations confirmed the allegation of verbal abuse. During an interview on 8/23/2022 at 3:20 PM, the Administrator confirmed the investigation was not completed and Licensed Practical Nurse (LPN) #3 was allowed return to work on 8/22/2022 before the investigation was completed and coaching was not done with LPN #3 until 8/23/2022. LPN #3 returned to work before the investigation was completed. The Administrator confirmed the staff member should not have been allowed to return to work until a thorough investigation had been completed. Review of a closed medical record, revealed Resident #551 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #551 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Grievance concern dated 6/2/2022, revealed Resident #551 reported the following .after 5pm [5:00 PM] it is like this place shuts down. You can't get a CNA. You stay in bed with feces on you. When it gets later, you get changed but after 12 am [12:00 AM], when you call for assistant [assistance] they say I'm going to let you stay in it until next shift .I experienced this myself. They talk to you like you ain't [aren't] night [right]. I don't know if the people that run this knows but from 5 pm to 6 am [5:00 PM-6:00 AM] it is bad service. They don't answer call lights .It's terrible .Findings employee failed to respond [to the resident's needs and call lights] in timely manner with resident's request stated via resident .explained the routine checks via nursing and ensure .staff would follow protocols. Action taken to correct problem .spoke with CNA about importance of answering call lights timely and to keep resident informed of approx. [approximate] time of arrival .[signed by the DON] . During an interview on 8/23/2022 at 5:58 PM, the DON stated, .when a resident isn't provided care that is neglect the resident's [Resident #551] allegation of neglect .this was not reported and was not investigated because Resident #551 said he just wanted to let someone know about it .I in serviced the staff . The facility did not identify an allegation of neglect and was unable to provide an investigation of the incident to protect other residents from neglect. Refer to F-610 and F-689.

Based on policy review, job description review, medical record review, and interview, the facility failed to report or timely report incidents of abuse, neglect, and misappropriation to the appropriate agencies for 8 of 13 sampled residents (Resident #5, #14, #25, #29, #30, #50, #72, and #551) reviewed for abuse. The facility's failure to report incidents of abuse to the State Survey Agency resulted in Immediate Jeopardy when the facility failed to report allegations of resident to resident verbal abuse and staff to resident verbal abuse for Resident #14, Resident #25, and Resident #72, an incident of resident to resident sexual abuse between Resident #14 and Resident #29, an incident of sexual abuse and misappropriation for Resident #5 by a facility staff member (Certified Nurse Assistant (CNA) #8), 3 incidents of misappropriation of resident property for Resident #25, Resident #30, and Resident #50, and an allegation of neglect for Resident #551 Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for on 8/24/2022 at 7:03 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-609. The facility was cited at F-609 at a scope and a severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 3/29/2022 and is ongoing. The findings include: Review of the facility's Abuse Prevention Policy, reviewed 11/1/2021, revealed .the resident had the right to be free from verbal, sexual, physical, and mental abuse .resident has the right to be free from .neglect and misappropriation of property .The abuse coordinator in the facility is the administrator. Reports of allegations or suspected abuse, neglect, or exploitation .will be reported immediately to: Facility Abuse Coordinator, Director of Nursing, State Agencies .Abuse means the willful infliction of injury .intimidation .depravation .of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Abuse may be resident to resident, staff to resident .Verbal abuse .use of oral .language that .includes disparaging and derogatory terms .Sexual abuse includes but not limited to sexual harassment, sexual coercion, or sexual assault .Physical abuse includes hitting, slapping, pinching, kicking .Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness .misappropriation of resident property .misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money . Review of the facility's signed Administrator job description date of 3/1/2022, revealed .Administration .The primary purpose of your job is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality of care can be provided to our residents at all times .Ensure that all employees, residents, visitors and the general public follow the facility's established policies and procedures . The facility's signed Director of Nursing job description dated 7/13/2021, revealed .The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medical Director .Report and investigate all allegations of resident abuse and/or misappropriation of resident property . Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a BIMS of 12, indicating moderately impaired cognition. Review of an Incident Report dated 7/13/2022, revealed .resident stated he had given a staff member [CNA #8] $187.50 . The incident of misappropriation on 7/13/2022 was not reported to the State Survey Agency (SSA) until 7/15/2022, 2 days after the incident occurred. Review of an incident reported by Adult Protective Services (APS) on 8/4/2022, revealed an allegation of sexual relationship involving Resident #5 and CNA #8. During an interview on 8/8/2022 at 4:02 PM, the DON was asked if there had been allegations of a sexual relationship and misappropriation concerning Resident #5. The DON stated, .no reports of a sexual relationship between a staff member and a resident until Adult Protective Services came .to investigate an allegation for [Named Resident #5] .I didn't .start an investigation because APS had already came [come] and you [State Survey Agency] were here . The DON confirmed APS came to interview Resident #5 on 8/5/2022 about a sexual relationship with a CNA #8. The DON was asked if the allegation was reported to the SSA. The DON stated, .no . During an interview on 8/10/2022 at 4:55 PM, Resident #5 stated, .she [CNA #8] asked me to borrow money to get back and forth to work on .she needed to get an apartment .her purse had gotten stolen .she borrowed money and was supposed to pay me back .then she started dodging me .I took a picture of her with my phone she knew I was taking a picture .she performed oral sex one time here in this room .I didn't report it .it was consensual . During an interview on 8/17/2022 at 11:31 AM, CNA #5 stated, .[Named Resident #5] told me that he thought someone had taken his debit card .I told him I would have to report it .I told [Named Social Worker] .[Named CNA #8] suddenly started staying over on nights and always wanted that hall assigned to her .in May [Named Resident #5] told me he was getting ready to move out into the apartments behind the facility with [Named CNA #8] .he told me he gave her [CNA #8] some money to pay down on an apartment .he told me she gave him oral sex and some of her panties .I told him [Resident #5] he needed to report it when he said he was giving her money for stuff . During an interview on 8/17/2022 at 4:45 PM, the [NAME] President of Clinical Operations was informed of the allegation of sexual abuse involving Resident #5 and CNA #8. The allegation of a sexual relationship was not reported by the facility until 8/19/2022, 14 days after the facility was notified of the allegation. Review of the medical record, revealed Resident #14 was admitted to the facility on [DATE] with readmission on 6/6/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #14 was assessed as having a Brief Interview for Mental Status (BIMS) score of 6, indicating severely impaired cognition, impaired decision making, and displaying physical and verbal behaviors directed toward others. Review of the quarterly MDS dated [DATE], revealed Resident #14 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan initiated on 6/16/2022 revealed Resident #14 had a behavior problem related to inappropriate sexual behaviors. Review of the medical record, revealed Resident #25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #25 had a BIMS of 15, which indicated intact cognition. Review of Resident #14's Progress Note dated 6/17/2022, revealed, .On yesterday, the resident [#14] rolled up behind a female resident [Resident #25] and threatened her by stating, I am going to beat your [explicit]. The female resident [Resident #25] notified this SW who then talked to the DON and psych [psychiatric] services . During an interview on 8/17/2022 at 2:00 PM, the [NAME] President of Clinical Operations confirmed this was an incident of abuse and it was not reported to the SSA until 8/19/2022. During an interview on 8/23/2022 at 8:32 AM, Resident #25 stated, .I had money come up missing in March . The surveyor notified the DON of Resident #25's misappropriation allegation on 8/27/2022 at 9:50 AM. During an interview on 8/30/2022 at 10:44 AM, the DON stated, .she [Resident #25] said the money was misplaced she didn't say it had been taken .just misplaced . During an interview on 8/30/2022 at 10:50 AM, the Administrator stated, .a grievance was filed on 8/22/2022 that the money was misplaced not missing .when I talked to her about it yesterday [8/29/2022] she said the money was missing and she thought someone took it .that's when it became an allegation .doesn't normally take a week to resolve a grievance but she said the money was misplaced .I reported it on 8/29/2022 . The facility did not report the allegation of misappropriation to the SSA until 8/29/2022, 2 days after the SSA notified the facility of the alleged misappropriation. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #29 was assessed as having a BIMS of 2, indicating severe cognitive impairment. Review of the Resident #14's Psychiatric Nurse Practitioner Progress Note dated 7/14/2022, revealed, .asked to see ahead of scheduled visit due to same problems staff reports he [Resident #14] touched a female resident [Resident #29] inappropriately on her breasts today. This is a pattern of behavior for this resident . The incident of sexual abuse involving Resident #14 and Resident #29 was not reported to the SSA until 8/19/2022. During an interview on 8/18/2022 at 9:49 AM, the [NAME] President of Clinical Operations stated, .these incidents are abuse, should have been reported .not reported timely .the policies and procedures were not followed . Review of the medical record, revealed Resident #30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #30 was assessed as having a BIMS of 15, indicating he was cognitively intact. Review of the Nurses' Note dated 7/28/2022, revealed Resident #30 reported he had $40.00 missing and his roommate knew where he kept his money. During an interview on 8/12/2022 at 1:02 PM, the DON was asked if the allegation of misappropriation was reported to the SSA. The DON stated, .no, I did not . During an interview on 8/12/2022 at 1:05 PM, the Administrator was asked about the allegation of misappropriation for Resident #30. The Administrator stated, .this is the first time I've heard about this . Review of the medical record, revealed Resident #50 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #50 was assessed as having a BIMS of 14, indicating he was cognitively intact. During an interview on 8/16/2022 at 3:20 PM, Resident #50 stated, .my debit card came up missing .it was here in my [book] .[Named CNA #8] came in the room to take care of my roommate .I left the room. When I came back the debit card wasn't in my book .I think the CNA took my card .I didn't know to report it .one of the CNAs told me I needed to report it .I went down to the Social Worker's office and left a note on the door .went back down there and the Social Worker was gone .I told [Named Interim Social Worker] that the CNA [Unknown CNA] told me to report it .I cancelled the card myself and ordered a new one .when it didn't show up I contacted [Named Interim Social Worker] to help me get another card . During an interview on 8/17/2022 at 9:39 AM, the Interim Social Worker was asked about the incident related to Resident #50's debit card. The Interim Social Worker stated, .[I] helped him get his debit card he said he misplaced it .he had the card in a [book] when the CNA [CNA#8] left out of the room he said he came back and didn't see his debit card .I suggested putting a hold on the card and requested a statement .I don't have any documentation about this, am I supposed to .I didn't look for the card .I thought it had already been reported since a CNA or a nurse knew about it .he said he had told the [former Social Worker] . The allegation of misappropriation was not reported to the SSA until 8/19/2022. Review of a closed medical record, revealed Resident #72 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurses' Note dated 6/10/2022 at 7:15 AM, revealed .Assigned nurse at cart 1 restocking. dietary personnel on floor at this time entering kitchen bring coffee for am breakfast. Resident [Resident #72] up in w/c [wheelchair] sitting several steps away from kitchen stated, 'To [to] dietary personnel to give a cup of coffee.' dietary staff attempted to explain she can't served [serve]. Nurse at side attempted to explains [explain that] dietary personnel unable to give coffee resident nursing staffs [staff] will serve [coffee to the resident]. Resident yelling at nurse with increase [increased] agitation and cursing. yelling in loud tones stating nurse a [NAME] U [you] hating on me about the coffee. you don't want nobody to like me you a street nigger and I will beat a [Explicit Words]. Stay out of my business. I was talking to that lady not you. Nurse voiced understanding and stepped away resident continue to approach with continue cursing's [continued cursing] Resident calming down some. Will continue to monitor . Review of the quarterly MDS dated [DATE], revealed Resident #72 had a BIMS score of 10, indicating moderately impaired cognition and verbal behavioral symptoms directed toward others. During an interview on 8/11/2022 at 11:35 AM, the Environmental Services Account Manager stated, .one of my employees has [had] witnessed verbal abuse .[Housekeeper #1] told me they heard a staff member threaten a resident in the Dining Room . During an interview on 8/11/2022 at 2:12 PM, the Housekeeper #1 stated, .I heard the [Named former Activities Assistant] threaten to slap the[OBSCENITY]out of [Named Resident #72] in the Dining Room about 2-3 weeks ago . During a telephone interview on 8/15/2022 at 5:27 PM, the former Activity Assistant stated, .I had reported the resident's abusive statements and treatment to the Administration, they didn't do anything .yes I told him I was going to slap the[OBSCENITY]out of him .he had run over me, threw an apron at me, knocked a box out of my hand and shoved a table at me . The allegation of verbal abuse was reported to the SSA on 6/20/2022, 3 days after the incident occurred on 6/17/2022. Review of a closed medical record, revealed Resident #551 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE], revealed Resident #551 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Grievance concern dated 6/2/2022, revealed Resident #551 reported the following .after 5pm [5:00 PM] it is like this place shuts down. You can't get a CNA. You stay in bed with feces on you. When it gets later, you get changed but after 12 am [12:00 AM], when you call for assistant [assistance] they say I'm going to let you stay in it until next shift .I experienced this myself. They talk to you like you ain't [aren't] night [right]. I don't know if the people that run this knows but from 5 pm to 6 am [5:00 PM-6:00 AM] it is bad service. They don't answer call lights .It's terrible .Findings employee failed to respond [to the resident's needs and call lights] in timely manner with resident's request stated via resident .explained the routine checks via nursing and ensure .staff would follow protocols. Action taken to correct problem .spoke with CNA about importance of answering call lights timely and to keep resident informed of approx. [approximate] time of arrival .[signed by the DON] . During an interview on 8/23/2022 at 5:58 PM, the DON was asked if not providing care or answering call lights would be considered neglect. The DON stated, yes .when a resident isn't provided care that is neglect The DON was asked about Resident #551's allegation of neglect. The DON stated, .this was not reported and was not investigated because he said just wanted to let someone know about it . The facility did not report the allegation of neglect to the SSA.

Based on policy review, review of the Director of Nursing (DON) job description, Grievance logs and report review, and facility investigation review, medical record review, and interview, the facility failed to complete a thorough investigation related to abuse for 9 of 13 sampled residents (Resident #5, #14, #25, #29, #30, #50, #72, #549, and #551) reviewed for abuse and neglect. The facility's failure to thoroughly investigate incidents and/or allegations of abuse resulted in Immediate Jeopardy when the facility failed to thoroughly investigate incidents of resident to resident verbal abuse and staff to resident verbal abuse for Resident #14, Resident #25, Resident #50, and Resident #72, failed to thoroughly investigate an incident of resident to resident sexual abuse between Resident #14 and Resident #29, failed to thoroughly investigate an incident of sexual abuse and misappropriation for Resident #5 by a facility staff member (Certified Nurse Assistant (CNA) #8), failed to thoroughly investigate 3 incidents of misappropriation of resident property for Resident #30, #25, and #50, failed to thoroughly investigate incidents of elopement when Resident #549 exited the building without staff knowledge or supervision on 2 occasions, 3 days apart, and failed to thoroughly investigate an allegation of neglect for Resident #551. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-610 during the complaint investigation on 8/12/2022 at 2:50 PM, in the Omega Room. The facility was cited Immediate Jeopardy at F-610. The facility was cited at F-610 at a scope and a severity of K, which is Substandard Quality of Care. The Immediate Jeopardy existed from 3/29/2022 and is ongoing. The findings include: Review of the facility's Abuse Prevention Policy, reviewed 11/1/2021, revealed .the resident had the right to be free from verbal, sexual, physical, and mental abuse .resident has the right to be free from .neglect and misappropriation of property .The abuse coordinator in the facility is the administrator. Reports of allegations or suspected abuse, neglect, or exploitation .will be reported immediately to: Facility Abuse Coordinator, Director of Nursing, State Agencies .Abuse means the willful infliction of injury .intimidation .depravation .of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Abuse may be resident to resident, staff to resident .Verbal abuse .use of oral .language that .includes disparaging and derogatory terms .Sexual abuse includes but not limited to sexual harassment, sexual coercion, or sexual assault .Physical abuse includes hitting, slapping, pinching, kicking .Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness .misappropriation of resident property .misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money .When abuse, neglect or exploitation is suspected the Licensed Nurse should .respond to the needs of the resident, and protect them from further abuse .notify the Director of Nursing and Administrator .complete an incident report and initiate an immediate investigation to prevent further potential abuse. Notify the attending physician, resident's family/legal representative and Medical Director .obtain witness statements following incident policies; suspend the accused employee .monitor and document the resident's condition, including the response to medical treatment or nursing interventions. Provide initial and follow-up counseling for the resident/s .document actions taken .All facility staff including contractors and volunteers will be educated on abuse, neglect, and exploitation .Investigations of alleged Abuse, Neglect and Exploitation .must start immediately .When suspicion or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted .Components of the investigation may include: Interview with the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area and visitors in the area .Document the entire investigation chronologically .Administrator will review investigational findings .Administrator will review outcome in monthly continuous quality improvement meeting . Review of the facility's signed Director of Nursing job description dated 7/13/2021, revealed .The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medial Director, to ensure that the highest degree of quality care is maintained at all times .Review complaints and grievances made by the resident and make a written/oral report to the Administration indicating what action(s) were taken to resolve the complaint or grievance .Report and investigate all allegations of resident abuse and/or misappropriation of resident property . Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 12, indicating moderately impaired cognition. Review of a facility investigation revealed the facility received an allegation of misappropriation of Resident #5's money on 7/13/2022. The facility's investigation included an Alleged Abuse Incident Report dated 7/13/2022 at 2:29 PM indicating Resident #5 stated he had given a staff member $187.50, an employee warning notice dated 7/14/2022 for CNA #8, and a printout of the Resident Account Statement from 3/2022 to 7/13/2022. There was no documentation of interviews with Resident #5's roommate or other interviewable residents regarding any unreported allegations of misappropriation by CNA #8. There were no additional staff interviews documented to attempt to identify if the staff had noticed any unreported inappropriate behaviors or statements regarding CNA #8 related to misappropriation. The allegation of misappropriation was not thoroughly investigated. During an interview on 8/8/2022 at 4:02 PM, the DON was asked if there had been allegations of a sexual relationship and misappropriation concerning Resident #5. The DON stated, .no reports of a sexual relationship between a staff member and a resident until Adult Protective Services [APS] came .to investigate an allegation for [Named Resident #5] .I didn't report it or start an investigation because APS had already came [come] and you [State Survey Agency] were here . During an interview on 8/10/2022 at 4:55 PM, Resident #5 stated, .she [CNA #8] asked me to borrow money to get back and forth to work on .she needed to get an apartment .her purse had gotten stolen .she borrowed money and was supposed to pay me back .then she started dodging me .I took a picture of her with my phone she knew I was taking a picture .she performed oral sex one time here in this room .I didn't report it .it was consensual . During an interview on 8/17/2022 at 11:31 AM, CNA #5 stated, .[Named Resident #5] told me that he thought someone had taken his debit card .I told him I would have to report it .I told [Named Social Worker] .[Named CNA #8] suddenly started staying over on nights and always wanted that hall assigned to her .in May [Named Resident #5] told me he was getting ready to move out into the apartments behind the facility with [Named CNA #8] .he told me he gave her [CNA #8] some money to pay down on an apartment .he told me she gave him oral sex and some of her panties .I told him [Resident #5] he needed to report it when he said he was giving her money for stuff . The facility was unable to provide documentation that the allegation of sexual abuse and misappropriation by a staff member was investigated and investigated timely. Review of the medical record, revealed Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Progress Note dated 3/29/2022, revealed .resident [#14] has been displaying inappropriate sexual behavior. Resident [#14] grabbing at staff members and descriptively describing their body parts. Resident [#14] stated, 'I'm going [Explicit Word] the [Explicit Word] out of them'. Resident [#14] then stated to niece on phone im [I'm] just [Explicit Word] with them and asking about their [Explicit Word] resident [#14] stated 'I want one of yall [ya'll] to hit me so I can slap the[OBSCENITY]out of yall [ya'll], put me out.' Resident [#14] cursing staff . Review of Resident #14's Progress Note dated 3/30/2022, revealed .On 3/29/22 [2022], the SW [Social Worker] was informed that the resident grabbed the buttocks of a housekeeper and then attempted to grab the activities assistant vaginal [the Activity Assistant's vagina]. The resident was making [NAME] and inappropriate comments and offer the staff money for sex. The SW talked to the resident who then admitted to the behaviors and then attempted the grab the SW. The SW went to the DON's office to report the incident. The resident was asked to come into the DON's office to talk about the incident. The resident admitted what he was accused of and then proceeded to call the staff [Explicit Word] . Review of Progress Note dated 3/31/2022, revealed, .new problem. Staff reports he [Resident #14] has been grossly verbally and physically inappropriate with female staff including threats of physical harm . Review of the quarterly MDS dated [DATE], revealed Resident #14 was assessed as having a BIMS score of 6, indicating severely impaired cognition, impaired decision making, and displaying physical and verbal behaviors directed toward others. Review of the quarterly MDS dated [DATE], revealed Resident #14 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan initiated on 6/16/2022, revealed Resident #14 was assessed for behavior problem related to inappropriate sexual behaviors. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #25 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident #14's Progress Note dated 6/17/2022, revealed .On yesterday, the resident rolled up behind a female resident and threatened her by stating, 'I am going to beat your [Explicit Word].' The female resident [Resident #25] notified this SW who then talked to the DON and psych [Psychiatric] services . The facility was unable to provide an investigation of this incident. Review of the medical record, revealed Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #29 was assessed as having a BIMS of 2, indicating severe cognitive impairment. Review of a Physician's Progress Note for Resident #14 dated 7/14/2022, revealed .increased sexual behaviors .[Resident #14] feeling on resident's [Resident #29] breast . Review of the Psychiatric Nurse Practitioner Progress Note dated 7/14/2022, revealed .asked to see ahead of scheduled visit due to same problems staff reports he [Resident #14] touched a female resident [Resident #29] inappropriate on her breasts today. This is a pattern of behavior for this resident .says the female resident invited him to touch her. Pointed out that she has little verbal and is not capable of that .continued to deny responsibility .more angry outbursts are occurring .continued instances of impulsive behaviors .Non pharm [pharmacological] interventions have been ineffective . The facility was unable to provide an investigation of this incident. During an interview on 8/18/2022 at 9:49 AM, the [NAME] President (VP) of Clinical Operations stated, .these incidents [of abuse] .were not investigated .the policies and procedures we have in place were not followed . During an interview on 8/23/2022 at 8:32 AM , Resident #25 stated, .I had money come up missing in March . Review of the 3/2022 Grievance Log, revealed there were no grievances related to Resident #25's missing money. Review of a Grievance dated 8/22/2022, revealed, .date of the incident unknown .resident says she had $20 misplaced when she was in room [named number] Resident unsure of what happened with the money .Resident admitted to room [named number] 3/2/22 [2022]. Resident says she told a staff member that no longer is employed @ [at] the facility. UM [Unit Manager] has no knowledge of missing money. Residents in the area denies having item missing .unable to validate the resident's accusation of misplaced money .The date complainant notified of the investigation results 8/29/2022 notified by the Administrator . The surveyor notified the DON of Resident #25's concern related to missing money on 8/27/2022 at 9:54 AM. During an interview on 8/30/2022 at 10:44 AM, the DON stated, .she said the money was misplaced she didn't say it had been taken .just misplaced . During an interview on 8/30/2022 at 10:50 AM, the Administrator stated, .a grievance was filed on 8/22/2022 that the money was misplaced not missing .when I talked to her about it yesterday [8/29/2022] she said the money was missing and she thought someone took it .that's when it became an allegation .doesn't normally take a week to resolve a grievance but she said the money was misplaced . The facility failed to start the investigation until 8/27/2022, 5 days after the Grievance. Review of the medical record, revealed Resident #30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #30 was assessed as having a BIMS of 15, indicating he was cognitively intact. Review of the Nurses' Note dated 7/28/2022, revealed Resident #30 reported he had $40.00 missing and his roommate knew where he kept his money. During an interview on 8/12/2022 at 1:02 PM, the DON was asked about a Grievance by Resident #30. The DON stated, .I talked to the resident [Resident #30] .we could not prove he had the $40.00 . During an interview on 8/12/2022 at 1:05 PM, the Administrator was asked about the Grievance by Resident #30. The Administrator stated, .this is the first time I've heard about this . The facility was unable to provide an investigation of this incident. Review of the medical record, revealed Resident #50 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #50 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/16/2022 at 3:20 PM, Resident #50 stated, .my debit card came up missing .it was here in my [book] .[Named CNA #8] came in the room to take care of my roommate .I left the room. When I came back the debit card wasn't in my book .I think the CNA took my card .I didn't know to report it .one of the CNAs told me I needed to report it .I went down to the Social Worker's office and left a note on the door .went back down there and the Social Worker was gone .I told [Named Interim Social Worker] that the CNA [Unknown CNA] told me to report it .I cancelled the card myself and ordered a new one .when it didn't show up I contacted [Named Interim Social Worker] to help me get another card . During an interview on 8/17/2022 at 9:39 AM, the Interim Social Worker was asked about the incident related to Resident #50's debit card. The Interim Social Worker stated, .[I] helped him get his debit card he said he misplaced it .he had the card in a [book] when the CNA [CNA #8] left out of the room he said he came back and didn't see his debit card .I suggested putting a hold on the card and requested a statement .I don't have any documentation about this, am I supposed to .I didn't look for the card .I thought it had already been reported since a CNA or a nurse knew about it . Review of the facility's investigation dated 8/19/2022, revealed Resident #50 notified the former Social Worker that his debit card was missing on or around 7/17/2022. The Social Worker notified the Administrator of the missing/alleged theft. The allegations related to misappropriation were not thoroughly investigated or investigated timely. Review of a closed medical record, revealed Resident #72 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurses' Note dated 6/10/2022 at 7:15 AM, revealed .Assigned nurse at cart 1 restocking. dietary personnel on floor at this time entering kitchen bring coffee for am breakfast. Resident [Resident #72] up in w/c [wheelchair] sitting several steps away from kitchen stated, 'To [to] dietary personnel to give a cup of coffee.' dietary staff attempted to explain she can't served [serve]. Nurse at side attempted to explains [explain that] dietary personnel unable to give coffee resident nursing staffs [staff] will serve [coffee to the resident]. Resident yelling at nurse with increase [increased] agitation and cursing. yelling in loud tones stating nurse a [NAME] U [you] hating on me about the coffee. you don't want nobody to like me you a street nigger and I will beat a [Explicit Words]. Stay out of my business. I was talking to that lady not you. Nurse voiced understanding and stepped away resident continue to approach with continue cursing's [continued cursing] Resident calming down some. Will continue to monitor . Review of the quarterly MDS dated [DATE], revealed Resident #72 had a BIMS score of 10, indicating moderately impaired cognition and verbal behavioral symptoms directed toward others. During an interview on 8/11/2022 at 11:35 AM, the Environmental Services Account Manager stated, .one of my employees has [had] witnessed verbal abuse .[Housekeeper #1] told me they heard a staff member threaten a resident in the Dining Room . During an interview on 8/11/2022 at 2:12 PM, Housekeeper #1 stated, .I heard the [Named former Activities Assistant] threaten to slap the[OBSCENITY]out of [Named Resident #72] in the Dining Room about 2-3 weeks ago .I wasn't interviewed about it or asked to write a statement . During an interview on 8/12/2022 at 1:54 PM, the Administrator stated, .I interviewed dietary and environmental no one said they heard anything .I don't have documented who specifically I interviewed and what they said . During a telephone interview on 8/15/2022 at 5:27 PM, the former Activities Assistant stated, .I had reported the resident's abusive statements and treatment to the Administration, they didn't do anything .yes I told him I was going to slap the[OBSCENITY]out of him .he had run over me, threw an apron at me, knocked a box out of my hand and shoved a table at me . The facility's investigation did not include the names of staff interviewed, there were no interviews with other residents or other staff members to ensure there were no other incidents related to the former Activity Assistant's threat of physical violence. Review of the medical record, revealed Resident #549 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Clinical Admission Evaluation dated 7/22/2022, revealed Resident #549 had disorganized thinking, walked with an unsteady gait and poor balance, and wandered at night. Review of the BIMS assessment dated [DATE], revealed Resident #549 had a score of 14 indicating he was cognitively intact. Review of the facility's investigation dated 7/27/2022, revealed .Resident last seen by nurse at 7:05 AM .was seen by another resident walking past her window .Speech Therapist saw resident sitting in front of the building [approximately 372 feet from the PUI Hall (Patient Under Investigation hall is where patients who have not been vaccinated for Covid are observed for covid symptoms for a number of days after being hospitalized ) exit door] and was brought back into the building .30-minute checks .wander guard applied to resident .instructed maintenance to check all exit doors . Review of the Elopement Risk assessment dated [DATE] revealed, Resident #549 was assessed as high risk for elopement. The intervention of a Wander guard bracelet (a monitoring device to alert staff of a resident attempting to exit the facility unattended) was initiated and every 30 minutes safety checks. Review of the Quality Assurance Performance Improvement (QAPI) Root Cause Analysis (RCA) dated 7/27/2022, revealed .[Director of Nursing [DON] not notified of incidences in timely manner .facility failed to complete through investigation of elopement .facility failed to obtain signed and dated written statements from staff with knowledge of the incident . Review of the facility's investigation dated 7/30/2022, revealed .6:40 AM last seeing the resident .Dr. Wander [code for a missing resident] initiated .staff out in cars and on foot .police notified of possible address resident may be located .10:59 AM found resident at [Named] Autobody and Body Panel Shop [approximately 21 miles from facility] .11:30 AM Resident refused to return to facility .signed AMA [Against Medical Advice] papers . Resident #549 was not located for approximately 4 hours. Review of the facility's investigation revealed the facility did not complete a thorough investigation for the incidents of elopement, there were no written statements from nurses providing care to the resident on the previous shifts. Review of the medical record, revealed Resident #551 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #551 was assessed as having a BIMS of 15, indicating he was cognitively intact. Review of a Grievance concern dated 6/2/2022, revealed Resident #551 reported the following .after 5pm [5:00 PM] it is like this place shuts down. You can't get a CNA. You stay in bed with feces on you. When it gets later, you get changed but after 12 am [12:00 AM], when you call for assistant [assistance] they say I'm going to let you stay in it until next shift .I experienced this myself. They talk to you like you ain't [aren't] night [right]. I don't know if the people that run this knows but from 5 pm to 6 am [5:00 PM-6:00 AM] it is bad service. They don't answer call lights .It's terrible .Findings employee failed to respond [to the resident's needs and call lights] in timely manner with resident's request stated via resident .explained the routine checks via nursing and ensure .staff would follow protocols. Action taken to correct problem .spoke with CNA about importance of answering call lights timely and to keep resident informed of approx. [approximate] time of arrival .[signed by the DON] . During an interview on 8/23/2022 at 5:58 PM, the DON stated, .when a resident isn't provided care that is neglect the resident's [Resident #551] allegation of neglect .this was not reported and was not investigated because Resident #551 said he just wanted to let someone know about it .I in-serviced the staff . The facility was unable to provide an investigation of the allegation of neglect. Refer to F-600.

Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to meet each resident's Dementia care and behavior needs and failed to provide behavior monitoring for 3 of 9 sampled residents (Resident #14, #25, and #29) reviewed for Dementia care and behaviors. The facility's failure to provide care and services for Dementia and behaviors resulted in Immediate Jeopardy when Resident #14, with a history of inappropriate sexual behaviors, verbally threatened to beat and rape Resident #25, and touched Resident #29's breast. The facility's failure resulted in Immediate Jeopardy (IJ) for Resident #14, #25, and #29. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The [NAME] President (VP) of Clinical Operations, Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy for on 8/26/2022 at 5:48 PM, in the Omega Room. The facility was cited Immediate Jeopardy at F-744. The facility was cited at F-744 at a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy existed on 3/29/2022 and is ongoing. The findings include: Review of the facility's policy titled, Mood and Behavior Policy, reviewed 11/18/ 2021, revealed .each resident must receive and the facility must provide the necessary behavioral health care and services .to attain or maintain the highest practicable physical, mental and psychosocial well-being .provide a plan of care that is individualized to the residents' needs .behavioral symptoms that may cause distress or are potentially harmful to the resident, or may be distressing or disruptive to .residents, staff members or the environment .identifying potential mood and behavior changes, support and care plan interventions .mood and behavior tracking documentation will be completed .will be reviewed by the interdisciplinary team .to determine trends and effectiveness of care plan .if resident displays behaviors or mood changes that are a potential danger to the safety, health or welfare of themselves or others, the interdisciplinary team will assess the resident's current status .make appropriate intervention . Review of the facility's policy titled, Abuse Prevention Policy, reviewed 11/1/2021, revealed .the resident has the right to be free from verbal, sexual, physical, and mental abuse .neglect and misappropriation of property .Abuse .intimidation .depravation .of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Abuse may be resident to resident, staff to resident .Verbal abuse .use of oral .language that .includes disparaging and derogatory terms .Sexual abuse includes but not limited to sexual harassment, sexual coercion, or sexual assault .Neglect means failure to provide goods and services necessary to avoid physical harm .When abuse, neglect or exploitation is suspected .respond to the needs of the resident, and protect them from further abuse . Review of the medical record, revealed Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's referral from another skilled nursing facility dated 10/18/2021, revealed .verbally aggressive towards a female resident .get things for him and trying to make her smoke .resident appeared to get angry .resident observed rubbing the arm of the female resident. The female resident asked the resident to stop but he would not .resident inappropriately grabbed a female resident on her buttocks while in the dining room . Review of the Progress Note dated 3/29/2022, revealed .Resident displaying inappropriate sexual behavior. Resident grabbing at staff members and descriptively describing their body parts. Resident stated, I'm going [explicit language] the [explicit language] out of them. Resident then stated to niece on phone I'm just [explicit language] with them and asking about their [explicit language] .resident stated I want one of yall [y'all] to hit me so I can slap the [explicit language] out of yall [y'all] put me out. Resident cursing staff . Review of the Progress Note dated 3/30/2022, revealed .On 3/29/22 [2022], the SW [Social Worker] was informed that the resident grabbed the buttocks of a housekeeper and then attempted to grab the activities assistant vaginal [the Activity Assistant's vagina]. The resident was making [NAME] and inappropriate comments and offer the staff money for sex. The SW talked to the resident who then admitted to the behaviors and then attempted the grab the SW. The SW went to the DON's office to report the incident. The resident was asked to come into the DON's office to talk about the incident. The resident admitted what he was accused of and then proceeded to call the staff [explicit language]. While the DON continued to talk with the resident about his behavior, the resident stated that if the SW wanted to hit him in the face that he would beat her [Explicit Language]. The resident then proceeded to come towards the SW in a threating manner. The DON stopped the resident and stated that the resident was attempting to provoke the SW and that she could be fearing for her safety. The resident attempted to come up on the SW at least three times while in the DON's office. The SW then left and went to her office and contacted the resident's family to report the incident. When the brother arrived, the SW escorted him to the DON's office where the resident's behavior was discussed. The brother stated that he wanted to take the resident out on LOA [leave of absence] to have a talk with him. At this time the SW has not seen the resident but will continue to report sexual inappropriate behavior as needed . Review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #14 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Progress Note dated 3/31/2022, revealed .new problem. Staff reports he has been grossly verbally and physically inappropriate with female staff including threats of physical harm . Review of Resident #14's Care Plan dated 3/21/2022, revealed the Care Plan was not updated until 6/20/2022 to reflect inappropriate sexual behaviors. Review of a quarterly MDS dated [DATE], revealed Resident #14 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review revealed, Resident #25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #25 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's Progress Note dated 6/17/2022, revealed .On yesterday, the resident [Resident #14] rolled up behind a female resident [Resident #25] and threatened her by stating, 'I am going to beat your [explicit language].' The female resident [Resident #25] notified this SW who then talked to the DON and psych [psychiatric] services. The resident [Resident #14] continues to be on psychiatric case load. Family will be notified today . During an interview on 8/18/2022 at 4:15 PM, the [NAME] President (VP) of Clinical Operations stated, .[Named Resident #14] was placed 1 on 1 because of the incident involving a verbal threat of rape made to [Named Resident #25] . Review of the Care Plan revealed there were no interventions added after the incident on 6/17/2022 to monitor Resident #25 for any negative outcomes related to verbal threats of physical and sexual abuse. Review of the medical record revealed, Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #29 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Care Plan revealed there were no interventions to monitor Resident #29 for any negative outcomes related to the sexual abuse allegation that occurred on 7/14/2022. Review of Resident #14's Physician's Progress Note dated 7/14/2022, revealed .increased sexual behaviors .[Resident #14] feeling on resident's [Resident #29] breast. Psych is following . Review of Resident #14's Psychiatric Nurse Practitioner Progress Note dated 7/14/2022, revealed .asked to see [Resident #14] ahead of scheduled visit due to same problems staff reports he touched a female resident [Resident #29] inappropriate on her breasts today. This is a pattern of behavior for this resident .says the female resident invited him to touch her. Pointed out that she has little verbal and is not capable of that .continued to deny responsibility .more angry outbursts are occurring .continued instances of impulsive behaviors .Non pharm [pharmacological] interventions have been ineffective . During an interview on 8/18/2022 at 4:15 PM, the [NAME] President (VP) of Clinical Operations stated, .Resident #14 was placed 1 on 1 because of the incident .touching a resident's [Resident #29] breast . Review of Resident #14's Care Plan revealed there were no new interventions added for the sexually inappropriate behavior with Resident #29. The facility failed to monitor Resident #25 and Resident #29 for outcomes related to verbal and sexual abuse. During an interview on 8/18/2022 at 5:05 PM, Licensed Practical Nurse (LPN) #13 stated, .monthly behavior meeting .unit managers, Assistant Director of Nursing (ADON), the Director of Nursing and the Psychiatric Nurse Practitioner attend the meeting .weekly meeting is Unit Managers, Social Worker, and Assistant Director of Nursing .review the 24 hour report to see if any behaviors exhibited .the Psych Nurse Practitioner sends a list of residents with medications and why they're on the medications .discuss behaviors exhibited .interventions how to address the situation .update plan of care .review the PAR [Patient At Risk] notes .and medication changes . During an interview on 8/12/2022 at 1:54 PM, the DON was asked what should be done for the residents involved in incidents of abuse. The DON stated, .increase the monitoring of the residents that are involved in incidents of abuse .

Based on policy review, police report review, facility investigation review, weather website review, medical record review, observation, and interview, the facility failed to ensure a safe environment to prevent 2 incidents of elopement for 1 of 6 sampled residents (Resident #549) reviewed for elopement and wandering behaviors and the facility failed to ensure a safe environment when unsecured chemicals were in 2 of 60 resident rooms (Resident #17 and #69's rooms). The facility's failure to ensure a safe environment to prevent elopements resulted in Immediate Jeopardy (IJ) when Resident #549 exited the facility without authorization or staff supervision through a malfunctioning exit door. Resident #549 was discovered approximately 372 feet from the PUI Hall (Patient Under Investigation hall is an area designated in the facility for residents who have not received the covid vaccination are monitored for a number of days after hospitalization to ensure they do not show Covid symptoms) exit door, sitting on a bench beside the front entrance. The facility was unaware Resident #549 had exited the building until staff brought him back into the building. Three days later, Resident #549, who was assessed as a risk for elopement, and was wearing a wander guard bracelet (a monitoring device to alert staff of a resident attempting to exit the facility unattended), exited the facility without authorization or staff supervision through the malfunctioning PUI Hall exit door. The PUI Hall exit door did not have a wander guard monitoring system. Staff were unaware of Resident #549's location for approximately 4 hours when he was found at his place of employment approximately 21 miles from the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 8/9/2022 at 6:20 PM, in the Omega Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ existed 3/29/2022 and is ongoing. The findings include: Review of the facility's undated policy titled, ELOPEMENT, revealed .While wander, door or building alarms can help to monitor a residents activities, staff must be vigilant in order to respond to them in a timely manner, Alarms do not replace necessary supervision, and require scheduled maintenance and testing to ensure proper functioning .Elopement occurs when a resident leaves the premises or a safe area without authorization .and/or any necessary supervision to do so .A resident who leaves a safe area may be a risk of .medical complications or being struck by a motor vehicle .policies that clearly define the mechanisms and procedures for assessing or identifying, monitoring and managing residents at risk for elopement can help minimize the risk of a resident leaving a safe area without authorization and/or appropriate supervision .Chemicals and Toxins .Various materials in the resident environment can pose a potential hazard to residents. Hazardous materials can be found in the form of solids, liquids, gases, mists, dusts, fumes, and vapors. The routes of exposure for toxic materials may include inhalation, absorption, or ingestion .For a material to pose a safety hazard to a resident, it must be toxic, caustic .accessible and available in a sufficient amount to cause harm. Toxic materials that may be present in the resident environment are unlikely to pose a hazard unless residents have access or are exposed to them. Some materials that would be considered harmless when used as designed could pose a hazards to a resident who accidentally ingests or makes contact with them . Review of the facility's policy titled, Abuse Prevention Policy, revised 3/1/2018, revealed .the resident has a right to a safe .environment . Review of a closed medical record, revealed Resident #549 was admitted to the facility on [DATE] with diagnoses of Cerebral Infraction, Hypertension, [CONDITION(S)], and [CONDITION(S)]. Resident #549 signed Against Medical Advice (AMA) and was discharged on [DATE]. Review of the Nurses' Note dated 7/25/2022, revealed .tobacco/alcohol abuse .on 7/5/2022 [prior to admission to this facility] boss not able to reach him [Resident #549] found him in the street nude trying to put his clothes on, confused, unbalanced, and had left sided weakness .ER [emergency room ] images revealed an acute infarct [infarction] with chronic infarct. He is functioning beneath baseline .It was thought he would benefit with intense tx [treatment] to increase independence and promote ADL [Activity of Daily Living] .Positive For: left [CONDITION(S)], impaired cognition . Review of the Clinical Admission Evaluation dated 7/22/2022, revealed mental status consisted of disorganized thinking, an unsteady gait, poor balance, abnormalities such as safety concerns and wandered at night. Review of the Nursing Initial 48 Hour Care Plan dated 7/22/2022, revealed .At Risk for Falls due to Fall Assessment score > [greater than] 10 . Review of the Brief Interview for Mental Status (BIMS) dated 7/23/2022, revealed Resident #549 was assessed with a score of 14, indicating he was cognitively intact. Review of the Physical Therapy (PT) Evaluation and (&) Plan of Treatment, dated 7/25/2022, revealed .Reason for Referral: Patient referred to PT due to new onset of decrease in strength, decrease in functional mobility, decrease in transfers, reduced ability to safely ambulate, reduced functional activity tolerance, reduced static dynamic balance, reduced ADL participation and increased need for assistance from others .Patients exhibits knee wobble which are associated with the underlying causes of muscle instability . Review of the Speech Therapy (ST) Evaluation & Plan of Treatment dated 7/25/2022, revealed .Pt [patient] presenting with cognitive deficits characterized by decreased attention to tasks (left neglect noted), decreased safety awareness, short term memory, problem solving, calculations and organizational skills .Reason for Referral .Patient referred to ST due to exacerbation of cognitive impairment and decreased safety awareness . Review of the facility's investigation dated 7/27/2022 revealed, .Resident last seen by nurse at 7:05 AM .was seen by another resident walking past her window .Speech Therapist saw resident sitting in front of the building [approximately 372 feet from the exit (PUI Hall) door] and was brought back into the building .30-minute checks .wander guard applied to resident .instructed maintenance to check all exit doors . Review of the Elopement Risk assessment dated [DATE], revealed Resident #549 was assessed as a high risk for elopement with an intervention to apply a wander guard bracelet with safety checks every 30 minutes. Review of a Nurses' Note dated 7/27/2022, revealed .resident was observed sitting outside on front porch of the facility .resident stated he went outside in search of 'shorts' [cigarettes previously smoked] .resident was assisted back in building .wander guard placed for monitoring .30-minute safety checks . Review of the facility's investigation dated 7/30/2022, revealed .6:40 AM last seeing the resident .Dr. Wander [code for a missing resident] initiated .staff out in cars and on foot .police notified of possible address resident may be located .10:59 AM found resident at [Named] Autobody and Body Panel Shop [approximately 21 miles from facility] .11:30 AM Resident refused to return to facility .signed AMA papers . Resident #549 was not located for approximately 4 hours. Review of a Nurses' Note dated 7/30/2022, revealed .not in assigned room .Staff on foot and in cars searching in progress .Officer also reports resident was seen 30 minutes ago reported by store personnel fitting description .heading downtown area .Day nurse reported resident in past would ask for rides from staff to get to [Named] Road .Emergency contact explains that addresses are his place of business .11:04 am resident located at [Named] Body and Panel Shop .upon discovery of the resident refused return to facility and requested to be discharged AMA . Review of a Police Report narrative dated 7/30/2022, revealed .responded to a missing person .patient had walked away from the scene eastbound between the hours of 0700 [7:00 AM] and 0800 [8:00 AM] .Additional information .at 11:36 [11:36 AM] victim located at [Named] road .11:56 [11:56 AM] officers made the scene with Engine [number] .checked him .released back to caretaker [DON] . According to the Local Weather.com, the high temperature on 7/27/2022 was 82 degrees, and on 7/30/2022 the temperature was 77 degrees and rainy. Review of the Quality Assurance Performance Improvement (QAPI) Root Cause Analysis (RCA) dated 7/27/2022 revealed .[Director of Nursing [DON] not notified of incidences in timely manner .facility failed to complete thorough investigation of elopement .facility failed to obtain signed and dated written statements from staff with knowledge of the incident . During an interview on 8/3/2022 at 12:06 PM, the Speech Therapist stated, .I was treating him [Resident #549] for safety awareness, cognition and not able to reason .I came to work, I recognized him. He was sitting by the front door on a bench, putting smoked cigarettes in his pockets .I assisted him back inside and met his [Named Certified Nursing Assistant (CNA) #2] from the East Hall, and we both carried him back to the Nursing Station, then to his room .the nurses told me they didn't know he was gone .I believe he got out the back door on that hall. I had talked with his RP [Responsible Party] and we discussed the resident need to be able to climb stairs to come home with him .he had no safety awareness .he was very impulsive, unsteady gait and left side neglect .he offered me fifty dollars to take him home .I think the unit manager would take him out to smoke . During an interview on 8/4/2022 at 9:20 AM, Licensed Practical Nurse (LPN) #6 stated, .his [Resident #549] main concern was going back to work .would come to the double door (fire doors) and knock wanting coffee .I did not see him when I came on shift that morning of 7/27/2022 .when he came back we put a wander guard monitor on him, assessed him for smoking, and I took him out to smoke .he told me he went through the plastic and went out the back door (PUI) exit door .he can read, he held it down for 15 seconds and the door opened .I did not hear the door alarm .you have to put in code to cut the alarm off .I checked myself and I pushed on the door it opened but did not alarm .I told maintenance about it . During an interview on 8/4/2022 at 10:08 AM, CNA #2 stated .I got to work late and left .I met the Therapist as I was going out of the door with [Named Resident #549], and I assisted her taking him back to his room .he told me he just wanted to go smoke .he is very unsteady when he walk [walks] .he wanders and never stays in his room, he was in observation . During an interview on 8/4/2022 at 11:40 AM, LPN #4 stated, .around 6:40 AM .I made him coffee and I went to the other hall to get him a sandwich .when I went to do my last check around 7:00 AM on him he was not in his room .Dr. Wander was initiated .I did not hear a door alarm and he did not go past me because I was at the desk and he has akward walk [walked awkwardly], I would have noticed .I knew he was gone I didn't see him anywhere on that hall .I believe he went out the exit door at the end of the hall . During an interview on 8/4/2022 at 3:06 PM, the Maintenance Supervisor was asked when he was made aware the PUI exit door was malfunctioning. The Maintenance Supervisor stated, .I was texted by the Administrator to check the PUI Unit exit door on 7/27 [2022] after an elopement. If the egress (handle) is held for 15 seconds, the door will open, the alarm should sound, and a code would have to be put in to shut it off. I checked the door and when opened the alarm was not sounding .it needed a battery .I did not replace the battery that day .I received another text on 7/30 [2022] from the Administrator about checking the (PUI) exit door .I did not fix the door until 8/1 [2022] .I dropped the ball . The Maintenance Supervisor confirmed the PUI exit door is not equipped with the wander guard monitor system and would not lock down if a wandering resident attempted to exit through the door. The Maintenance Supervisor was asked how often the door alarms are checked. The Maintenance Supervisor stated, .I check the doors, but not every week .probably once a month . During an interview on 8/4/2022 at 3:30 PM, the Administrator stated .I was notified about the elopements, and we determined that he exited through the [PUI] exit door both times. A text message was sent to the Maintenance Supervisor to check all the exit doors and to check the camera footage on 7/27 [2022] .I did not follow up .he texted OK .I was unaware that the PUI exit door was malfunctioning until after the 2nd elopement on 7/30 [2022] .the exit door alarm was not sounding to alert staff when opened .the door should alarm when opened and code put in to cut the alarm off .I am ultimately responsible for the safety and maintenance of the building. The Administrator was asked if there was adequate supervision to monitor and perform 30-minutes checks for Resident #549 on 7/30/2022, if there was knowledge the PUI exit door was malfunctioning. The Administrator stated .he should have been 1 on 1 [1:1] .so he could have been watched more closely . Observation of the PUI Hall exit door on 8/5/2022 at 12:37 PM, the Maintenance Supervisor was checking PUI exit door, the egress (handle) was held for 15 seconds, the door opened, the alarm sounded until he entered the code into a keypad entry. The fire doors to the hall were closed. No staff entered the hall to check the sounding alarm. Three staff members were seated at the desk and did not respond to the alarm. During an interview on 8/5/2022 at 12:37 PM, the Maintenance Supervisor was asked when the alarm was fixed on the PUI exit door. He confirmed it was fixed on Monday, 8/1/2022. The Maintenance Supervisor was asked if he checked to see if the alarm on the PUI hall exit door was loud enough to be heard by staff at the Nurses' Station when the fire doors were closed. He stated, No, I did not .I assumed they could hear it .It will continue to alarm until a code is put in the keypad and it is secured . During an interview on 8/5/2022 at 1:10 PM, Resident #67 stated, .[I] was awake in room between the hours 6:30 AM, and saw a shadow passing by my window .I let him [Resident #549] use my phone to call his employer, all he talked about was going home .he didn't sleep much always up and restless walking up and down the hall .I asked him how he got out when he got out the first time he told me he got out the door [PUI exit door] behind the plastic to find cigarettes to smoke .he brought some back, they were falling out of his pocket on the floor .I did not hear a door alarm neither time he left . During an interview on 8/8/2022 at 12:15 PM, the DON was asked if the wander guard monitor would alarm if a resident with a wander guard exited the PUI exit door. The DON stated .no it would not, only the front and back entrance doors are equipped with the wander guard system. The DON was asked if staffing was adjusted so that Resident #549 could be monitored with 30 minutes safety checks and other wandering residents on the East Hall could be monitored. The DON stated, .I did not check the staffing after the elopement .so I don't know . Observation in Resident #17's room on 8/22/2022 at 1:09 PM, revealed an uncapped bottle of pinkish colored body wash on the resident's sink. Observation in Resident #17's bathroom on 8/22/2022 at 5:42 PM, revealed a gallon of pinkish colored body wash and a spray bottle of a toilet cleaner. Observation in Resident #69's room on 8/23/2022 at 9:55 AM, revealed a gallon of uncapped a pinkish colored body wash and pinkish colored body wash inside a clear plastic cup. During interview on 8/22/2022 at 1:09 PM, CNA #2 confirmed the uncapped body wash should not be on the sink in a resident's room. During an interview on 8/22/2022 at 5:42 PM, CNA #12 confirmed the unsecured items should not be kept in the residents' rooms. During an interview on 8/23/2022 at 9:55 AM, LPN #6 confirmed the body wash should not be in the resident's room, and she stated, .because one of the residents could get a hold of it and drink it. Refer to F-600

Based on policy review, medical record review, observation, and interview, the facility failed to ensure that preventative foot care was provided to prevent pain and decreased mobility. The facility failed to make necessary appointments with podiatrists for 2 of 3 sampled residents (Resident #25 and #93) reviewed for foot care. The facility's failure to identify, assess, report, and provide podiatry services causing pain resulted in actual Harm for Resident #25 and Resident #93. The findings include: Review of the facility's undated policy titled, Resident Rights Notice, revealed .Right to a dignified existence .and Receive Proper Care . Review of the medical record revealed Resident #25 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 3/22/2022, revealed Resident #25 had Diabetes Mellitus and was at risk of complications from the disease processes, Activities of Daily Living (ADL) Self Care Performance Deficit with interventions to inspect feet daily for open areas, sores, pressure areas, blister, [CONDITION(S)], or redness. CNA will report of the above to the Nurses. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact, required extensive assistance from 1 staff member for Activities of Daily Living (ADL) and uses a wheelchair for mobility. Review of the ADL/Shower Sheets provided dated 5/5/2022, 5/31/2022, and 6/9/2022, revealed Resident #25 received showers and bed baths with no toenail issues identified. No other shower sheets were provided for Resident #25. Review of the Physician Order dated 6/21/2022, revealed a Podiatry consult for evaluation and treatment as indicated. Review of the Physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] .every 8 hours for pain .[MEDICATION(S)] .every 24 hours as needed for pain at bedtime . Review of the 7/2022 and 8/2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Podiatry list for 8/18/2022, revealed Resident #25's name was handwritten on the typed list. Review of the medical revealed Resident #25 was not seen by (Named) Podiatry Services on 6/21/2022 or 8/18/2022. Review of the Weekly Skin Assessments dated 4/28/2022 through 8/22/2022 documented no skin issues and toenails were not identified. Observation in the East Hall on 8/18/2022 at 3:30 PM, revealed Resident #25 was in a wheelchair propelling herself using her right foot wearing tennis shoes and socks. Resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/18/2022 at 3:30 PM, Resident #25 was asked if her toenails were cut today. Resident #25 stated, .no .my toenails are long and they hurt .they need cutting bad they are sticking into my other toe .it hurts .I have to use this foot to get around in my wheel chair .they [staff] told me they were going to cut them but haven't .have you [surveyor] told them and put me on list .they told me I was going to get them cut but they have not .they been like this for a while . Resident #25 confirmed she did not see the Podiatrist on 8/18/22. During a telephone interview on 8/25/2022 at 4:20 PM, the Podiatrist stated, the Podiatrist was asked why Resident #25 had not been seen while at the facility on 8/18/2022. The Podiatrist stated, .must not had her registered properly to be seen .I don't know why .if for some reason resident's need to be seen such as diabetic foot care, pain, or toe nail infection then we should be seeing them .I talked with the DON [Director of Nursing] about this when I was at the facility .someone should be looking at the residents' feet during bathing or showers and putting them on the list to be seen .the ball is being dropped somewhere .if for some reason they are not seen the day we come an Emergency appointment can be made .it definitely concerns me especially for diabetic residents not getting foot care . Observation in the resident's room on 8/26/2022 at 7:59 AM, revealed Licensed Practical Nurse (LPN) #6 pulled back the covers to Resident #25's lower extremities exposing her feet, removed her socks and exposed her toenails, which revealed her toenails to the right foot were hard, dark grayish black and curled and crooked over and under the toes resting on the back of the foot resting on the ball of her feet on all 5 toes and the left foot toenails were just a fraction above the skin straight but the same color and thick as well. During an interview on 8/26/2022 at 7:59 AM, Resident #25 confirmed she is sometimes in pain related to the long unkept and uncut toenails and it is painful to wear shoes. During an interview on 8/26/2022 at 8:01 AM, Licensed Practical Nurse (LPN) #6 was asked how often the Podiatrist comes. LPN #6 stated, .I'm not sure .I thought they saw her [Resident #25] . During an interview on 8/27/2022 at 9:54 AM, the DON was asked if she was aware of the condition of Resident 25's toenails. The DON stated, .No I do not . The DON confirmed toenail care should be addressed on the shower sheets and skin assessment .and on admission . Review of the medical record revealed Resident #93 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Weekly Skin Assessments dated 4/29/2022 through 7/22/2022, documented no skin issues and toenails were not identified. Review of the Shower sheets for 5/25/2022 and 6/13/2022 (the facility only provided 2 shower sheets), revealed Resident #93 received showers and bed baths with no toenail issues identified. Review of the Physician Orders dated 7/6/2022, revealed a Podiatry consult for evaluation and follow up as indicated. Review of the updated Care Plan dated 7/11/2022, revealed .ADL Self Care Performance Deficit .Limited Mobility . There were no interventions related to nail care or pain. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 12, indicating Resident #93 was moderate cognitively impaired, and required assistance from staff with ADLs. Observation in the Lobby on 8/3/2022 at 12:00 PM, revealed Resident #93 had his eyes closed wearing open toe slippers, his toenails were dark and yellow, long and curved over his toes. Observation in the Front Hallway on 8/8/2022 at 5:05 PM, revealed Resident #93 had slippers on revealing long yellow curved toenails. Review of the Podiatry list for 8/18/2022, revealed Resident #93's name was handwritten on the typed list with a notation to see the resident first. Review of the (Named) Podiatry Services Progress Note dated 8/18/2022, revealed .Date 8/18/2022 .nails cut per podiatrist . Review of the Podiatry Service Progress Note dated 8/18/2022, revealed .Reason for Visit: Thick/Myotic [Mycotic] Nails [a fungal infection that affects toenails or fingernails] .Painful on left great toe, left, 2nd toe, left 3rd toe, right great toe right 2nd toe, right 4th toe .Thicken .Brown on left great toe .Dystrophic (deformed thicken and discolored) on left great toe .Incurvated [portion of the nail presses into flesh, causing pain] on left great toe .Alignment .Toes Rigid right and left hammertoe .patient plan performed with nail clippers to reduce thickness and length of all mycotic nails to relieve pain . During an interview on 8/18/2022 at 12:00 PM, Nurse #7 was asked if Resident #93 had his toenails cut today. Nurse #7 stated, .I sure hope so .toenails are bad .he is at [CONDITION(S)] don't know if he did or not .he had started staying in the bed a lot .I asked him why he did not want to get out of bed and he told me 'my toenails too long and they hurt' .he altering his walk .walking on the sides of his feet .he was not seen last visit because of his [CONDITION(S)] they come on his [CONDITION(S)] days so he was not seen last visit . During an interview on 8/18/2022 at 12:30 PM, the Podiatrist was asked if Resident #93's toenails were cut today. The Podiatrist stated, .the resident is at [CONDITION(S)] and has not returned and we are finished seeing patients for the day but if it's an urgent case, I will try to work something out .I will stay and see him . During an interview on 8/18/2022 at 4:30 PM, the DON stated .[Named Resident #93] was not seen by the Podiatrist today because he was gone to [CONDITION(S)] and that [is] why he was not seen last month, they [Podiatry] come on his [CONDITION(S)] days .if he is not seen today we will make arrangements for him to go to a Podiatry clinic .the Social Worker will set up the appointment . The DON was asked why the appointment was not made for emergency foot service when Resident #93 missed his foot service due to [CONDITION(S)]. The DON stated, I don't know, the Social Worker will usually take care of that but since we don't have a Social Worker at this time the acting Social Worker would take care of this . The DON was not aware of Resident #93's nails being trimmed on 8/18/2022. During a telephone interview on 8/25/2022 at 4:20 PM, the Podiatrist stated, I trimmed the resident's toenails on 8/18/2022, I waited for him to get back [CONDITION(S)] and had to wait for a Physician Order .but I stayed. The Podiatrist was asked if the length of Resident #93's toenails would cause pain or change his gait when walking. The Podiatrist stated, .Yes, most definitely. His big toenail was long as one of my fingers and curved. His toenails were in bad shape and should have been identified before now. The staff should have noted the need for nail care and length during shower or bath and reported especially since he was complaining of pain .by the length of the nails, they had not been cut for 6 months or more. The DON is aware of the process of getting us out here, we could do an emergency visit for diabetics, I discussed this with her and if they are having foot pain, we could have done an emergency visit if we had been notified. I was very concerned that they [toenails] were in that bad of shape .Someone is dropping the ball . diabetic foot care is very important and needs to be addressed timely . During an interview on 8/27/2022 at 9:54 AM, the DON was asked where toenails should be documented and when toenails should be assessed. The DON stated, .they [staff] should document on the weekly head to toe assessment .Weekly Skin Assessment and Shower Sheets .the CNAs to make the nurse aware .the nurse reviews Shower Sheets daily . The DON confirmed CNAs should document toenails on the Bath and Shower Sheets, and report abnormal findings to the nurses, and nurses should be assessing the toenails when completing the Weekly Skin Assessment. During an interview on 8/30/2022 at 10:45 AM, the DON was asked about the two (2) Shower sheets provided for Resident #93. The DON stated, .these were the only 2 shower sheets we could find .CNAs [Certified Nursing Assistants] are not allowed to trim nails of diabetics the nurses should review the shower sheet . The facility's failure to identify, assess, report toenails, and provide Podiatry toenail care and services causing pain resulted in actual Harm for Resident #25 and Resident #93.

Based on policy review, job description review, document review, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that identified opportunities for improvement related to resident neglect; reported a missing resident incidence to the State Survey Agency and other appropriate agencies; performed tracking and trending of an incident of a missing resident and resident to resident altercation; and failed to implement corrective action or performance improvement activities for a missing resident and resident to resident altercation in order to provide a safe environment for residents, and ensure systems and processes were in place and consistently followed by staff and administration. Failure of the QAPI committee to ensure residents were free from abuse/neglect and ensure an incident of a missing resident was identified, thoroughly investigated, and reported to the appropriate agencies, resulted in Immediate Jeopardy when Resident #294 was missing for over an hour and found in a locked chemical storage (housekeeping) closet and Resident #293 and #294 were involved in a resident-to-resident altercation that resulted in Resident #294 receiving multiple facial fractures. Resident #293 was not sent out of the facility for medical evaluation until the next day. Resident #293 was sent to his room, with the door closed, and told to remain there. The next day he was sent to a psychiatric facility. Neither incident was thoroughly investigated, and interventions were not implemented to avoid it reoccurring. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator was notified of the Immediate Jeopardy for F-867 on 9/17/2020 at 6:32 PM, in the Omega Room. The facility was cited Immediate Jeopardy at F-600, F-609, F-610, F-689, F 835, and F-867. The facility was cited F-600, F-609, F-610, and F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 7/8/2021 through 9/19/2021. An acceptable Removal Plan, which removed the immediacy of the Jeopardy was received on 9/19/2021 at 12:16 PM, and was validated onsite by the surveyors on 9/19/2021 and 9/20/2021 through review of the root cause analysis, in-services, audits, and staff interviews conducted on all shifts. The findings include: Review of the facility's policy titled, Quality Assurance Performance Improvement Plan, dated 2015, revealed, Standard of Practice It is the intent of this facility to conduct an on-going quality assurance /performance improvement program designed to systematically monitor and evaluate the quality and appropriateness of resident care, pursue opportunities to improve resident care, resolve identified problems and identify opportunities for improvement. Performance improvement supports the overall goals of the facility and examines both outcomes and processes relevant to these outcomes with the objective of improving the organization's overall performance .The Quality Assurance and Performance Improvement Committee is set up to provide structure and direction for the Performance Improvement Program and Risk Management .The facility will identify areas for Quality Assurance/Performance Improvement monitoring and tools/resources to be used. These monitoring activities should focus on those processes that significantly affect resident outcomes. This ongoing monitoring is used to establish the facility's baseline and the predictability of various outcomes . Criteria for selecting aspects of care for improvement are based on the following .High Volume-aspect of care occurs frequently or affects large number of resident/patient population .High risk-residents/patients are at risk of serious consequences .Problematic-the aspect of care has tended in the past to produce problems for staff, resident and facility .Elopement .Abuse Prohibition .(PIP) Performance Improvement Project Team will be established for the purpose of finding the root cause of the identified areas of concern .The department/committee will document findings, initiate corrective action as directed and present results to the Quality Assurance Performance Improvement Committee . Review of the facility's policy titled, Abuse Prevention Policy, revised 3/1/2018, revealed .The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from .neglect .Notify the Director of Nursing and Administrator .Complete an incident report and initiate an immediate investigation to prevent further potential abuse .Obtain witness statements following incident policies .Monitor and document the resident's condition .Document actions taken .in the medical record .It is the responsibility of all staff to provide a safe environment for the residents .Examples of ways to protect a resident .during an investigation of .neglect .Temporary one on one supervision . Review of the facility's policy titled, Elopement Of Resident, dated 9/1/2018, revealed .Should an employee discover that a resident is missing .If not located in 15 minutes .Notify the Administrator and the Director of Nursing Services .Notify the resident's representative .Notify the attending physician .Notify law enforcement officials .Determine the time and location the resident was last seen .Once the Resident is Located .The resident will be assessed by M.D. [medical doctor] and documented .The Charge Nurse will complete an Incident Report .The Administrator/Director of Nursing Services will notify the Department of Health per State Regulations .A complete and thorough root-cause analysis of the elopement should be done .reviewed at the next QAPI meeting . Review of the facility's policy titled undated Residents Rights, revealed .The Resident has the right to be free from verbal, sexual, physical or mental abuse . The facility was unable to provide documentation of in-services or education provided to staff related to an incident of a missing resident that occurred on 7/13/2021. Review of a QAPI document provided by the facility dated 8/25/2021, revealed the committee discussed the incident of the missing resident that occurred on 7/13/2021. This discussion was 6 weeks after the event with the .Root Cause: Left safe area .Increased resident to resident reportables . Review of the facility's undated Administrator job description, revealed, .The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times .inform the Medical Director of all suspected or known incidents of resident abuse .Review accident/incident reports .Monitor to determine the effectiveness of the facility's risk management program .Ensure that facility procedure manuals .identify safety precautions .that could cause bodily injury or exposure to a hazardous chemical .Ensure that the facility is maintained in a .safe manner for resident comfort and convenience . Review of the facility's undated Director of Nursing job description, revealed, .The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times .Plan, develop organize, implement, evaluate, and direct the nursing service department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the nursing care facilities .Develop, implement, and maintain an ongoing quality assurance program for the nursing service department .Assist the Quality Assessment & Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies .Monitor the facility's QI [Quality Improvement], QM [Quality Management], and survey reports. Assist in developing plans of action to correct potential or identified problem areas .Evaluate and implement recommendations from established committees as they may pertain to nursing services .Assist the In-service Director/Educator in developing annual facility in-service training programs (e.g .Abuse Prevention, Safety, Infection Control, etc.) .Assist the Safety Officer in developing safety standards for the nursing service department .Report and investigate all allegations of resident abuse and/or misappropriation of resident property . Review of the facility's Charge Nurse job description, revealed .The primary purpose of your job description is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility .to ensure that the highest degree of quality care is maintained at all times .Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility .Complete accident/incident reports as necessary .Report and investigate all allegations of resident abuse and/or misappropriation of resident property . During a telephone interview on 9/17/2021 at 3:01 PM, the Medical Director confirmed that during the Quality Assurance (QA) meeting the resident-to-resident altercation was discussed and the altercation .wasn't handled the way it should have been . The Medical Director confirmed a resident who was being sent to another facility due to the aggressive behaviors should be supervised and the staff should be certain the resident that was injured was treated promptly. During an interview on 9/17/2021 at 3:59 PM, the Administrator confirmed he was responsible for reporting incidents to the State Survey Agency. He confirmed if a resident wandered into an unsafe environment unsupervised, the incident should be reported and investigated. He confirmed the incident that occurred in July 2021 was not discussed by the QAPI team until August 2021 and the staff did not .handle the incident with Resident #294 appropriately . The Charge Nurse did not notify administration in a timely manner and no education was conducted with the staff. The Administrator confirmed the incidents that occurred in July 2021 were not discussed until the August 2021 QAPI meeting. The Administrator confirmed there had been no in-services or education provided to the staff after this QAPI meeting. The facility could not provide documentation of an Ad Hoc (impromptu) QAPI meeting for the incident on 7/9/2021 of the resident- to- resident altercation or of the missing resident on 7/12/2021. Refer to F-600, F-609, F-610, F-689, and F-835. The facility was previously cited Immediate Jeopardy at F-656, F-678, F-835, and F-867 on 6/12/2020. The surveyors verified the Removal Plan by: 1. On 9/17/2021, a Root Cause Analysis was completed, and it was identified the QAPI Committee failed to implement a systematic approach to ensure staff were trained to identify, investigate, and attempt to identify the root cause for resident-to-resident altercation and missing residents. The Charge Nurse failed to notify the Administrator of the resident-to-resident altercation, and the Administrator failed to notify the State Agency of the missing resident. The surveyors reviewed the Root Cause Analysis conducted by the Regional Director of Clinical Director of Operations (RDCO). 2. On 9/17/2021, a QAPI Ad Hoc meeting was held and led by the Administrator, and was attended by the Medical Director, Clinical Director of Operations (CDCO/Director of Nursing (DON), Assistant Clinical Director of Operations, Unit Managers, Admissions Director and included a Root Cause Analysis, education on Abuse and Neglect Prevention, Resident Rights, the Elder Justice Act, Failure to Investigate, Accidents, Elopement, Storage of Medication, Biologicals, and Chemicals, and Behavior Management and Monitoring. The surveyors reviewed the minutes and interviewed QAPI members. 3. The Administrator and/or CDCO will submit a daily audit log of the monitoring reports of any incidents or accidents, the daily internal communications from electronic clinical dashboard data to ensure any resident incident/accident is consistently identified, investigated, and a root cause is performed with appropriate action. The surveyors reviewed the daily audit log form and interviewed the Administrator. 4. On 9/18/2021, the RDCO re-educated the Interdisciplinary Team (IDT) including the Administrator on the QAPI Program policies and procedures. The surveyors reviewed the in-service education provided and interviewed the Administrator and RDCO. 5. All actions, educations, audits, and monitors will be a part of the QAPI process and reviewed by the QAPI committee. The surveyors interviewed members of the QAPI committee. 6. The QAPI committee will meet monthly or Ad Hoc QAPI meetings will be held after incidents such as resident to resident altercations and missing residents. The surveyors interviewed members of the QAPI committee. The facility's noncompliance at F-867 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, video camera footage review, medical record review, observation, and interview, the facility failed to ensure adequate supervision to prevent neglect of vulnerable and confused residents for 2 of 10 sampled residents (Resident #293 and #294) reviewed for abuse and wandering. The facility's failure resulted in Immediate Jeopardy when Resident #293 willfully struck Resident #294 which resulted in multiple facial fractures and when Resident #294 was found locked in a chemical storage closet (housekeeping closet) unsupervised for approximately 1 hour. Resident #293 and #294 did not have adequate supervision and interventions were not implemented for these behaviors. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Chief Director of Clinical Operations (CDCO/Director of Nursing) were notified of the Immediate Jeopardy for F-600 on 9/17/2021 at 2:03 PM, in the Omega Room. The facility was cited Immediate Jeopardy at F-600. The facility was cited F-600 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 7/8/2021 through 9/19/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 9/19/2021 at 12:16 PM, and was validated onsite by the surveyors on 9/19/2021 and 9/20/2021 through review of root cause analysis, in-services, audits, and staff interviews conducted. The findings include: Review of the facility's policy titled, Abuse Prevention, revised on 3/1/2018, revealed .The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property .This facility will establish an environment .that treats each resident with respect and dignity .Physical abuse .includes hitting .Neglect .means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental Illness .when abuse, neglect or exploitation is suspected the Licensed Nurse should .Notify the Director of Nursing and Administrator .Complete an incident report and initiate an immediate investigation to prevent further potential abuse .Obtain witness statements following incident policies .Monitor and document the resident's condition .Document actions taken .in the medical record .It is the responsibility of all staff to provide a safe environment for the residents .Examples of ways to protect a resident from harm during an investigation of abuse, neglect and exploitation may include .Temporary one on one supervision .When suspicion or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted .Interview with the involved resident, if possible and document all responses. If the resident is cognitively impaired, interview the resident several times to compare responses. Interview all witnesses separately .Obtain witness statements . Review of the facility's policy titled, Elopement Of Resident, dated 9/1/2018, revealed .Should an employee discover that a resident is missing .If not located in 15 minutes .Notify the Administrator and the Director of Nursing Services .Notify the attending physician .Determine the time and location the resident was last seen .Once the Resident is Located .The resident will be assessed by M.D. [Medical Doctor] and documented .The Charge Nurse will complete an Incident Report .The Administrator/Director of Nursing Services will notify the Department of Health per State Regulations .A complete and thorough root-cause analysis of the elopement should be done .reviewed at the next QAPI [Quality Assurance Performance Improvement] meeting . Review of the facility's policy titled, Unsafe Wandering-Elopement Risk Policy, dated 9/21/2017, revealed Every effort will be made to prevent unsafe wandering .Should an elopement episode occur, an incident report will be completed .If an elopement episode occurs, a monitoring schedule will be implemented to ensure resident safety .The resident's care plan will be updated as to the implementation of the monitoring . Review of the medical record, revealed Resident #293 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #293 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated he was severely cognitively impaired for decision making, had no physical behaviors, wandered on 1-3 days of the 7-day assessment period, and was able to transfer and walk without physical assistance from staff. Review of a Skilled Evaluation for Resident #293 dated 7/8/2021 at 8:40 PM, revealed .Resident does not obey commands .Resident is confused .Mood is pleasant, no unwanted behaviors witnessed . Review of an SBAR (Situation, Assessment, Background, Recommendation) note dated 7/9/2021 at 3:18 AM, revealed, .The Change In Condition/s reported on this CIC [Change In Condition] Evaluation are/were: Behavioral symptoms .Physical aggression . Review of a Behavior Note dated 7/9/2021 at 1:31 PM, revealed Resident #293 made the Social Worker (SW) aware of the physical altercation between Resident #293 and Resident #294 when Resident #294 entered Resident #293's room and made crude comments to him. Resident #293 asked Resident #294 to leave the room. When Resident #294 did not leave the room, Resident #293 .gave him [Resident #294] a karate chop [on the side of his head] because he disrespected me [Resident #293] Review of the medical record, revealed Resident #294 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #294 had a BIMS of 3, which indicated he was severely cognitively impaired for decision making, wandered on 1-3 days of the 7-day assessment period, and required limited physical assistance with transfer and ambulation. Review of the Care Plan dated 6/24/2021, revealed, Resident #294 had wandering behavior and wore a wander guard (a mechanical bracelet device that will cause the door to alarm when the resident gets close to the door) bracelet that was initiated on 7/13/2021. Review of the Elopement Evaluation dated 6/28/2021, revealed Resident #294 was a wanderer, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an undated statement written by Licensed Practical Nurse (LPN) #1 revealed a Resident contacted her and stated Resident #293 hit Resident #294. When LPN #1 asked Resident #293 if he struck Resident #294, he denied hitting the resident, but admitted to .pushing [Named Resident #294] down . LPN #1 stated Resident #294 had no injuries at that time and the resident remained at the desk in view of the staff. Review of a Nurse's Note dated 7/9/2021 at 4:40 PM, revealed that Resident #294's face was swollen. The right eye was swollen with purple and dark red bruising. This was the first documentation of Resident #294's injuries from the altercation that occurred on 7/8/2021. Review of a Nurse's Note dated 7/9/2021 at 11:04 PM, revealed Resident #294 returned from the hospital emergency room to the facility on [DATE] at 8:38 PM with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the video footage provided by the facility revealed that on 7/8/2021 at 5:38 PM, the doors of the 100-111 Hall were closed and there were no staff present in the hall. Resident #294 ambulated out of his room into the hallway. At 5:39 PM, Resident #294 ambulated toward the room across the hall and was struck on the left side of the face by Resident #293, knocking Resident #294 to the floor. Resident #294 was in the middle of the hallway on his right side. He sat up and appeared to be trying to get to a standing position when the video ended. Review of a facility's investigation dated 7/9/2021, revealed .After reviewing the camera it is found that residents [Residents #293 and Resident #294] .were having an argument .[Named Resident #293] struck [Named Resident #294] in the face .In order to keep this from happening again the said Residents were on the same wing together but [Resident #294] is being moved to a separate wing to be monitored closer. Resident [#293] is sent to a local Psychiatric Hospital .Resident [#294] returned with dx [diagnosis] of comminuted fractures involving the anterior and lateral walls of the left maxillary [MEDICATION(S)] and additional fractures throughout the lateral wall of the left orbit and left zygomatic bone . The facility was unable to provide documentation that Resident #293 was monitored, or increased supervision was provided after the altercation to prevent further physically aggressive behaviors toward Resident #294 or any other residents from the time of the incident on 7/8/2021 at 5:39 PM, until he was transferred out of the facility on 7/9/2021 at 5:30 PM. During an interview on 9/16/2021 at 11:08 AM, the Administrator was asked to describe the investigation related to the altercation between Resident #293 and Resident #294. The Administrator stated, .The night that [Named Resident #293] and [Named Resident #294]'s altercation [occurred], it wasn't witnessed .a resident reported the incident to the nurse .at first he [Resident #294] had no injuries and when the next shift came on, he had started bruising . The Administrator was asked if there were any interventions implemented to protect the other residents in the facility after the altercation occurred. The Administrator stated, .They were separated and [Named Resident #293] was actually transferred to psych [psychiatric facility] [the next day] . During an interview on 9/16/2021 at 1:54 PM, the Regional Director of Clinical and Operations (RDCO) was asked if she was aware of the incident between Resident #293 and Resident #294 on 7/8/2021. The RCDO stated, I am familiar. The RDCO was asked what interventions were implemented to prevent Resident #294 from harming other residents. The RDCO stated, I know the aggressor .took him to his room where the door would be closed, they were rounding on him to make sure he stayed in his room and wasn't in contact with other residents .the next day he was transferred out. The RDCO confirmed there was no documentation of close supervision of Resident #294 after the incident and there was no further investigation. During a telephone interview on 9/16/2021 at 9:00 PM, LPN #1 was asked if the altercation between Resident #293 and Resident #294 on 7/8/2021 was witnessed. LPN #1 stated, No, I did not. LPN #1 was asked where Resident #293 was located following the altercation with Resident #294. LPN #1 stated, .in his room. He went to bed. LPN #1 confirmed that Resident #293 did not have any additional monitoring or increased supervision after the incident. During an interview on 9/17/21 at 8:47 AM, LPN #4 was asked about the incident between Resident #293 and Resident #294 on 7/8/2021. LPN #4 stated when she arrived for work the next morning, the nurse stated another resident observed Resident #293 punch Resident #294 in the face. When she saw Resident #294's bruising she contacted the Nurse Practitioner to obtain orders to send the resident to the hospital for evaluation to .make sure nothing was broken or fractured . LPN #4 was asked if the bruising appeared severe enough to think there was a fracture. LPN #4 stated, It was bad . She further stated Resident #293 was also sent out for an evaluation. LPN #4 was asked if Resident #293 had any injuries and she replied, He did not. LPN #4 was asked if Resident #293 remained in his room all day the day of the incident. LPN #4 stated, He did, I asked him to stay in his room. LPN #4 was asked how often staff monitored Resident #293 to assure he was in his room. LPN #4 stated, .at least every 2 hours but in that situation, I believe I went down there every hour. [Named Resident #293] liked to walk . LPN #4 confirmed neither resident was evaluated by a physician. Resident #293 was not evaluated by psychiatric services prior to being transferred out of the facility on 7/9/2021. During a telephone interview on 9/17/2021 at 3:01 PM, the Medical Director was asked if a resident that was being transferred out of the facility after a violent behavior should be monitored until they were transferred. The Medical Director stated, Yes. During an interview on 9/17/2021 at 3:59 PM, the Administrator was asked what involvement he had in the altercation between Resident #293 and #294. The Administrator stated, I'm the Abuse Coordinator so they called me . The Administrator was asked when he was notified. The Administrator stated, Not until the next day. The Administrator was asked if he provided any instructions as to what the staff should do regarding this situation and the Administrator stated, I didn't . During an interview on 9/17/2021 at 5:37 PM, the RDCO confirmed she was the acting DON from May 5/25/2021-7/12/2021 and was working the day Resident #293 struck Resident #294 in the face, knocked him to the floor, and Resident #294 sustained multiple facial fractures. The RDCO confirmed she did not provide guidance to the Administrator and staff regarding the altercation between Resident #293 and Resident #294. Review of a Nurse's Note dated 7/13/2021 at 12:00 AM, revealed [Named Resident #294] wonders [wanders] the building day/night and was last seen by nurse before her lunch break after 8pm [8:00 PM on 7/12/2021]. Upon return from nurses [nurse's] lunch break, the CNA [Certified Nursing Assistant] asked nurse had she saw [seen] resident because she was ready to change him and get him ready for bed. Nurse responded No. After about 30 min [minutes], CNA informed nurse that she still was unable to find resident [Resident #294] and need [needed] help locating resident. Nurse and CNA began looking room to room calling residents [resident's] name trying to locate him. After about 15/20 mins [15 to 20 minutes] of looking we called a DR [doctor] Find Me [code for elopement or missing residents] for all employees to help locate resident. Nurse contacted Nurse Manager and informed her that we had been looking for resident for about any [an] hour with no progress. Nurse Manager called Administrator and DON to inform them about the situation as all in-house staff continues to search the entire inside and outside. Nurse Manager arrived the search continued. As nurses and Nurse manager were making their way back up the East Wing towards the nursing station we heard a call for help coming from the housekeeping closet. Resident had got himself locked into the closet and was calling for help out. Administrator informed Nurse Manager on the location to of housekeeping's closet keys so we could unlock door to get resident out. Opening closet door nurse observed resident sitting on floor. We assisted resident out and evaluated. No signs of injury . The facility was unable to provide an incident report, investigation of the incident, or documentation of monitoring implemented to ensure Resident #294's safety. Observation of the housekeeping closet on the East Hall on 9/15/2021 at 1:14 PM and 1:25 PM, revealed the door was unlocked and had an over-head shelf that contained 2 (1 quart) containers of antibacterial cleaner, 1 (1 quart) container of a liquid cream cleanser, and 1 (1 quart) bottle of toilet bowl cleaner on the shelf. Observation of the housekeeping closet on the West hall on 9/15/2021 at 1:21 PM, revealed the door was unlocked and had an over-head shelf that contained 1 (1 quart) bottle of furniture cleaner and 1 (1 quart) bottle of floor cleaner on the shelf. During an interview on 9/15/2021 at 5:17 PM, LPN #2 was asked how staff monitored wandering residents. LPN #2 stated, When we figure out, they are [wanderers] we put wander guards on them .helps us with doorway or exiting .as far as monitoring on a day-to-day basis we do the best we can . LPN #2 was asked if any doors to rooms or offices were left unlocked making it accessible for a resident to wander into the room and not be easily observed by any staff. LPN #2 stated, .there was an incident when there was a door that was not secured and locked and a resident got into it .I think it was a housekeeping closet and I think the housekeeper left it unlocked or didn't close it all the way .I thought that was like an electrical closet . LPN #2 was asked who located Resident #294 when the resident was locked in the housekeeping closet. LPN #2 stated, .It was a group of us walking up the hall .heard him yelling .our Unit Manager was walking past the door and said she thought he was in there .we knocked, and he knocked back . LPN #2 was asked if Resident #294 was injured when he was located and she stated, No . LPN #2 further stated the staff searched for Resident #294 for .probably an hour . During an interview on 9/15/2021 at 5:49 PM, the Director of Nursing (DON) was asked if she could recall the incident with Resident #294 on 7/12/2021. The DON stated, Yes .I received a call saying they could not find the resident and I was headed here .but he was found in a closet .In a maintenance or storage closet, I think it was maintenance or housekeeping .one of them down on the East Hall . The DON was asked if these rooms should be unlocked. The DON stated, No. During an interview on 9/16/2021 at 10:49 AM, LPN #3/Unit Manager was asked about the incident where Resident #294 was missing. LPN #3/Unit Manager stated, I was actually on vacation but I was in the area .they [staff] called me on how to move forward, I'm down the street, said we've been looking for [Named Resident #294] about 30 minutes .he was in the Housekeeper's closet [Chemical Storage Closet] .on East [Hall] .I could hear him saying open the door or something like that . LPN #3/Unit Manager was asked was the door locked when they located the resident. LPN #3/Unit Manager stated, It was, I had to locate a key. LPN #3/Unit Manager was asked if that closet was usually unlocked. LPN #3/Unit Manager stated, No, it's supposed to be locked . LPN #3/Unit Manager was unable to recall if chemicals were stored in the closet the night of the incident. During an interview on 9/16/2021 at 11:11 AM, the Administrator was asked when he was made aware Resident #294 went missing. The Administrator stated, .I got a call maybe if I had to guess, in the 9 o'clock hours, called maybe 10 minutes later the resident had been located . The Administrator was asked if there had been an investigation of the incident and were witness statements obtained. The Administrator stated, .I told them to put an incident report in PCC [the electronic medical record] in the system .then we did the QA [Quality Assurance] on our protocol . The Administrator was asked why the facility had failed to investigate the incident of a missing resident. The Administrator stated, .Because the Unit Manager was there and she had the team to write the note in the system .found the door was actually locked but it wasn't latched, closed, he didn't have the capacity to lock or unlock a door, when he went in it slammed behind him and he couldn't get out . The Administrator was asked when the resident was last seen prior to being identified as missing. The Administrator stated, .I talked to [Named LPN #3/Unit Manager] and they [the staff] weren't able to tell her .in my mind great, he wasn't outside, he wasn't hit, nobody brought him to us .they told me he was in the chemical [housekeeping] closet . The Administrator was asked if he looked back at the video camera footage to see how long the resident had been in the storage room. The Administrator stated, No. During an interview on 9/16/2021 at 1:54 PM, the RDCO was asked what interventions were implemented for Resident #294 after he was found locked in the housekeeping closet. The RDCO stated, I wanted him to have a trauma assessment, talked to the doctor .Safety Committee . The RDCO confirmed no in-services were provided to staff related to the incident. During an interview on 9/16/2021 at 3:00 PM, the RDCO provided documentation that the incident that occurred on 7/12/2021 was discussed by the Safety Committee on 8/25/2021, 6 weeks after the incident. During a telephone interview on 9/17/2021 at 3:01 PM, the Medical Director was asked if he was aware of an incident regarding a missing resident. The Medical Director stated, Yes, I was, it was brought up [in a Quality Assurance meeting] and it wasn't handled the way it should have been, we talked about that. The Medical Director was asked if he made any recommendations on how it should have been handled. The Medical Director stated, Earlier notification of the Physician or Nurse Practitioner on call, Administrator, DON, try to get people sent out as soon as possible, one with injuries make sure to notify the family right away .I guess the people working that night did not understand that . During an interview on 9/17/2021 at 3:59 PM, the Administrator was asked what involvement he had when there was a missing resident. The Administrator stated, .the staff called to notify me that they had not seen him [Resident #294] .I would have never thought he was in a chemical [housekeeping] closet. The Administrator stated the resident was located before he was able to get to the facility. The Administrator was asked if there were any in-services conducted or staff education done after this incident to remind the staff to keep the doors locked. The Administrator stated, There was not . Refer to F-609, F-610, and F-689. The surveyors verified the removal plan by: 1. On 9/17/2021, a Root Cause Analysis was completed and found the Abuse Coordinator was not notified of the resident-to-resident altercation timely, the Charge Nurse failed to document immediate interventions, and failed to document monitoring of residents after the resident-to-resident altercation. The surveyors reviewed the Root Cause Analysis conducted by the RDCO. 2. On 9/17/2021, the RDCO re-educated the Administrator, CDCO (DON), Assistant CDCO, Staff Development Coordinator (SDC), and Unit Managers on Abuse and Neglect Prevention, Resident Rights, Elder Justice Act, Storage of Medications, Biologicals, and Chemicals, Elopement, and Behavior Management and Monitoring. The surveyors reviewed the in-service education provided and interviewed the Administrator, SDC, and DON. 3. On 9/17/2021 and 9/18/2021, 100 percent (%) of all current resident and or resident representatives (if resident is cognitively impaired) were re-educated on the Abuse & Neglect Prevention Policy, Resident Rights and Elder Justice Act. The surveyors interviewed alert and oriented residents and reviewed the medical record for family notification. 4. On 9/17/2021 and 9/18/2021, staff were re-educated on Abuse & Neglect Prevention, Resident's Rights, Elder Justice Act, and Elopement. All licensed nurses were educated on Abuse Reporting and Investigation Guidelines, documentation guidelines, Behavior Management and Monitoring, and Elopement policy. Employees will not be allowed to work until in-services are completed. The surveyors reviewed the in-services and interviewed staff on all shifts. 5. The Administrator and Social Services will monitor and audit all reports of alleged abuse and neglect weekly for 8 weeks, then monthly for 3 months. The surveyors reviewed the audits and interviewed the Administrator. 6. The Administrator will submit all reports of alleged abuse weekly to the RDCO to review to ensure the process meets regulatory guidelines. The surveyors interviewed the RDCO. The facility's noncompliance of F-600 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, and interview, the facility failed to report an incident of a missing resident for 1 of 7 sampled residents (Resident #294) reviewed with wandering behaviors. The facility's failure to report incidents of missing residents and neglect to the State Survey Agency and other appropriate agencies resulted in Immediate Jeopardy when Resident #294 was missing and found locked in a chemical storage (housekeeping) closet after approximately one hour without staff knowledge of the location of the resident. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Chief Director of Clinical Operations (CDCO/Director of Nursing) were notified of the Immediate Jeopardy on 9/17/2021 at 2:04 PM, in the Omega Room. The facility was cited Immediate Jeopardy at F-609. The facility was cited F-609 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy for F-609 was effective from 7/12/2021 through 9/19/2021. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 9/19/2021 at 12:16 PM, and was validated onsite by the surveyors from 9/19/2021 and 9/20/2021 through observations, review of audits, meeting minutes, and staff interviews. The findings include: Review of the facility's Abuse Prevention Policy, revised on 3/1/2018, revealed .The resident has the right to be free from mistreatment, neglect and misappropriation of property . Review of the facility's policy titled, Elopement Of Resident, dated 9/1/2018, revealed .Should an employee discover that a resident is missing .If not located in 15 minutes .Notify the Administrator and the Director of Nursing Services .Notify the resident's representative .Notify the attending physician .Notify law enforcement officials .The Charge Nurse will complete an Incident Report .The Administrator/Director of Nursing Services will notify the Department of Health per State Regulations . Review of the facility's policy titled, Incident Report - Documentation, Investigating, And Reporting, revised 10/2019, revealed .The Administrator/Director of Nursing will notify the appropriate Regulatory Agency in accordance with reporting guidelines in the event the incident is reportable . Review of the facility's Quality Assurance Performance Improvement (QAPI) document, dated 8/25/2021, revealed .Elopement risk and incident discussed with the QAA [Quality Assurance Agency] team .Resident Missing, nurses could not find him. Charge Nurse did not notify the Admin [Administrator] in a timely man [manner] .Root Cause: Left safe area . Review of the medical record, revealed Resident #294 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurse's Note dated 7/13/2021, at 12:00 AM, revealed, [Named Resident #294] who wonders [wanders] the building day/night and was last seen by nurse before her lunch break after 8pm [8:00 PM on 7/12/2021]. Upon return from nurses [nurse's] lunch break, the CNA [Certified Nursing Assistant] asked nurse had she saw [seen] resident because she was ready to change him and get him ready for bed. Nurse responded No. After about 30 min [minutes], CNA informed nurse that she still was unable to find resident and need [needed] help locating resident. Nurse and CNA began looking room to room calling residents [resident's] name trying to locate him. After about 15/20 mins [15 to 20 minutes] of looking we called a DR [doctor] Find Me [code for elopement or missing resident] for all employees to help locate resident. Nurse contacted Nurse Manager and informed her that we had been looking for resident for about any [an] hour with no progress [unable to locate Resident #294]. Nurse Manager called Administrator and DON to inform them about the situation as all in-house staff continues to search the entire inside and outside. Nurse Manager arrived the search continued. As nurses and Nurse manager were making their way back up the East Wing towards the nursing station we heard a call for help coming from the housekeeping closet. Resident had got himself locked into the closet and was calling for help out. Administrator informed Nurse Manager on the location of housekeeping's closet keys so we could unlock door to get resident out. Opening closet door nurse observed resident sitting on floor. We assisted resident out and evaluated. No signs of injury .Resident unable to explain what happened . This incident of missing resident on 7/12/2021, was not reported to the State Survey Agency and APS. During an interview on 9/15/2021 at 6:11 PM, the Director of Nursing (DON) confirmed the missing resident incident was not reported to the Ombudsman, the State Survey Agency, and APS. During an interview on 9/16/2021 at 10:49 AM, Licensed Practical Nurse (LPN) #3/Unit Manager stated, .they [staff] called me .said we've been looking for [Resident #294] for about 30 minutes .I am down the street .I pulled up .I called them [The Administrator and the Regional Director of Clinical and Operations (RDCO), the acting DON at the time] .she [RDCO] said I am on the way .before they [RDCO and the Administrator] could make it I actually found him .ha was in the Housekeeper's closet [Chemical Storage Closet] .on East [Hall] .he was sitting [on the floor] .he was just confused . LPN #3 confirmed the door was locked from the inside and she had to locate a key to unlock it. LPN #3 was asked if chemicals were stored in the closet. LPN #3 stated, I do not recall .I remember looking to see if there were open containers, but I do not recall. LPN #3 confirmed the door was supposed to be locked. During an interview on 9/16/2021 at 1:54 PM, The RDCO confirmed she was the acting DON at the time of the incident with Resident #294. The RDCO confirmed the incident when Resident #294 was locked in the chemical storage closet was not reported to the State Survey Agency and APS. During an interview on 9/17/2021 at 3:59 PM, the Administrator was asked why he did not investigate or report the incident with Resident #294. The Administrator stated, Being that I can't report what I don't know, I did not [investigate or report the incident] . The Administrator was asked if an unsupervised resident wandered into an unsafe environment, should that incident be investigated and reported. The Administrator stated, Per our policy, yes. Refer to F-600, F-610, and F-689. The surveyors verified the Removal Plan by: 1. On 9/17/2021, a Root Cause Analysis (RCA) was completed. The Charge Nurse was suspended for 4 days for failure to notify the Administrator and the RDCO when the incident occurred. The RDCO re-educated the Administrator, the DON, Assistant Chief Director of Clinical Operation, Staff Development Coordinator, and unit Managers on Abuse and Neglect Prevention, Resident's Rights, the Elder Justice Act, Reporting Guidelines, Storage of Medications, Biological and Chemicals, Elopement, Behavior Management & Monitoring. The RCA was reviewed by the surveyors and staff interviews were conducted with Administrative staff, the Staff Development Coordinator, and Unit Managers. 2. On 9/17/2021 and 9/18/2021, all current resident and/or resident representatives for cognitively impaired residents were re-educated on Abuse & Neglect Prevention, Resident's Rights, and the Elder Justice Act. The surveyors interviewed alert and oriented residents and reviewed the medical record for family notification. 3. On 9/17/2021 and 9/18/2021, staff were re-educated on Abuse & Neglect Prevention, Resident's Rights, the Elder Justice Act, Abuse Reporting Guidelines, and Elopement. Employees will not be allowed to return to work until the in-services are completed. The surveyors reviewed the in-services and interviewed staff on all shifts. 4. On 9/17/2021 and 9/18/2021, all licensed nurses were educated on Abuse reporting guidelines, documentation guidelines, behavior management & monitoring, and elopement policy. Employees will not be allowed to return to work until in-services are completed. The surveyors reviewed the in-services and interviewed staff on all shifts. 5. The Administrator or DON will monitor, audit, and ensure all reports of alleged abuse are submitted to the appropriate state agency and report findings in the monthly QAPI meeting for 3 months or until compliance is achieved. The surveyors reviewed the audit log form and interviewed the Administrator and DON. 6. The RDCO will review all reports of alleged abuse weekly and ensure regulatory guidelines are met. The surveyors interviewed the RDCO. The facility's noncompliance of F-609 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, video camera footage review, medical record review, observation, and interview, the facility failed to thoroughly investigate an incident of resident-to-resident abuse and a missing resident for 2 of 10 sampled residents (Resident #293 and #294) reviewed for abuse and wandering. The facility's failure resulted in Immediate Jeopardy when the facility failed to implement interventions to ensure the safety of other residents when Resident #293 willfully struck Resident #294, resulting in multiple facial fractures and when Resident #294 was missing for approximately 1 hour without staff knowledge and was found locked in a chemical storage (housekeeping) closet. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Chief Director of Clinical Operations (CDCO)/Director of Nursing) were notified of the Immediate Jeopardy for F-610 on 9/17/2021 at 2:03 PM, in the Omega Room. The facility was cited Immediate Jeopardy at F-610. The facility was cited F-610 at a scope and severity of J, which is Substandard Quality of Care. The IJ was effective from 7/8/2021 through 9/19/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 9/19/2021 at 12:16 PM, and was validated onsite by the surveyors on 9/19/2021 and 9/20/2021 through review of root cause analysis, in-services, and staff interviews conducted on all shifts. The findings include: Review of the facility's policy titled, Abuse Prevention, revised on 3/1/2018, revealed .The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property .when abuse, neglect or exploitation is suspected the Licensed Nurse should .Notify the Director of Nursing and Administrator .Complete an incident report and initiate an immediate investigation to prevent further potential abuse .Obtain witness statements following incident policies .Monitor and document the resident's condition .Document actions taken .in the medical record .Examples of ways to protect a resident from harm during an investigation of abuse, neglect and exploitation may include .Temporary one on one supervision .When suspicion or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted .Interview with the involved resident, if possible and document all responses. If the resident is cognitively impaired, interview the resident several times to compare responses. Interview all witnesses separately .Obtain witness statements . Review of the facility's policy titled, Elopement Of Resident, dated 9/1/2018, revealed .Should an employee discover that a resident is missing .If not located in 15 minutes .Notify the Administrator and the Director of Nursing Services .Notify the attending physician .Determine the time and location the resident was last seen .Once the Resident is Located .The resident will be assessed by M.D. [medical doctor] and documented .The Charge Nurse will complete an Incident Report .A complete and thorough root-cause analysis of the elopement should be done .reviewed at the next QAPI [Quality Assurance Performance Improvement] meeting . Review of the facility's Unsafe Wandering-Elopement Risk Policy, dated 9/21/2017, revealed Every effort will be made to prevent unsafe wandering .Should an elopement episode occur, an incident report will be completed .If an elopement episode occurs, a monitoring schedule will be implemented to ensure resident safety .The resident's care plan will be updated as to the implementation of the monitoring . Review of the facility's policy titled Incident Report - Documentation, Investigating, And Reporting, revised 10/2019, revealed .The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall promptly initiate and document investigation of the accident or incident .The supervisor designee is to document the investigation of the event and the intervention put into place . Review of the medical record, revealed Resident #293 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #293 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated he was severely cognitively impaired for decision making, wandered on 1-3 days of the 7-day assessment period, and was able to transfer and walk without physical assistance from staff. Review of a Skilled Evaluation dated 7/8/2021 at 8:40 PM, revealed .Resident does not obey commands .Resident is confused .Mood is pleasant, no unwanted behaviors witnessed . Review of an SBAR (Situation, Assessment, Background, Recommendation), note dated 7/9/2021 at 3:18 AM, revealed The Change In Condition/s reported on this CIC [Change In Condition] Evaluation are/were: Behavioral symptoms .Physical aggression . Review of a Nurse's Note dated 7/9/2021 at 11:41 AM, revealed Licensed Practical Nurse (LPN) #1 was informed Resident #294 and Resident #293 had an altercation in the hallway of the East station and that Resident #293 hit Resident #294 with his fist. Resident #293 stated to LPN #1 he pushed Resident #294. Both residents were assessed and were reported to not have any physical injuries at that time. Review of a Behavior Note dated 7/9/2021 at 1:31 PM, revealed SW [Social Worker] informed that resident had a physical altercation with another resident .[Named Resident #293] said, I gave him [Resident #294] a karate chop because he disrespected me. [Named Resident #293] pointed to the side of his head when asked where he hit the other resident. [Named Resident #293] noted with dx [diagnosis] of dementia and [CONDITION(S)] . Review of the medical record, revealed Resident #294 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #294 had a BIMS of 3 which indicated he was severely cognitively impaired for decision making, wandered on 1-3 days of the 7-day assessment period, and required limited assistance with transfer and ambulation. Review of the video camera footage provided by the facility, revealed that on 7/8/2021 at 5:38 PM, the doors of the 100-111 hallway were closed and no staff were seen in the hall. Resident #294 ambulated out of his room into the hallway. At 5:39 PM, Resident #294 ambulated toward a room across the hall and was struck on the left side of his face by Resident #293 and the force of the blow knocked him to the floor. Resident #294 fell in the middle of the hallway on his right side. He then sat up and appeared to be trying to get to a standing position when the video ended. Review of a Nurse's Note for Resident #294 dated 7/9/2021 at 4:40 PM, revealed While making morning rounds with off-going nurse this writer cbserved [observed] resident's face swollen, right eye red swollen with purple and dark red bruising, per off-going nurse a resident to resident altercation happened . Review of a Nurse's Note for Resident #294 dated 7/9/2021 at 11:04 PM, revealed Resident returned back from [Named Hospital] @ 20:38pm [at 8:38 PM]. He returned with dx [diagnosis] of comminuted fractures [the bone was broken into more than 2 fragments] involving the anterior and lateral walls of the left maxillary [MEDICATION(S)] and additional fractures through the lateral wall of the left orbit and left zygomatic [the bone at the upper, outer part of the face forming the prominence of the cheek] bone (Multiple Facial Fractures) . Review of the facility's investigation dated 7/9/2021, revealed .After reviewing the camera it is found that residents [Resident #293 and #294] .were having an argument .[Named Resident #293] struck [Named Resident #294] in the face .In order to keep this from happening again the said Residents were on the same wing together but [Resident #294] is being moved to a separate wing to be monitored closer. Resident [#293] is sent to a local Psychiatric Hospital . [Resident #294] returned with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was unable to provide documentation that interventions were implemented for Resident #293 to prevent further aggressive behaviors toward Resident #294 or other residents until he was transferred to a psychiatric facility on 7/9/2021 at 5:30 PM. Resident #293 was in his room with his door closed and no other interventions were documented to monitor Resident #293 and prevent any further adverse actions. During an interview on 9/16/2021 at 11:08 AM, the Administrator was asked to describe the investigation related to the altercation between Resident #293 and Resident #294 . The Administrator stated, .The night that [Named Resident #293] and [Named Resident #294]'s altercation [occurred], it wasn't witnessed .a resident reported the incident to the nurse .at first he [Resident #294] had no injuries and when the next shift came on, he had started bruising . The Administrator was asked if there were any interventions implemented to protect the other residents in the facility after the altercation occurred. The Administrator stated, .They were separated and [Named Resident #293] was actually transferred to psych [psychiatric facility] [the next day] . During an interview on 9/16/2021 at 1:54 PM, the Regional Director of Clinical Operations (RDCO) confirmed she was the acting Director of Nursing at the time of the resident-to-resident altercation on 7/8/2021. The RDCO was asked if any interventions were implemented to keep Resident #294 from harming the other residents. The RDCO confirmed the residents were on the same hall and the staff took Resident #293 to his room, closed the door so he would not be in contact with other residents, and checked on him to make sure he stayed in his room until he was transferred to the psychiatric facility. The RDCO was asked if any interventions were implemented to protect the other residents. The RDCO stated, .there was no documentation that 1 on 1 supervision or every 15-minute checks were performed . During a telephone interview on 9/17/2021 at 3:01 PM with the Medical Director for the facility. The Medical Director was asked if the other vulnerable residents in the facility should have been protected until Resident #294 was transferred to the psychiatric hospital due to his violent aggressive behavior and if Resident #294 should have been more closely supervised until he was transferred. The Medical Director stated, Yes. During an interview on 9/17/2021 at 3:59 PM, the Administrator was asked when he was notified of the resident-to-resident altercation. The Administrator stated, .it was the next morning . The Administrator was asked what instructions he gave the staff for monitoring Resident #294 until he was transferred to the psychiatric hospital. The Administrator stated, .I didn't . The Administrator was asked considering the severity of Resident #293's injuries and that he was ambulatory, should Resident #293 have been provided increased supervision. The Administrator stated, .I believe monitoring was in order, I trusted the nurses to do that that night. I was disappointed there was nothing done for the resident .I take the heat because I'm the Abuse Coordinator, but I can't report things I don't know .my number is throughout the building, no texting, but to call me .I'm always on call and keep my computer and work phone, and can report from wherever . Review of a Nurse's Note dated 7/13/2021 at 12:00 AM, revealed [Named Resident #294] wonders [wanders] the building day/night and was last seen by nurse before her lunch break after 8pm [8:00 PM on 7/12/2021]. Upon return from nurses [nurse's] lunch break, the CNA [Certified Nursing Assistant] asked nurse had she saw [seen] resident because she was ready to change him and get him ready for bed. Nurse responded No. After about 30 min [minutes], CNA informed nurse that she still was unable to find resident [Resident #294] and need [needed] help locating resident. Nurse and CNA began looking room to room calling resident's name trying to locate him. After about 15/20 mins [15 to 20 minutes] of looking we called a DR [doctor] Find Me [code for elopement or missing resident] for all employees to help locate resident. Nurse contacted Nurse Manager and informed her that we had been looking for resident for about any [an] hour with no progress .Nurse Manager arrived the search continued. As nurses and Nurse Manager were making their way back up the East Wing towards the nursing station we heard a call for help coming from the housekeeping closet. Resident had got himself locked into the closet and was calling for help out. Administrator informed Nurse Manager on the location of the housekeeping's closet keys so we could unlock door to get resident out. Opening closet door nurse observed resident sitting on floor. We assisted resident out and evaluated. No signs of injury . The facility was unable to provide any documentation that an investigation of this incident was conducted, or documentation of monitoring implemented to ensure Resident #294's safety. Observation of the housekeeping closet on the East hall on 9/15/2021 at 1:14 PM and 1:25 PM, revealed the door was unlocked and had an over-head shelf with 2 (1 quart) containers of Antibacterial Heavy-Duty Cleaner & Odor Counter, 1 (1 quart) of a liquid cream cleanser and 1 (1 quart) bottle of toilet bowl cleanser on the shelf. There was a mop bucket in the closet. Observation of the housekeeping closet on the West hall on 9/15/2021 at 1:21 PM, revealed the door was unlocked and had an over-head shelf with 1 quart bottle of floor cleaner on the shelf. During an interview on 9/15/2021 at 5:09 PM, the DON was asked who had the responsibility to report the incident to the state and investigate the incident. The DON stated, [Named Administrator] and confirmed the incident had not been reported or investigated. During an interview on 9/16/2021 at 10:49 AM, Licensed Practical Nurse (LPN) #3/Unit Manager was asked to recall the incident when Resident #294 was missing. The LPN stated, .I was actually on vacation, but I was in the area .they [staff] called me on how to move forward .said we've been looking for [Named Resident #294] about 30 minutes. I called the Administrator, and he didn't answer, and I called our acting DON which was the Regional Director of Clinical Operations (RDCO) and she told me she was on the way. I actually found the resident before the DON made it . The LPN was asked where she located the resident. The LPN stated, .he was in the housekeeper's closet .on East [hall] .the door was locked, and I had to locate a key . The LPN was asked if he appeared in distress. The LPN stated, .he was sitting .he was just confused . The LPN was asked if there were any chemicals in the closet. The LPN stated, .I do not recall .I remember looking to see if open containers, but I do not recall . The LPN was asked if the housekeeping closet was routinely left unlocked. The LPN stated, No, it's not supposed to be. The LPN was asked how long she looked for the resident. The LPN stated, .About 10 minutes, if that long .got about 3 rooms in and we reached the closet . The LPN was asked if she completed a statement or incident report. The LPN stated, I did not, I asked the nurse to document the incident . The LPN was asked if she provided any education to the staff after the incident. The LPN stated, .Yes, I was asked that we routinely go and check those doors and make sure the closet was locked .something I did on my way out . The LPN was asked if there was documentation by the staff validating attendance at the in-service. The LPN stated, I did not, it was kind of unofficial. The LPN was asked how she became aware the resident was in the closet. The LPN stated, I could hear him saying open the door or something like that . During an interview on 9/16/2021 at 11:08 AM, the Administrator was asked when he was informed Resident #294 was missing. The Administrator stated, .I got a call maybe if I had to guess, in the 9 o'clock hours, called maybe 10 minutes later the resident had been located . The Administrator was asked if there had been an investigation and were witness statements obtained. The Administrator stated, .I told them to put an incident report in PCC [the electronic medical record] .then we did the QA [Quality Assurance] on our protocol . The Administrator was asked why the incident of the missing person had not been investigated. The Administrator stated, .Because the Unit Manager was there and she had the team to write the note in the system .found the door was actually locked but it wasn't latched, closed, he didn't have the capacity to lock or unlock a door, when he went in it slammed behind him and he couldn't get out . The Administrator was asked when the resident was last seen prior to staff being aware the resident was missing. The Administrator stated, .I talked to [Named LPN #3/Unit Manager] and they [the staff] weren't able to tell her .in my mind great, he wasn't outside, he wasn't hit, nobody brought him to us .they told me he was in the chemical [housekeeping] closet and I know that door has a heavy close . The Administrator was asked if he had reviewed the video camera footage to see how long the resident had been in the closet. The Administrator stated, No. During an interview on 9/16/2021 at 1:54 PM, the RDCO was asked if the incident related to Resident #294 being locked in the housekeeping closet was investigated or reported to the state. The RDCO stated, No. The RDCO was asked if there was any education provided to the staff regarding elopement and wandering residents. The RDCO stated, I don't think so. During a telephone interview on 9/17/2021 at 3:01 PM, the physician confirmed he was the Medical Director (MD) for the facility. The Medical Director was asked if he was aware of an incident when a resident was missing. The Medical Director stated, Yes I was, it was brought up [in a QAPI meeting] and it wasn't handled the way it should have been, we talked about that. The Medical Director was asked if he made any recommendations on how it should have been handled. The Medical Director stated, Earlier notification of the Physician or Nurse Practitioner on all, Administrator, DON, try to get people sent out as soon as possible, one with injuries make sure to notify the family right away .I guess the people working that night did not understand that . During an interview on 9/17/2021 at 3:59 PM, the Administrator was asked what involvement he had in the incident when Resident #294 was locked in the housekeeping closet. The Administrator stated, .the staff called to notify me that they had not seen him, I was going to advise them of places to look .I would have never thought of the chemical closet [housekeeping closet] .that door is typically latched, everyone is constantly pulling on that door . The Administrator was asked if after Resident #294 was located was any education regarding the closets being locked provided for the staff. The Administrator stated, .There was not . The Administrator was asked if any staff member conducted an investigation. The Administrator stated, .I can't say it was . The Administrator was asked why the incident of a missing resident was not investigated. The Administrator stated, .I can't report what I don't know .when it was brought to me 5 or 10 minutes later, he was already found so I didn't do that .now that I'm finding out they had been looking for him . The Administrator was asked if an incident of a resident wandering into an unsafe environment unsupervised should be investigated and reported. The Administrator stated, .per our policy, yes. Refer to F-600, F-609 and F-689. The surveyors verified the removal plan by: 1. A Root Cause Analysis was completed on 9/17/2021. The Root Cause Findings identified were the Abuse Coordinator was not notified of the resident-to-resident altercation timely; the Charge Nurse failed to document immediate interventions: and the Charge Nurse failed to document monitoring of residents after a resident-to-resident altercation. The Charge Nurse was suspended for 4 days for failure to notify the Administrator and the Regional Director of Clinical Operations (RDCO) when the incident occurred. The RCA was reviewed by the surveyors 2. On 9/17/2021, the RDCO re-educated the Administrator, Chief Director of Clinical Operations, the Assistant Chief Director of Clinical Operations, the Staff Development Coordinator, and Unit Managers on Abuse & Neglect Prevention, Resident Rights, the Elder Justice Act, the Reporting Guidelines, Storage of Medications, Biologicals & Chemicals, Elopement Behavior Management & Monitoring. The surveyors reviewed the education and interviewed the Administrator, Chief Director of Clinical Operations, the Assistant Chief Director of Clinical Operations, the Staff Development Coordinator, and Unit Managers. 3. On 9/17/2021 & 9/18/2021, 100 % of all current resident and/or resident representatives (if the resident is cognitively impaired) were re-educated on the Abuse & Neglect Prevention Policy, Resident Rights, & the Elder Justice Act. Resident representatives were re-educated on the Abuse & Neglect Prevention Policy, Resident Rights, & the Elder Justice Act. The surveyors interviewed alert and oriented residents and reviewed the medical record for family notification. 4. On 9/17/2021 & 9/18/2021, staff were reeducated on Abuse & Neglect Prevention, Resident Rights, the Elder Justice Act, Abuse Reporting Guidelines, Investigation, and Elopement. Employees will not be able to accept a work assignment until the in-services are completed. New hires and employees on leave of absence (LOA) will not be placed on the schedule and/or will not be allowed to return to work until in-services are completed. The surveyors reviewed the in-services and interviewed staff on all shifts. 5. On 9/17/2021 & 9/18/2021, all licensed nurses were educated on Abuse reporting and investigation guidelines, documentation guidelines, behavior management & monitoring, and elopement policies. Employees will not be allowed to accept a work assignment until they have completed the education. The surveyors reviewed the in-services and interviewed nurses on all shifts. 6. The Administrator or CDCO will monitor and audit all reports of alleged abuse and missing residents to assure they are investigated thoroughly. Monitoring will be weekly for 8 weeks then monthly x 3 months. The Administrator will report the findings in the Quality Assurance Performance Improvement (QAPI) meeting monthly for 3 months or until a period of compliance is achieved. The surveyors reviewed the audit log form and interviewed the Administrator and the DON. 7. The Administrator will submit all reports of alleged abuse weekly to the RDCO to review to ensure the process meets regulatory guidelines. The surveyors interviewed the RDCO. The facility's noncompliance of F-610 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on video camera footage review, policy review, medical record review, observation, and interview, the facility failed to ensure adequate supervision of cognitively impaired residents that were at risk for wandering and failed to ensure the facility was free of accident hazards for 2 of 10 sampled residents (Resident #293 and #294) reviewed for abuse and wandering. The facility's failure resulted in Immediate Jeopardy when Resident #293 struck Resident #294 which resulted in multiple facial fractures; when Resident #294 wandered from a safe area to an unsafe area without staff knowledge and was found approximately 1 hour later locked in a chemical storage (housekeeping) closet; and when 2 of 2 housekeeping closets [East and West Hall housekeeping closets] were found unlocked, unattended, and chemicals were stored in the closets. The facility failure to ensure a safe environment that provided supervision for a cognitively impaired resident at risk of wandering and prevent accidents that resulted in actual harm when Resident #293 struck Resident #294 resulting in multiple facial fractures. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Chief Director of Clinical Services (CDCO/Director of Nursing) were notified of the Immediate Jeopardy for F-689 on 9/17/2021 at 2:04 PM, in the Omega Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 7/8/2021 through 9/19/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 9/19/2021 at 12:16 PM, and was validated onsite by the surveyors on 9/19/2021 and 9/20/2021 through review of root cause analysis, in-services, audits, and staff interviews conducted on all shifts. The findings include: Review of the facility's policy titled, Abuse Prevention, revised on 3/1/2018, revealed .The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property .It is the responsibility of all staff to provide a safe environment for the residents when abuse, neglect, or exploitation is suspected the Licensed Nurse should .Notify the Director of Nursing and Administrator .Complete an incident report and initiate an immediate investigation to prevent further potential abuse .Interview with the involved resident, if possible and document all responses. If the resident is cognitively impaired, interview the resident several times to compare responses. Interview all witnesses separately .Obtain witness statements .Notify the Ombudsman .Ensure that all alleged violations .are reported immediately, but no later than 2 hours after the allegation is made . Review of the facility's policy titled Elopement Of Resident, dated 9/1/2018, revealed .Should an employee discover that a resident is missing .If not located in 15 minutes .Notify the Administrator and the Director of Nursing Services .Notify the attending physician .Determine the time and location the resident was last seen .Once the Resident is Located .The resident will be assessed by M.D. [Medical Doctor] and documented .The Charge Nurse will complete an Incident Report .The Administrator/Director of Nursing Services will notify the Department of Health per State Regulations .A complete and thorough root-cause analysis of the elopement should be done .reviewed at the next QAPI [Quality Assurance Performance Improvement] meeting . Review of the facility's Unsafe Wandering-Elopement Risk Policy, dated 9/21/2017, revealed Every effort will be made to prevent unsafe wandering .Should an elopement episode occur, an incident report will be completed .If an elopement episode occurs, a monitoring schedule will be implemented to ensure resident safety .The resident's care plan will be updated as to the implementation of the monitoring . Review of the facility's policy titled, Storage Of Medications, Biologicals And Chemicals, dated 10/26/2017, revealed .the facility should ensure that all medications, biologicals and chemicals, including treatment items, are secured in a locked cabinet/cart or locked medication room and locked storage room that is inaccessible by residents and visitors . Review of the medical record, revealed Resident #293 was admitted to the facility on [DATE] with diagnoses of Congestive Heart Failure, [CONDITION(S)], Diabetes, Hypertension, and [CONDITION(S)]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #293 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated he was severely cognitively impaired for decision making, wandered on 1-3 days of the 7-day assessment period, and was able to transfer and walk without physical assistance from staff. Review of a Skilled Evaluation for Resident #293 dated 7/8/2021 at 8:40 PM, revealed .Resident does not obey commands .Resident is confused .Mood is pleasant, no unwanted behaviors witnessed . Review of an SBAR (Situation, Assessment, Background, Recommendation) note dated 7/9/2021 at 3:18 AM, revealed, .The Change In Condition/s reported on this CIC [Change In Condition] Evaluation are/were: Behavioral symptoms .Physical aggression . Review of the medical record, revealed Resident #294 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], Hypertension, [CONDITION(S)], History of Falling, [CONDITION(S)], [CONDITION(S)], Age Related Debility, and Protein Calorie Malnutrition. Review of the admission MDS dated [DATE], revealed Resident #294 had a BIMS of 3 which indicated he was severely cognitively impaired for decision making, wandered on 1-3 days of the 7-day assessment period, and required limited assistance with transfer and ambulation. Review of the video camera footage provided by the facility, revealed that on 7/8/2021 at 5:38 PM, the doors of the 100-111 hallway were closed and no staff were seen in the hall. Resident #294 ambulated out of his room into the hallway. At 5:39 PM, Resident #294 ambulated toward a room across the hall and was struck on the left side of his face by Resident #293 and the force of the blow knocked him to the floor. Resident #294 fell in the middle of the hallway on his right side. He then sat up and appeared to be trying to get to a standing position when the video ended. Review of a Nurse's Note dated 7/9/2021 at 11:41 AM, revealed Resident #293 and Resident #294 had an altercation in the hallway of the East Station on 7/8/2021. Resident #293 hit Resident #294 with his fist and according to the documentation there were no physical injuries identified at that time. Review of the Nurse's Note dated 7/9/2021 at 4:40 PM. revealed the resident was noted to have a swollen right eye with dark bruising and was sent to the hospital for evaluation. Review of the Nurse's Note dated 7/9/2021 at 11:04 PM, revealed Resident #294 returned to the facility from the acute care hospital on with diagnoses of multiple facial and nasal bone fractures. The facility was unable to provide documentation that Resident #293 had close supervision after the altercation on 7/9/2021 to prevent further aggressive behaviors toward Resident #294 or any other resident in the facility from the time of the incident on 7/8/2021 until he was transferred to a psychiatric facility on 7/9/2021 at 5:30 PM. During an interview on 9/16/2021 at 1:54 PM, the Regional Director of Clinical and Operations (RDCO) confirmed there was no documentation of close supervision for Resident #293 after the incident. During a telephone interview on 9/16/2021 at 9:00 PM, Licensed Practical Nurse (LPN) #1 was asked where Resident #293 was located following the altercation with Resident #294 and the LPN #1 stated the resident was in his room and Resident #293 did not have any increased supervision after the altercation with Resident #294. During an interview on 9/17/2021 at 8:47 AM, LPN #4 was asked how often staff monitored Resident #293 after the incident with Resident #294 to assure he was in his room and LPN #4 stated, .at least every 2 hours but in that situation, I believe I went down there every hour . There was no documentation Resident #293 was monitored closely to assure the resident remained in his room and there were no further incidents or altercations with other residents. Review of the Care Plan for Resident #294 dated 6/24/2021, revealed .has wandering behavior .impaired safety awareness. Resident wanders aimlessly .Maintain wander guard [a mechanical bracelet device that will cause the door to alarm when the resident gets too close to the door] bracelet [initiated 7/13/2021] . Review of the Elopement Evaluation dated 6/28/2021, revealed Resident #294 was a wanderer, had a history of attempting to leave the facility without informing staff, and had verbally expressed the desire to go home. Review of a Skilled Evaluation dated 7/5/2021 at 1:30 PM, revealed, Resident #294 was confused, did not obey commands, had an unsteady gait, wandered, and was exit seeking. Review of a Nurse's Note dated 7/13/2021 at 12:00 AM, revealed Resident #294 wandered throughout the facility during the day and night and was last seen by a nurse on 7/12/2021 after 8:00 PM. Upon return from the lunch break, the Certified Nursing Assistant (CNA) asked the nurse if she had seen Resident #294 as she wanted to prepare him to go to bed for the night. The nurse told her she had not seen the resident.After about 30 minutes the CNA informed the nurse that she still was unable to find the resident and needed assistance locating the resident. The nurse and CNA began looking through all the rooms, calling the resident's name in an attempt to locate the resident. After about 15 to 20 minutes, they decided to call a DR [doctor] Find Me [which is the code for an elopement or missing resident] for all the employees to assist in locating the resident. The nurse contacted the Nurse Manager and informed her that they had been looking for the resident for about an hour with no progress in locating the resident. The Nurse Manager called the Administrator and the DON to inform them while the staff continued to search the facility inside the building and outside the building. As the nursing staff and the Nurse manager were returning to the East Wing toward the nurses station they heard a call for help coming from the housekeeping closet . Resident #294 was locked in the closet and calling for help. The Nurse Manager obtained the keys to the housekeeping closet so they could unlock the door for the resident to come out of the closet. When they opened the door the resident was sitting on the floor of the closet and .no signs of an injury . The facility was unable to provide an incident report, investigation of the incident, or any documentation of monitoring put in place to ensure Resident #294's safety. Observation of the East Hall housekeeping closet on 9/15/2021 at 1:14 PM and 9/15/2021 at 1:25 PM, revealed the door was unlocked, had an over-head shelf with 2 (1 quart) containers of Antibacterial Heavy-Duty Cleaner & Odor Counter, 1 (1 quart) container of a liquid cream cleanser, and 1 (1 quart) bottle of toilet bowl cleaner on the shelf. Observation of the West hall housekeeping closet on 9/15/2021 at 1:21 PM, revealed, the door was unlocked and had an over-head shelf with 1 (1 quart) bottle of furniture cleaner and 1 (1 quart) bottle of floor cleaner on the shelf. During an interview on 9/15/2021 at 1:56 PM, the Housekeeping Manager confirmed that chemical storage closets should be locked at all times. During an interview on 9/15/2021 at 5:17 PM, LPN #2 was asked how wandering residents are provided the supervision they require. LPN #2 stated, When we figure out, they are [wanderers] we put wander guards on them .as far as monitoring on a day-to-day basis we do the best we can .it's hard to babysit a wanderer . LPN #2 was asked if any doors to rooms or offices were left unlocked where a wandering resident could enter and not be easily observed. LPN #2 stated, .there was an incident when there was a door that was not secured and locked and a resident got into it .I think it was a housekeeping closet and I think the housekeeper left it unlocked or didn't close it all the way .I thought that was like an electrical closet . LPN #2 was asked who located Resident #294 when it was identified he was missing. LPN #2 stated, .It was a group of us walking up the hall .heard him yelling .our Unit Manager was walking past the door and said she thought he was in there .we knocked, and he knocked back . She stated the resident was .sitting in the floor when he was found . LPN #2 stated Resident #294 the staff searched for the resident Probably an hour . and had no injuries when he was located. During an interview on 9/15/2021 at 5:49 PM, the Director of Nursing (DON) was asked about the incident when resident #294 was missing and found locked in the closet. The DON stated, .I received a call saying they could not find the resident and I was headed here .but he was found in a [housekeeping] closet .In a maintenance or storage closet, I think it was maintenance or housekeeping .one of them down on the East Hall . The DON was asked if those closets should be left unlocked. The DON stated, No. During an interview on 9/16/2021 at 10:49 AM, LPN #3/Unit Manager was asked if she recalled the incident when Resident #294 was missing. LPN #3/Unit Manager stated, I was actually on vacation but I was in the area .they [staff] called me on how to move forward, I'm down the street .said we've been looking for [Named Resident #294] about 30 min [minutes] .he was in the housekeeper's closet .on East [Hall] .I could hear him saying open the door or something like that . LPN #3/Unit Manager was asked if the door was locked. LPN #3/Unit Manager stated, It was, I had to locate a key. LPN #3/Unit Manager was asked if that closet was usually unlocked. LPN #3/Unit Manager stated, No, it's supposed to be locked . LPN #3/Unit Manager was unable to recall if chemicals were stored in the closet the night of the incident. During an interview on 9/16/2021 at 1:54 PM, the Regional Director of Clinical Operations (RDCO) was asked what interventions were implemented for Resident #294 after he was found locked in a housekeeping closet on 7/12/2021. The RDCO stated, I wanted him to have a trauma assessment, talked to the doctor .Safety Committee . The RDCO confirmed the incident was not investigated, not reported to the state, and no in-services were provided to staff related to the incident. During an interview on 9/16/2021 at 3:00 PM, the RDCO stated the Safety Committee met on 8/25/2021 related to the incident that occurred on 7/12/2021, 6 weeks after the occurrence. During a telephone interview on 9/17/2021 at 3:01 PM, the Medical Director was asked if he was aware of an incident of a missing resident. The Medical Director stated, Yes I was, it was brought up [in a Quality Assurance meeting] and it wasn't handled the way it should have been, we talked about that. The Medical Director was asked if he made any recommendations on how it should have been handled. The Medical Director stated, Earlier notification of the Physician or Nurse Practitioner on call, Administrator, DON, try to get people sent out as soon as possible .one with injuries make sure to notify the family right away .I guess the people working that night did not understand that . During an interview on 9/17/2021 at 3:59 PM, the Administrator was asked what his involvement was in the incident of the missing resident. The Administrator stated, .the staff called to notify me they had not seen him [Resident #294] .I would have never thought he was in a chemical [housekeeping] closet. The Administrator confirmed that the resident was found before he was able to get to the facility. The Administrator was asked if any in-services or staff education were conducted after the incident to assure the doors of the closet should be locked at all times. The Administrator stated, There was not . Refer to F-600, F-609, F-610, and F-689. The surveyors verified the removal plan by: 1. On 9/17/2021, a Root Cause Analysis was completed and found the resident was not provided adequate supervision, the area was made unsafe by failure to properly secure chemical storage and elopement was not reported to proper contacts in a timely manner. The surveyors reviewed the Root Cause Analysis conducted by the RDCO. 2. On 9/17/2021, the RDCO re-educated the Administrator, DON, Assistant CDCO, Staff Development Coordinator, and Unit Managers on Abuse and Neglect Prevention, Resident Rights, the Elder Justice Act, Reporting and Investigation guidelines, Storage of Medications, Biologicals, and Chemicals, Elopement, and Behavior Management and Monitoring. The surveyors reviewed the in-service education provided and interviewed the Administrator, the Staff Development Coordinator, and the DON. 3. On 9/17/2021 and 9/18/2021, 100 percent (%) of all current resident and or resident representatives if the resident was cognitively impaired were re-educated on the Abuse & Neglect Prevention Policy, Resident Rights and the Elder Justice Act. The surveyors interviewed alert and oriented residents and reviewed the medical record for family notification. 4. On 9/17/2021 and 9/18/2021, staff were re-educated on Abuse & Neglect Prevention, Resident's Rights, the Elder Justice Act, the Abuse Reporting and Investigation Guidelines, and Elopement. Employees will not be allowed to work until the in-services are completed. The surveyors reviewed the in-services and interviewed staff on all shifts. 5. The Administrator and the DON will monitor residents identified as at risk for elopement or unsafe wandering in the clinical meeting 5 times per week. The surveyors interviewed the Administrator and the DON. 6. The Administrator, DON, and Director of Maintenance will monitor and audit Storage of Medications, Biologicals and Chemicals specifically to ensure that all appropriate doors are closed and locked. Monitoring will be weekly for 8 weeks then monthly for 3 months. The Administrator will report findings in the QAPI meeting monthly for 3 months or until compliance is achieved. The surveyors reviewed the audit log form and interviewed the Administrator and the Maintenance Director. 7. The RDCO will review all reports of alleged abuse weekly and ensure regulatory guidelines are met. The surveyors interviewed the RDCO. The facility's noncompliance of F-689 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, Administrator job description review, Director of Nursing (DON) job description review, and interview, facility Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable well-being of residents with wandering behaviors and dementia. Administration failed to provide oversight to monitor and provide a safe resident environment for residents with wandering behaviors and dementia. These failures resulted in Immediate Jeopardy when Resident #293 struck Resident #294 in the face, knocked him to the floor, and Resident #294 sustained numerous facial fractures, and when Resident #294 was missing and was located approximately one hour later in a locked chemical storage (housekeeping) closet. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Chief Director of Operations (CDCO/Director of Nursing) were notified of the Immediate Jeopardy on 9/17/2021 at 6:31 PM, in the Omega Room. The facility was cited Immediate Jeopardy at F-600, F-609, F-610, F-689, F-835, and F-867. The facility was cited Immediate Jeopardy at F-600, F-609, F-610, and F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 7/8/2021 through 9/19/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 9/19/2021 at 12:16 PM, and was validated onsite by the surveyors on 9/19/2021 and 9/20/2021 through review of review of the root cause analysis, in-services, audits, and staff interviews conducted on all shifts. The findings include: Review of the facility's policy titled, Abuse Prevention Policy, revised 3/1/2018, revealed .The resident has the right to be free from mistreatment, neglect .Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness .When abuse, neglect .is suspected the Licensed Nurse should .Respond to the needs of the resident, and protect them from further abuse .Notify the Director of Nursing and Administrator .Complete an incident report and initiate an immediate investigation to prevent further potential abuse .It is the responsibility of all staff to provide a safe environment for the residents .Examples of ways to protect a resident from harm during an investigation of abuse, neglect .may include .Temporary one on one supervision of a resident .Report and Investigate .Notify the Local Ombudsman office .Ensure that all alleged violations involving abuse, neglect .are reported immediately, but no later than 2 hours after the allegation is made .to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services [APS] . Review of the undated Administrator job description, revealed .The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times .Ensure that all employees, residents, visitors, and the general public follow the facility's established policies and procedures .Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed .Inform the Medical Director of all suspected or known incidents of resident abuse .Review accident/incident reports .Monitor to determine the effectiveness of the facility's risk management program .Ensure that facility procedure manuals .identify safety precautions .that could cause bodily injury or exposure to a hazardous chemical .Ensure that the facility is maintained in a .safe manner for resident comfort and convenience . Review of the undated DON Services job description revealed, .The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations .and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times .make daily rounds of the nursing service department to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards .Ensure that residents who are unable to call for help are checked frequently .Assist the In-service Director/Educator in developing annual facility in-service training programs .Abuse .Safety .Assist the Safety Officer in developing safety standards for the nursing service department .Ensure that all resident care rooms, treatment areas, etc. [et cetera] are maintained in a .safe .manner .Report and investigate all allegations of resident abuse . During an interview on 9/15/2021 at 5:49 PM, the DON confirmed her employment date was 7/12/2021. The DON was asked about the incident where Resident #294 was missing and was located in the housekeeping closet. The DON stated she was notified they could not locate Resident #294, and she was enroute to the facility when the Administrator notified her Resident #294 had been located in the housekeeping closet on the patient care unit. The DON was asked if the incident should have been reported to the State Survey Agency, the Ombudsman, and Adult Protective Services (APS). The DON stated, I would say if he's missing over a certain amount of time. The DON was asked how long Resident #294 was missing. The DON stated, It appears to be around 30 minutes .[would report] anything over 30 minutes .give them time to look around the facility and outside . During an interview on 9/15/2021 at 6:11 PM, the DON informed the survey team that the incident where Resident #294 had been found locked in a housekeeping closet had not been reported to the State Survey Agency or other appropriate agencies. During an interview on 9/15/2021 at 6:27 PM, the DON informed the survey team an investigation of this incident when Resident #294 had been found locked in a housekeeping closet had not been conducted. The facility was unable to provide an incident report and investigation related to the incident where Resident #294 was found locked in a housekeeping closet. During an interview on 9/16/2021 at 11:08 AM, the Administrator confirmed he did not review the facility camera footage to determine how long Resident #294 was locked in the housekeeping closet. The Administrator confirmed he did not investigate the incident where Resident #294 was locked in the closet. The Administrator confirmed they were unable to identify when Resident #294 was last observed by staff prior to being found locked in the housekeeping closet. During an interview on 9/16/2021 at 1:54 PM, the RDCO confirmed she was aware of the incident when Resident #293 hit Resident #294 in the face. The RDCO was asked what interventions were implemented to protect the other residents from Resident #293, a cognitively impaired resident with aggressive behaviors. The RDCO stated, .took him to his room where the door would be closed, they were rounding on him to make sure he stayed in his room .the next day he was transferred out . The RDCO confirmed the facility did not implement increased supervision of the resident after the incident with Resident #293. The RDCO confirmed the incident was not reported to the State Survey Agency and APS. The RDCO confirmed that education on elopement or locating a missing resident was not provided to staff after Resident #294 was found locked in a housekeeping closet. During an interview on 9/17/2021 at 3:01 PM, the Medical Director confirmed he was aware of the missing resident incident that occurred on 7/12/2021. The Medical Director stated it was discussed in a Quality Assurance meeting and it .wasn't handled the way it should have been, we talked about that. The Medical Director confirmed the Physician or Nurse Practitioner should have received earlier notification. The Medical Director stated, .try to get people sent out as soon as possible, one with injuries make sure to notify the family right away .I guess the people working that night did not understand that . During an interview on 9/17/2021 at 3:59 PM, the Administrator confirmed he was notified the following morning of the incident where Resident #293 struck Resident #294, knocked him to the floor, and caused multiple facial fractures. The Administrator confirmed he did not give staff any instructions on what to do with Resident #293 when he was notified of the incident. The Administrator was asked with the severity of Resident #294's injuries and the fact that Resident #293 was ambulatory, should Resident #293 have been provided closer supervision. The Administrator stated, I believe monitoring was in order .trusted the nurses to .that night I was disappointed, there was nothing done for the resident .I take the heat because I'm the Abuse Coordinator, but I can't report things I don't know . The Administrator confirmed he was notified the staff could not locate Resident #294 on 7/12/2021. The Administrator stated, .Called to notify me that they [staff] had not seen him [Resident #294] .I was going to give them advisement of places to look .would have never thought of the chemical closet [housekeeping closet] .that door is typically latched [locked] . The Administrator confirmed that education to ensure the housekeeping closet was locked was not provided to staff after the incident when Resident #294 was found locked in the closet and an investigation was not conducted on the incident. The Administrator stated, .When it was brought to me .he was already found so I didn't do that [investigation] . The Administrator confirmed he was responsible for reporting incidents to the State Survey Agency. The Administrator was asked if an incident where a resident wandered into an unsafe area unsupervised by staff should be thoroughly investigated and reported. The Administrator stated, Per our policy, yes. During an interview on 9/17/2021 at 5:37 PM, the RDCO confirmed she was the acting DON from 5/25/2021-7/12/2021 and was working the day Resident #293 struck Resident #294 in the face, knocked him to the floor, and he sustained multiple facial fractures. The RDCO confirmed she did not provide guidance to the Administrator and staff regarding the altercation and action that should have been taken after the altercation between Resident #293 and #294. Refer to F-600, F-609, F-610, F-689, and F-867. The surveyors verified the removal plan by: 1. A Root Cause Analysis was completed and found that the Administrator failed to meet standards of his job description as evidenced by a lack of oversight to monitor and provide a safe resident environment, to ensure the facility's resources are utilized effectively to attain and maintain the highest practicable well-being of the residents, and to ensure policies and procedures for Abuse and Neglect, Incident Reporting, Incident Investigation, Accidents, and Quality Assurance and Performance Improvement (QAPI) were followed. The surveyors reviewed the Root Cause Analysis conducted by the RDCO. 2. On 9/17/2021, the Regional Director of Clinical and Operations (RDCO) re-educated the Administrator on his job description including his roles, responsibilities & expectations for ensuring supervision and monitoring of staff to ensure policies and procedures for Abuse and Neglect Prevention, Incident Reporting, Incident Investigation, Accidents, and Quality Assurance Performance Improvement (QAPI) were followed. The surveyors reviewed the in-service education provided and interviewed the Administrator. 3. On September 18, 2021, the RDCO placed the Administrator on a Performance Improvement Plan (PIP) due to the failure to ensure policies and procedures for Abuse and Neglect Prevention, Resident Rights, Elder Justice Act, Reporting and Investigating, Accidents, Elopement, Storage of Medication, Biologicals, and Chemicals, and Behavior Management and Monitoring. The surveyors reviewed the PIP conducted and interviewed the Administrator and RDCO. 4. The RDCO re-educated the Administrator on the QAPI Program policies and procedures on 9/18/2021. The surveyors reviewed the in-service education provided and interviewed the Administrator and RDCO. 5. The Administrator will submit a daily audit log of all resident incidents and accidents to ensure a root cause analysis, an investigation, and appropriate actions have been completed. Any accidents or incidents that meet the requirement of reportable events will be reported within 2 hours, if injury has occurred, and otherwise reported within 24 hours to the appropriate agencies. Findings will be reported to the QAPI committee for review of departmental performance data and communication to ensure residents are protected from abuse and neglect, wandering, and elopement risks. The surveyors reviewed the daily audit log form and interviewed the Administrator. 6. The RDCO will monitor the facility's monthly QAPI committee's internal processes and systems for compliance and follow up related to Abuse and Neglect Prevention, Incident Reporting, Incident Investigation, and Accidents weekly. The surveyors interviewed the RDCO and the Administrator. The facility's noncompliance at F-835 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, job description review, and interview, the facility Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain and maintain the highest practicable well-being of the residents. Administration failed to provide oversight to monitor and provide training of staff to ensure Advance Directives (a written statement of a person's wishes regarding medical treatment, made to ensure those wishes are carried out should the person be unable to communicate them) were honored, and failed to ensure care plan interventions were followed for a Advance Directives. The failure of the facility Administration to ensure residents' Advance Directives were followed placed 1 of 6 sampled residents (Resident #1) in Immediate Jeopardy when Resident #1 was found unresponsive and pulseless, and staff failed to provide life-saving Cardiopulmonary Resuscitation (CPR) measures according to his Advance Directives. Resident #1 expired at the facility on [DATE]. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on [DATE] at 3:05 PM, in the Omega Room. The facility was cited F-656, F-678, F-835, and F-867 at a scope and severity of J. F-678 is Substandard Quality of Care. A partial-extended survey was conducted on [DATE]. The Immediate Jeopardy was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 12:25 PM, and was validated onsite by the surveyors on [DATE] through review of training records, Performance Improvement Plan, audit forms, and interviews. The findings include: Review of the facility's policy titled, CPR, SELF-DETERMINATION, AND DO NOT CARDIOPULMONARY RESUSCITATION (CPR) REQUESTS, reviewed [DATE], showed, .CPR will be attempted for all residents unless there is a DNR [Do Not Resuscitate] order written by the physician on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not provide evidence that the CPR policy had been reviewed since [DATE]. Review of the Administrator job description showed, .The primary purpose of your job is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times .Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards or practice .Review the facility's policies and procedures at least annually and make changes as necessary to assure continued compliance with current regulations .Ensure that all employees .follow the facility's established policies and procedures .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies .Assist the Medical Director in the development and implementation of medical and nursing services policies and procedures and professional standards of practice .Ensure that physicians are in compliance with facility policies governing .medical treatment .plan of care .orders .Report problems areas to the Medical Director .Assist department directors in the topic selection, planning, conducting, and scheduling of in-service training classes and on-the-job training and orientation programs to assure that current material and programs are continuously provided .Ensure that the resident's rights to .self-determination .are well established and maintained at all times . Review of the Director of Nursing Services job description showed, .The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times .you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties .In the absence of the Medical Director, you are charged with carrying out the resident care policies established by this facility .Maintain a reference library of written nursing material .Standards of Practice .that will assist the nursing service department with meeting the day-to-day needs of the resident .Assist the Quality Assessment & [and] Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies .Delegate to nursing service supervisory personnel the administrative authority, responsibility, and accountability necessary to perform their assigned duties .ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards .Ensure that direct nursing care be provided by a licensed nurse .qualified to perform the procedure .Provide direct nursing care as necessary .Assist the In-service Director/Educator in developing advanced directive in-service training programs for the staff and community .Ensure that all personnel involved in providing care to the resident are aware of the resident 's [resident's] care plan .Ensure that nursing personnel refer to the resident's care plan .Ensure that medical and nursing care is administered in accordance with the resident's wishes, including the implementation of advanced directives .Ensure that the facility's policies and procedures governing advance directives are reviewed with the resident . During a telephone interview on [DATE] at 9:58 AM, the Assistant Director of Nursing (ADON) was asked what happened when Resident #1 was found unresponsive on [DATE]. The ADON stated, .When I went in there, I saw him on the floor. [Named RN #1] had checked for pulse and he did not have one. We got the DON. She told us to call 911 . The ADON was asked if anyone started CPR. The ADON stated, No ma'am . The ADON confirmed one of the nurses had checked his code status. The ADON was asked what his code status (whether or not he was to be resuscitated) was. The ADON stated, He was a full code [his wishes were to be resuscitated] . During a telephone interview on [DATE] at 10:10 AM, the DON was asked what happened when Resident #1 was found unresponsive on [DATE]. The DON stated, .It appeared he didn't have any vitals so we called 911 .The nurses had checked them before I got there . The DON was asked what his code status was. The DON stated, I believe he was a [full code . During a telephone interview on [DATE] at 9:43 AM, the Medical Director was asked if CPR should have been initiated on Resident #1 when he was found unresponsive, without a pulse or respirations on [DATE]. The Medical Director stated, If he was a full code .I would say they should have done something .I would have started CPR . During a telephone interview on [DATE] at 1:07 PM, the DON was asked if CPR should have been initiated. The DON stated, Yes ma'am. During an interview on [DATE] at 11:42 AM, the ADON was asked if Resident #1 should have been resuscitated. The ADON stated, Yes. The ADON was asked in what circumstance a nurse should make the decision not to perform CPR. The ADON stated, Really and truly we don't have the power to make that call .If they are full code we should always do CPR on that person .I know we are supposed to get the doctor involved. The ADON was asked if the doctor was called. The ADON stated, Not while I was there . During a telephone interview on [DATE] at 12:12 PM, the Medical Director stated, .You can't not code them [if their wishes are to be resuscitated] . During an interview on [DATE] at 12:30 PM, the Administrator was asked how staff would know a resident's code status in case of an emergency. The Administrator stated, When it's a new patient, they have rounds at the nurses station and tell the staff .They should be able to find information [Named electronic medical record (EMR) system] in Miscellaneous .pull up code status and it will show you if you are supposed to resuscitate or not. Usually what should happen .while taking care of the patient, the other nurse should be pulling it up saying yes he is a full code or not . The Administrator was asked if staff should have followed Resident #1's Advance Directive which called for CPR/full treatment. The Administrator stated, Wow. That is a good one. To be honest, if that's what our policy says, then we should have followed the policy .yes . The Administrator was asked when this incident was first recognized as a problem. The Administrator stated, When you all came in and told us, and started asking questions about it. [Survey team entered the facility on [DATE]]. During an interview on [DATE] at 1:45 PM, the DON was asked how nurses knew what a resident's code status was. The DON stated, They are in-serviced on it. It is on [Named EMR system] at the top of the MAR [Medication Administration Record]. The DON was asked how staff were trained for emergency situations. The DON stated, Through in-services. The DON was asked how she ensured staff knew what to do in an emergency. The DON stated, We offer in-services, and also through the codes that we do have in the building. The DON was asked if she expected the residents' Advance Directives to be honored. The DON stated, Yes ma'am. Refer to F656, F678, and F867. The surveyors verified the Removal Plan by: 1. The Vice President of Operations re-educated the Administrator on [DATE] on her job description including but not limited to: Roles, Responsibilities, and Expectations for ensuring supervision and monitoring of staff to ensure Life Saving Measures and Advance Directives are followed. The surveyors reviewed the re-education and interviewed the Administrator. 2. The Vice President of Operations placed the Administrator on a Performance Improvement Plan due to failure to ensure the policy and procedures were followed for CPR, Comprehensive Care Plan and QAPI (Quality Assurance Performance Improvement) on [DATE]. The Performance Improvement Plan includes weekly monitoring of all issues identified with the Regional Director of Clinical Operations and/or Vice President of Clinical Operations with the Administrator. The Vice President of Clinical and Operations and/or Regional Director of Operations is responsible for the weekly monitoring. The surveyors reviewed the Performance Improvement Plan and interviewed the Administrator. 3. The Vice President of Operations re-educated the Administrator on the QAPI Program and QAPI Policies on [DATE]. The surveyors reviewed the re-education and interviewed the Administrator. 4. The facility Administrator will monitor monthly QAPI committee's processes, systems and expectations: review and maintain weekly audit tools for Advance Directives/CPR, Comprehensive Care Plans and CPR/Life Saving Certification Compliance. The surveyors reviewed the audit forms and interviewed the Administrator. 5. The Regional Director of Clinical Operations will monitor the facility's monthly QAPI committee's internal processes and systems for compliance and follow up related to: Advance Directives/CPR compliance with orders, Comprehensive Care Plans, and Kardex, licensed nurses CPR/Life Saving Measure Training/certification, and Risk Management. The surveyors interviewed the Administrator. The facility's noncompliance continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction

Based on medical record review and interview, the facility failed to ensure care plan interventions were followed for Advance Directives (a written statement of a person's wishes regarding medical treatment, made to ensure those wishes are carried out should the person be unable to communicate them) for 1 of 6 sampled residents (Resident #1) reviewed. This failure placed Resident #1 in Immediate Jeopardy when staff failed to initiate lifesaving Cardiopulmonary Resuscitation (CPR) according to the care plan when Resident #1 was found unresponsive with no pulse or respirations and Resident #1 expired at the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on [DATE] at 3:05 PM, in the Omega Room. The facility was cited at F-656 at a scope and severity of J. A partial-extended survey was conducted on [DATE]. The Immediate Jeopardy was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 12:25 PM, and was validated onsite by the surveyors on [DATE] through review of medical records, Advance Directive binders, Care Plans, Kardex, in-service training records, audits, and staff interviews. The findings included: Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated [DATE], showed that Resident #1 had interventions of Full Code/CPR and to respect Resident #1's request for Full Code/CPR, full treatment and long term artificial nutrition by a tube. Review of the Nurse's Note Late Entry dated [DATE] at 10:41 [AM], showed, .The charge Nurse was called to resident's [Resident #1's] room by the CNA [Certified Nursing Assistant] .observed resident [Resident #1] lying on bathroom floor .13:53 [1:53 PM] Resident was pronounced deceased at 1023 [10:23] A.M. by EMT [Emergency Medical Technician] services . There was no documentation CPR was performed by the Nursing staff. During a telephone interview on [DATE] at 9:20 AM, Licensed Practical Nurse (LPN) #1 confirmed she remembered the incident on [DATE] when Resident #1 was found unresponsive. LPN #1 was asked if she started CPR. LPN #1 stated, No ma'am. I did not. During a telephone interview on [DATE] at 9:54 AM, Registered Nurse (RN) #1 was asked if anyone initiated CPR when Resident #1 was found unresponsive on [DATE]. RN #1 stated, No. During a telephone interview on [DATE] at 9:58 AM, the Assistant Director of Nursing (ADON) was asked if anyone started CPR when Resident #1 was found unresponsive on [DATE]. The ADON stated, No ma'am . During a telephone interview on [DATE] at 1:07 PM, the DON was asked if any staff member was performing CPR when she got to Resident #1's bathroom after he was found unresponsive on [DATE]. The DON stated. Not at that moment. The DON was asked why CPR was not initiated. The DON stated, .I'm going to say because of the hysteria of how he was found. That's the only reason I can come up with . The DON was asked if CPR should have been initiated. The DON stated, Yes ma'am. The Care Plan interventions were not followed when Resident #1 became unresponsive on [DATE], and CPR was not initiated. The surveyors verified the Removal Plan by: 1. A 100% audit and reconciliation was completed on [DATE] by the Minimum Data Set (MDS) staff on all 79 in house residents. All 79 residents in house have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyors reviewed the audits, Plan of Care, Advance Directive binders, and interviewed staff on each shift. 2. Vice President of Clinical Operations conducted in-services regarding the regulation of F656 with the Administrator, DON, ADON, Social Services Director (SSD), Unit manager (UM ), and Minimum Data Set (MDS) staff. The surveyors reviewed in-service records and interviewed the Administrator, DON, ADON, SSD, UM, and MDS staff. 3. Audits for compliance with Advanced Directive and Code Status on the Comprehensive Care Plan to be monitored by MDS Director and Administrator weekly and reported to the facility Quality Assurance Performance Improvement (QAPI) committee monthly. In the event of noncompliance with the comprehensive care plan the QAPI committee will recommend corrective action. The surveyors reviewed the audit forms. 4. 100% of residents' Advance Directives/Code Statuses have been verified to have Physician Orders, Advance Directive Care Plan and on the Kardex in the current electronic medical record and Code Status binder. The surveyors reviewed the electronic medical records, Care Plan, Kardex, Code Status binder, and interviewed staff on each shift. 5. During the admission process, the Advance Directive will be reviewed and provided to the resident/resident representative by the facility representative. Upon completion of the Advance Directive, the resident's preference will be communicated and the facility will scan the completed form into the electronic medical record (Care Plan and Kardex) and Code Status binder for every resident. The surveyors reviewed the Code Status binder, electronic medical record, and interviewed staff on each shift. 6. Residents with a change in Advance Directives will have preferences updated and documented on Comprehensive Care Plan by the MDS staff. DON and SSD will report to the QAPI committee monthly. The surveyors interviewed staff on each shift, the DON, and the SSD. Noncompliance at F-656 continues at a scope and severity level of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on review of Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 12th Edition, review of the American Heart Association guidelines, policy review, medical record review, and interview, the facility failed to ensure 1 of 6 sampled residents (Resident #1) received Cardiopulmonary Resuscitation (CPR) according to his Advance Directive (a written statement of a person's wishes regarding medical treatment, made to ensure those wishes are carried out should the person be unable to communicate them) for CPR/Full Treatment, when Resident #1 was found unresponsive with no pulse or respirations on [DATE] which resulted in Immediate Jeopardy when Resident #1 expired in the facility on [DATE]. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on [DATE] at 3:05 PM, in the Omega Room. F-678 was cited at a scope and severity of J, which is Substandard Quality of Care. A partial-extended survey was conducted [DATE]. The Immediate Jeopardy was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 12:25 PM, and was validated onsite by the surveyors on [DATE] through review of medical records, Advance Directive binders, in-service training records, audits, and staff interviews. The findings include: Review of Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 12th Edition, page 843, showed, .In [CONDITION(S)], pulse, and blood pressure are lost immediately .The pupils of the eyes begin dilating within 45 seconds .The risk of irreversible brain damage and death increases with every minute from the time that circulation ceases .the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the American heart Association Hands-Only CPR FACT SHEET dated [DATE], showed, .[CONDITION(S)] .is a leading cause of death .When a person has [CONDITION(S)], survival depends on immediately receiving CPR . Review of the American Heart Association life is why Instructor's Manual dated 2016, showed, .Adult CPR .Assesses victim and activates emergency response system .within a maximum of 30 seconds .Checks for responsiveness by tapping and shouting .Checks for no breathing .Checks carotid pulse .Can be done simultaneously with check for breathing .Checks for a minimum of 5 seconds and no more than 10 seconds .Performs high-quality chest compressions .immediately after recognition of [CONDITION(S)] . Review of the facility's policy titled, CPR, SELF-DETERMINATION, AND DO NOT CARDIOPULMONARY RESUSCITATION (CPR) REQUESTS, reviewed [DATE], showed, .CPR will be attempted for all residents unless there is a DNR [Do Not Resuscitate] order written by the physician on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record showed, Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment, no behaviors, and was independent with transfers and toilet use. Review of the Tennessee Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #1's preference was, .Resuscitate (CPR) .Full Treatment .In addition to care described in Comfort Measures Only and Limited Interventions above, use intubation, advanced airway interventions mechanical ventilation as indicated .Transfer to hospital and/or intensive care unit if indicated .Treatment Plan .Full Treatment including the intensive care unit .Long-term artificial nutrition by tube . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .CODE STATUS: FULL CODE [Resuscitate with CPR] . Review of the Care Plan dated [DATE], showed, .has Advance Directive: Full Code .Interventions .Full Code/CPR .Respect resident's request for Full Code/CPR, Full treatment and long term artificial nutrition by tube . Review of the Nurse's Note Late Entry dated [DATE] at 10:41 [AM], showed, .The charge Nurse was called to resident's [Resident #1's] room by the CNA [Certified Nursing Assistant] .observed resident lying on bathroom floor .to the left side of toilet .on his knees .with his back against the wall .[his body in a forward roll position] appearing to rest on his neck .13:53 [1:53 PM] Resident was pronounced deceased at 1023 [10:23] A.M. by EMT [Emergency Medical Technician] services .police were notified by paramedics .report was taken by MPD [Named City Police Department] .family was notified .Body released to .[Named Funeral Home] . Review of the discharge MDS dated [DATE], showed Resident #1 died in the facility. The facility was unable to provide documentation of the exact time Resident #1 was found unresponsive. Review of the Emergency Services Report (EMS) Report dated [DATE], showed, .arrived on scene to find a 68 y/o [year old] male slumped over on the floor in the bathroom. Pt [Patient] was a resident of a nursing home. Pt was found by healthcare staff. Staff stated they had last seen pt about an hour to an hour and a half earlier .Pt's head was bent underneath his body at an awkward angle. Pt was moved to a supine position in order to perform assessment. Pt was not breathing and had no pulse .Disposition .DOA [Dead on arrival] . During a telephone interview on [DATE] at 9:20 AM, Licensed Practical Nurse (LPN) #1 confirmed she remembered the incident when Resident #1 was found unresponsive on [DATE]. LPN #1 stated, .just seen him 30 to 45 minutes before . LPN #1 was asked if she started CPR. LPN #1 stated, No ma'am. I did not. LPN #1 was asked how long it took EMS to get there. LPN #1 stated, .can't tell you exactly, but it wasn't 10 minutes [was under 10 minutes] . LPN #1 was asked why she did not initiate CPR on Resident #1 when he was found unresponsive without a pulse or respirations. LPN #1 stated, I really just called for help. The whole thing was just so bizarre .I don't know. It is disturbing to recall . During a telephone interview on [DATE] at 9:33 AM, LPN #2 confirmed she remembered the incident when Resident #1 was found unresponsive on [DATE]. LPN #2 was asked what happened. LPN #2 stated, .The charge nurse [LPN #1] came and got me and told me he was in the bathroom floor. I went in there .The nurses was like we wasn't supposed to move him because we could tell he had a neck injury . LPN #2 was asked if she assessed Resident 1's vital signs. LPN #2 confirmed he had no pulse. LPN #2 was asked if she or anyone else initiated CPR. LPN #2 stated, No . During a telephone interview on [DATE] at 9:43 AM, CNA #1 confirmed she remembered the incident when Resident #1 was found unresponsive on [DATE]. CNA #1 confirmed she had found him unresponsive. CNA #1 was asked what happened. CNA #1 stated, .I had just got done talking to him. I don't remember the time. I went on break, and I came back maybe 30 minutes later .found him .It was kind of a bizarre way that we found him. He was like on top of his neck kind of upside down on his knees, and his arms were behind him .I ran out to inform my nurse [LPN #1] . During a telephone interview on [DATE] at 9:48 AM, LPN #3 confirmed she remembered the incident when Resident #1 was found unresponsive on [DATE]. LPN #3 was asked what happened. LPN #3 stated, .The nurse that was orienting me [LPN #1], she checked his vitals .We didn't know if we should move him or not, because it looked like a neck injury .decided not to move him until the EMTs came . LPN #3 was asked how long it took for EMS to arrive. LPN #3 stated, I want to say 10 or 15 minutes after we called them. During a telephone interview on [DATE] at 9:54 AM, Registered Nurse (RN) #1 was asked what happened during the incident when Resident #1 was found unresponsive on [DATE]. RN #1 stated, .The CNA [CNA #1] came and said he was unresponsive .I went down there .no pulse . RN #1 was asked if anyone initiated CPR. RN #1 stated, No. During a telephone interview on [DATE] at 9:58 AM, the Assistant Director of Nursing (ADON) was asked what happened when Resident #1 was found unresponsive on [DATE]. The ADON stated, .When I went in there, I saw him on the floor. [Named RN #1] had checked for pulse and he did not have one. We got the DON. She told us to call 911. We knew not to move him because of how he was positioned .head on the floor and his body was contortioned to the side . The ADON was asked if anyone started CPR. The ADON stated, No ma'am . The ADON confirmed one of the nurses had checked his code status. The ADON was asked what his code status was. The ADON stated, He was a full code . During a telephone interview on [DATE] at 10:10 AM, the DON was asked what happened when Resident #1 was found unresponsive on [DATE]. The DON stated, .It appeared he didn't have any vitals so we called 911 .The nurses had checked them before I got there. I was shocked to see him in the position he was in . The DON was asked what his code status was. The DON stated, I believe he was a [full] code, but 911 got here so fast, and because of how he was positioned, we were not sure we were supposed to move him or not . During a telephone interview on [DATE] at 9:43 AM, the Medical Director was asked if CPR should have been initiated on a Resident #1 when he was found unresponsive, without a pulse or respirations on [DATE]. The Medical Director stated, If he was a full code .I would say they should have done something .I would have started CPR . During a telephone interview on [DATE] at 3:47 PM, the EMS Paramedic was asked what happened during the incident when Resident #1 was found unresponsive on [DATE]. The EMS Paramedic stated, .We went in .there was nobody in the bathroom with him .I don't know how he got into the position he was in .head turned up under him .We held his head and pulled him around .asystole .I don't know if anyone even tried to check for a pulse . The Paramedic was asked if he would have expected staff to initiate CPR on Resident #1 if he had Advanced Directives for CPR/Full Treatment. The Paramedic stated, I would have assumed they would have at least checked him and started something. During a telephone interview on [DATE] at 1:07 PM, the DON was asked if any staff member was performing CPR when she got to Resident #1's bathroom after he was found unresponsive on [DATE]. The DON stated. Not at that moment. The DON was asked why CPR was not initiated. The DON stated, .I'm going to say because of the hysteria of how he was found. That's the only reason I can come up with . The DON was asked if CPR should have been initiated. The DON stated, Yes ma'am. During a telephone interview on [DATE] at 12:12 PM, the Medical Director stated, .they need to get enough people to get the neck fixed and get them rolled, but you have to code them. You can't not code them . The surveyors verified the Removal Plan by: 1. CPR training will be initiated until 100% compliance with certification is achieved. Licensed nurses without a current CPR will be removed from the schedule until a current certification is obtained. All new hires will be required to have CPR certification prior to attending orientation. Two licensed nurses were identified out of compliance. The surveyors reviewed training records, working schedule, and interviewed staff on each shift. 2. CPR/BLS (Basic Life Support) classes were scheduled for [DATE] at 5:00 PM and [DATE] at 5:30 AM. The surveyors reviewed the education completed on [DATE] to all licensed nurses and certified nursing assistants on CPR/Advance Directives and a Basic Life Support recertification class was held onsite for nursing staff with 2 different opportunities to attend and provide return demonstration of skills. 3. Licensed nurses in-serviced on [DATE] on proper procedure to initiate life saving measures, Advance Directive/Code Status Identification, and activation of life saving emergency systems. Employees will not be able to work until the in-services are completed. The surveyors reviewed in-service records and interviewed staff on each shift. 4. On [DATE], 100% audit and reconciliation of all Advance Directives was completed. Staff in-services conducted by the DON and SDC (Staffing Development Coordinator) regarding Advance Directives, where to locate the code status in the electronic medical record and Code Status binders on the units with return demonstration. Employees will not be able to work until the in-services are completed. The surveyors reviewed the in-service records, electronic medical record, Advance Directive binders, and interviewed staff on each shift. 5. Binders with the up to date Code Status/Advance Directives were implemented for all 79 current residents. The surveyors reviewed the Advance Directive binders. 6. Audits for compliance with Advance Directives and Code Status to be monitored by the Administrator weekly and reported to the Quality Assurance Performance Improvement (QAPI) committee monthly. The surveyors reviewed the audits and interviewed the Administrator. 7. 100% of residents' code statuses have been verified in the current medical record (care plan, kardex) and Code Status binder. The surveyors reviewed the electronic medical record, the Code Status binder, and interviewed staff on each shift. 8. During the admission process, the Advance Directive will be reviewed and provided to the resident/resident representative by the facility representative. Upon completion, the resident's preference will be communicated and the facility will scan the completed form into the electronic medical record and code status binder for every resident. The surveyors reviewed the Code Status Binder. 9. Residents with a change in Advance Directives will have preferences documented in the electronic medical record by Social Services Director (SSD), Nursing, and Physician. Code status will be updated and documented in the electronic medical record and Code Status binder. The DON and SSD will report to the QAPI committee monthly. The surveyors interviewed staff on each shift, the DON, and the SSD. Noncompliance of F-678 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, review of the Quality Assurance Performance Improvement (QAPI) Plan, job description review, and interview, the QAPI committee failed to ensure an effective QAPI program when the committee failed to ensure a resident's care plan interventions were followed related to Advance Directives (a written statement of a person's wishes regarding medical treatment, made to ensure those wishes are carried out should the person be unable to communicate them). The committee failed to ensure staff were trained to respond to an emergency situation in accordance with a resident's Advance Directive. The failure of the committee to ensure staff identified an emergency situation and initiated life-saving Cardiopulmonary Resuscitation (CPR) measures according to the resident's Advance Directive and comprehensive Care Plan placed 1 of 6 sampled residents (Resident #1) reviewed in Immediate Jeopardy. Resident #1 was found unresponsive and pulseless, expired at the facility on [DATE] when staff failed to initiate CPR according to his Advanced Directive wishes. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on [DATE] at 3:05 PM, in the Omega Room. The facility was cited F-656, F-678, F-835, and F-867 at a scope and severity of J. F-678 is Substandard Quality of Care. A partial-extended survey was conducted [DATE]. The Immediate Jeopardy was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 12:25 PM, and was validated onsite by the surveyors on [DATE] through review of in-service training records, audit tools, and staff interviews. The findings include: Review of the facility policy titled, CPR, SELF-DETERMINATION, AND DO NOT CARDIOPULMONARY RESUSCITATION (CPR) REQUESTS, reviewed [DATE], showed, .CPR will be attempted for all residents unless there is a DNR [Do Not Resuscitate] order written by the physician on the physician's order sheet and documentation from the resident, family, or responsible party of this request . Review of the facility's Quality Assurance Performance Improvement Plan showed, .It is the intent of this facility to conduct an on-going quality assurance /performance improvement program designed to systematically monitor and evaluate the quality and appropriateness of resident care, pursue opportunities to improve resident care, resolve identified problems and identify opportunities for improvement. Performance improvement supports the overall goals of the facility and examines both outcomes and processes relevant to these outcomes with the objective of improving the organization's overall performance .The program will be a coordinated effort among all department and services within the organization .The Quality Assurance and Performance Improvement Committee is set up to provide structure and direction for the Performance Improvement Program and Risk Management .is responsible for establishing priorities, approving key quality indicators and assigning project team/s if deemed appropriate .shall include .Administrator .Director of Nursing .Medical Director .monitoring activities should focus on those processes that significantly affect resident outcomes .The following sources of data will be use [used] .Resident electronic health record .Direct observation .Accident/incident log .Risk Management Reports .The department/committee will document findings, initiate corrective action as directed and present results .Documentation will include .significance of study .Responsible person .Decision making process .Methodology .Findings .Recommended improvement activities .Evaluation and Outcome .Follow-up time frame .has the responsibility for designing and implementing corrective action plans as needed to resolve identified resident aspects or care/service problems . Review of the Administrator job description showed, .The primary purpose of your job is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times .Ensure that all employees .follow the facility's established policies and procedures .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies .Report problems areas to the Medical Director .Assist department directors in the topic selection, planning, conducting, and scheduling of in-service training classes and on-the-job training and orientation programs to assure that current material and programs are continuously provided .Ensure that the resident's rights to .self-determination .are well established and maintained at all times . Review of the Director of Nursing Services job description showed, .The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times .Assist the Quality Assessment & [and] Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies .ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards .Assist the In-service Director/Educator in developing advanced directive in-service training programs for the staff and community .Ensure that all personnel involved in providing care to the resident are aware of the resident 's [resident's] care plan .Ensure that medical and nursing care is administered in accordance with the resident's wishes, including the implementation of advanced directives .Ensure that the facility's policies and procedures governing advance directives are reviewed with the resident . During a telephone interview on [DATE] at 9:58 AM, the Assistant Director of Nursing (ADON) was asked what happened when Resident #1 was found unresponsive on [DATE]. The ADON stated, .When I went in there, I saw him on the floor. [Named RN #1] had checked for pulse and he did not have one . The ADON was asked if anyone started CPR. The ADON stated, No ma'am . The ADON was asked what his code status was. The ADON stated, He was a full code . During a telephone interview on [DATE] at 9:43 AM, the Medical Director was asked if CPR should have been initiated on a Resident #1 when he was found unresponsive, without a pulse or respirations on [DATE]. The Medical Director stated, If he was a full code .I would say they should have done something .I would have started CPR . During a telephone interview on [DATE] at 1:07 PM, the DON was asked if any staff member was performing CPR when she got to Resident #1's bathroom when he was found unresponsive on [DATE]. The DON stated. Not at that moment. The DON was asked if CPR should have been initiated. The DON stated, Yes ma'am. During an interview on [DATE] at 11:42 AM, the ADON was asked when nurses should make the decision not to do CPR. The ADON stated, Really and truly we don't have the power to make that call .If they are full code we should always do CPR on that person .I know we are supposed to get the doctor involved. The ADON was asked if the doctor was called. The ADON stated, Not while I was there . During an interview on [DATE] at 12:30 PM, the Administrator was asked how often policies were reviewed and revised. The Administrator stated, We try to do it at the first of the year with the Medical Director when we have our first QA [Quality Assurance] meeting .don't think they had revised anything this year . The Administrator was asked when the CPR/Advanced directive policies were last reviewed. The Administrator stated, The CPR policy .that's a good question . The Administrator was asked if Resident #1's incident and death had been discussed in QA. The Administrator stated, We have not. The Administrator was asked what should have been done. The Administrator stated, Followed the policy. We're supposed to attempt CPR and in his case it did say we were supposed to resuscitate him. We should have followed our policy. The Administrator was asked when this incident was first recognized as a problem. The Administrator stated, When you all came in and told us, and started asking questions about it. [Survey team entered the facility on [DATE]]. Refer to F656, F678, and F835. The surveyors verified the Removal Plan by: 1. A Quality Assurance Performance Improvement (QAPI) ADHOC meeting was held on [DATE] led by Administrator, and attended by the Medical Director, DON, ADON, Unit Manager, and Admissions Director. Minutes included root cause analysis, education on Advance Directives/Code Status, Care Plans and falls. The surveyors reviewed the minutes and interviewed committee members. 2. The Vice President of Clinical and Operations in-serviced IDT (Interdisciplinary team) including the Administrator on the QAPI policy and procedure. The surveyors reviewed the in-services and interviewed members of the IDT. 3. All actions, in-services, audits, and monitors will be a part of the QAPI process and reviewed by the QAPI committee. The surveyors reviewed the audit tools. The facility's noncompliance continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.