Every finding on record at Peak Resources - Pinelake

Based on record reviews, and resident, Family Member, Nurse Practitioner (NP), Medical Director, local law enforcement officer, and staff interviews, the facility failed to protect a resident's right to be free from resident-to-resident abuse when a severely cognitively impaired male resident (Resident #86) grabbed a cognitively intact male resident's (Resident #19's) arm as he was coming out of the bathroom. This was for 1 of 3 residents reviewed for resident-to-resident abuse (Resident #19). The findings included: Resident #19 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy, chronic fatigue, bipolar II disorder, and depression. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #19's cognition was intact, he had no behaviors and was independent with using his wheelchair or walker. Resident #19's care plan dated 9/18/2025 indicated the resident had problem areas that included verbal behavioral symptoms directed toward others; and the resident had poor sense of boundaries. Resident #19 had Level II Pre-admission Screening and Resident Review (PASRR) related to bipolar II disorder. Resident #86 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia with other behavioral disturbances, urinary tract infection, and anxiety. Resident #86's care plan dated 8/25/25 indicated the resident had problem areas that included resident had physical behavioral symptoms towards others; resident had behavioral symptoms with Level II PASRR in place for Alzheimer's dementia and anxiety; resident had a memory/recall problem related to dementia; and resident was at risk for adverse consequences related to receiving antipsychotic medication. The interventions included assessing whether the behaviors endangered the resident and/or others and intervene as necessary, avoid over stimulation and provide a calm environment, resident would receive specialized services recommended by PASRR, to administer medication as ordered and change as necessary, and referral to psychiatric services as needed. An admission MDS assessment dated [DATE] indicated that Resident #86's cognition was severely impaired, he had no behaviors noted and was independent with using his wheelchair. An initial allegation report dated 9/8/25 at 8:43 PM completed by the Director of Nursing (DON) indicated there was an allegation of resident-to-resident abuse between Resident #19 and Resident #86 on 9/8/25. The initial report recorded the facility became aware of the incident on 9/8/25 at 7:00 PM. Details of the allegation stated that Resident #86 physically assaulted Resident #19. Resident #19 was exiting the bathroom when Resident #86 was attempting to get in the bathroom. Resident #86 ran into Resident #19 with his wheelchair and then grabbed Resident #19's arm. Resident #19 then hit Resident #86 on his hands trying to get him to let go. The residents were immediately separated by Nurse Aide (NA) #1 and Nurse #1. Resident #86 was moved to another room immediately. Skin assessments were completed on both residents. Resident #19's skin assessment showed some redness to his right shoulder. Resident #86's skin assessment showed no injury at that time. Local law enforcement made aware of the allegation on 9/8/25 at 7:00 PM and came to the facility and interviewed both residents. Resident #86 had no recollection of the events that occurred, and Resident #19 declined to press charges. Both residents were initiated on 15-minute checks for 72 hours. A skin assessment was completed by the DON on 9/8/25 at 7:00 PM for Resident #86. Skin assessment revealed that no new injury was identified. Medical Director and NP were both made aware of the findings. A skin assessment was completed by the DON on 9/8/25 at 8:34 PM for Resident #19. Skin assessment revealed some redness to the right shoulder; Resident #19 had no concern for pain or discomfort. Medical Director and NP were both made aware of the findings. A written statement completed on 9/8/25 by NA #1 indicated that NA #1 observed Resident #86 trying to back over Resident #19. Resident #19 tried to stop Resident #86, then Resident #86 grabbed Resident #19 by the right arm. On 09/25/2025 at 11:10 AM an interview occurred with NA #1. NA #1 reported that she was walking down the hall from the laundry area when she saw Resident #86 grabbing the arm on Resident #19. NA #1 stated that it appeared that Resident #86 was trying to back into Resident #19 with his wheelchair. NA #1 indicated that Resident #86 was in the doorway area and Resident #19 was coming out of the bathroom. NA #1 did not report that Resident #86 said anything. NA #1 recalled when she saw this happening she went down the hallway to get help from Nurse #1. NA #1 reported that she came back with Nurse #1 and Nurse #1 separated the two residents immediately. A written statement completed on 9/8/25 by Nurse #1 revealed on 9/8/25 around 7:00 PM, NA #1 called Nurse #1 down to the room of Resident #86 and Resident #19. Upon entering the room Nurse #1 saw Resident #86 holding Resident #19 by the arm tightly. Resident #19 was hitting Resident #86's hands in attempt to get Resident #86 to let go. Nurse #1 separated the two residents as soon as possible. Resident #86 stated to Nurse #1, I'll beat the dog shit out of him. On 09/25/2025 at 11:49 AM an interview occurred with Nurse #1. Nurse #1 reported that she was notified by NA #1 that something was going on between Resident #86 and Resident #19. Nurse #1 stated she immediately went down to the room and Resident #86 was grabbing the top right part of Resident #19's arm. She recalled Resident #19 was hitting Resident #86's hands to get him to let go. Nurse #1 reported that Resident #86 told Resident #19 that he would beat the dog shit out of him. Nurse #1 reported that she immediately separated the two residents and Resident #86 was immediately moved to another room. The facility's investigation report dated 9/11/25 completed by the Director of Nursing (DON) indicated the following: The resident-to-resident abuse did occur between Resident #86 and Resident #19. Resident #86 and Resident #19 were immediately separated as soon as the incident occurred, and Resident #86 was moved to another hall in the facility to keep as much space between the two residents. Skin assessments were completed for both residents and on 9/9/25 the redness to Resident #19's shoulder was assessed and was noted to be completely resolved. 15-minute watches were started on both residents on 9/8/25 for the next 72 hours to monitor for aggression. The facility substantiated the allegation of resident-to-resident abuse secondary to witness statements and investigation results. On 09/25/2025 at 10:30 AM an interview was attempted with Resident #86. Resident #86 had no recollection of the events that occurred on 9/8/25. On 09/25/2025 at 12:37 PM an interview occurred with the family member of Resident #86. The Family Member reported that Resident #86 had dementia and oftentimes did not remember things and often got agitated and displayed behavioral problems. The Family Member stated this had happened in the past and they had to talk to his doctor about the concerns. The Family Member indicated she was satisfied with how the facility handled the incident by moving Resident #86 for his safety and for the safety of Resident #19. The Family Member reported that overall, she was pleased by the treatment provided to Resident #86 by the facility and had no additional concerns. On 09/25/2025 at 11:21 AM an interview occurred with Resident #19. Resident #19 stated that while he was coming out of the bathroom, Resident #86 tried to back into him with his wheelchair and then grabbed the fat part of the top of his right arm. Resident #19 could not recall the exact date of the incident, just that it had occurred a couple of weeks ago. Resident #19 reported that he shouted at him (Resident #86) to stop and that was when staff came in and helped. Resident #19 indicated that it hurt a little, but not enough to complain about. Resident #19 recalled Resident #86 told him that he would beat the dog stuff out of him. Resident #19 reported that staff immediately moved Resident #86 out and into another room on a different hall. Resident #19 stated when the police spoke to Resident #86 about the incident, Resident #86 could not remember it happening. On 09/25/2025 at 10:37 AM an interview occurred with Nurse #2. Nurse #2 reported that Resident #86 had problems with his short-term memory. Nurse #2 stated that if Resident #86 was asked about his military time in [NAME] 20-plus years prior then he would probably be able to recall that information but nothing recent. On 09/25/2025 at 12:10 PM an interview occurred with the Social Worker (SW). SW reported that the incident was reported to her, and she then made a report to Adult Protective Services on 9/9/25. SW stated that she also contacted the Resident Representatives for both residents, and they were made aware of incident. On 09/25/2025 at 12:21 PM an interview occurred with the Administrator. The Administrator stated that he was off work at the time when the incident between Resident #19 and Resident #86 occurred. The Administrator reported that he came to the facility immediately that evening once he was made aware of the incident and took immediate action for the safety of all residents including the proper reporting measures. He stated the residents were not aggressive towards each other prior to the incident and now Resident #86 does not even remember the incident happening. On 09/25/2025 at 12:39 PM an interview occurred with the Psychiatric Nurse Practitioner (NP) working with Resident #86. The Psychiatric NP reported that the week prior to the incident she had reduced Resident #86's Risperdal because of drowsiness he was experiencing in the morning. The Psychiatric NP stated that Resident #86 had reported behavioral issues prior to his admission, and he was also being assessed for a urinary tract infection that could have also caused the confusion and behaviors. The Psychiatric NP indicated after the incident she increased his Risperdal back to the original dose and when she sees him next time she will re-evaluate to lower it again if appropriate. On 09/25/2025 at 12:54 PM an interview occurred with the Medical Director. The Medical Director reported that he saw both residents after the incident, evaluated for any injuries and had no concerns following the incident. Resident #86 was found to have a urinary tract infection and was treated accordingly. He reported that the Resident Representatives were contacted, and residents were separated for safety. On 09/26/2025 at 4:10 PM an interview occurred with the Investigating Officer from local law enforcement. The Officer reported the same details of the incident that Resident #19 was coming out of the bathroom when Resident #86 tried to run into him with his wheelchair and grabbed Resident #19's top right arm. The Officer stated both residents were interviewed, and Resident #86 did not remember the incident happening and neither resident wanted to make an official report or press charges. The facility provided the following corrective action plan: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. The residents were immediately separated, and Resident #86 was moved to room [ROOM NUMBER]. The clinical supervisor completed skin checks on both residents. Resident #19 has some redness on his right shoulder, while Resident #86 has no observed injuries. Both residents were placed on 15-minute checks to monitor any aggressive behaviors. The Carthage police department was notified and interviewed both residents on 9/8/25, Resident #19 declined to press charges and Resident #86 had no recollection of the event. The Medical Director and Psychiatric Nurse Practitioner (PNP) were notified of the incident on 9/8/20205. Both residents had lab tests performed, including urinalysis, complete blood count (CBC), and basic metabolic panel (BMP). Resident #86 was diagnosed with a urinary tract infection (UTI) and was prescribed the appropriate antibiotics. Resident #86's Risperdal was increased by a PNP on 9/9/25; both parties were seen by PNP on 9/11/25 and by the Medical Director on 9/10/25. Adult Protective Services (APS) was made aware of the incident on 9/9/25. Education was provided to Resident #19 on how to handle the incident without resorting to physical violence.2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.The Director of Nursing (DON) on 9/8/25 performed a 100% review of all residents. The alert residents were asked if they had been affected by any resident who had shown aggressive behavior towards them; none were identified. Residents who were unable to communicate, the DON and designee completed 100% skin audits, which were reviewed for any injuries related to resident-to-resident altercation, but none were identified. The DON reviewed all events, including falls, bruises, or skin tears, to see if any were related to resident-to-resident aggressive behavior for the past three months; none were identified. DON reviewed all 24-hour reportable events for the last three months for resident-to-resident altercations; none were identified. The event was isolated to the resident's room, and residents were under 15-minute observation after the event, with no other aggressive behavior noted. No other residents were affected by this event.3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Resident #86 was permanently relocated to room [ROOM NUMBER] to maintain social distancing between residents. Resident #86 was treated for a urinary tract infection. Resident #86 had recently had a decrease of his antipsychotic medication. The psychiatric nurse practitioner reviewed the medical regimen of the resident on 09/09/2025 and decided to increase the dosage back due to the recent aggressive behavior. There have been no further incidents of aggression by either resident. All staff were educated to observe residents for signs of increased agitation and incidents of aggression, and to develop appropriate interventions to manage the behavior and prevent any escalation, in accordance with our Abuse Policy. This education was completed on 9/11/25 by DON or designee. Any staff out on leave or PRN status were educated by nursing administration before returning to duty. The staff development coordinator educates all staff on abuse prevention during the orientation process. There is also annual education for all staff on abuse prevention. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.On 9/8/25, an audit tool was created by the DON with the following questions, - Residents were asked if any aggressive behavior had been shown against them.- Residents were asked, have you seen any aggressive behaviors towards others in the facility. - Residents were asked if they had seen any signs of agitation that would lead to aggressive behaviors?- If any of the above questions are checked yes, are appropriate interventions in place to protect residents?The DON or designee will conduct audits on five alert and oriented residents daily x 2 weeks, then weekly x 10 weeks. The DON or the designee will audit 100% of progress notes and events daily for any aggressive behaviors. The results of these audits will determine the need for further monitoring. The DON will present all results to Quality Assurance and Performance Improvement (QAPI) every month until 12/1/25. The results of these audits will determine the need for further monitoring. Alleged compliance date: 9/12/25 As part of the validation process, the plan of correction was reviewed and verified through review of audit sheets, education records and staff interviews. Education was provided to all staff about abuse policy. Review of the monitoring audits revealed they were completed as stated in the corrective action plan with no concerns identified. Interviews conducted with staff revealed they had received education on identifying and reporting any suspicions, allegations, or witnessed abuse. Supervision of residents by staff was observed as part of the recertification survey and no concerns were noted. Residents were interviewed during the survey, and none reported having any issues with staff's ability to protect them from abuse. The compliance date of 9/12/25 for the corrective action plan was validated.

Based on staff interviews and record review, the facility failed to identify the need for a significant change Minimum Data Set (MDS) for a resident with declines in weight, skin condition and activities of daily living. This was for 1 (Resident #37) of 20 residents reviewed for comprehensive MDS completion. The findings included: Resident #37 was admitted on [DATE] with Dementia, Diabetes and Congestive Heart Failure. He was diagnosed with Osteomyelitis on 7/25/24. His previous quarterly MDS dated [DATE] indicated Resident #37 was not coded for any weight loss, a weight of 220 pounds, no skin conditions, requiring supervision for bed mobility, lying to sit to stand , stand to sit to lying, toileting transfers, ambulation and not coded for the use of a wheelchair. Review of a wound consult note dated 6/12/24 read Resident #37 developed a diabetic ulcer to his right first and second toes. Review of another wound consult note dated 7/24/24 read Resident #37 was diagnosed with Osteomyelitis of his right first and second toes and a midline intravenous catheter was ordered and placed for intravenous antibiotics on 7/26/24. Resident #37 most recent quarterly MDS dated [DATE] indicated Resident #37 was coded for unprescribed weight loss, a weight of 207, an infected diabetic foot ulcer, coded for the use of antibiotics, intravenous medications, substantial to maximum assistance with bed mobility, lying to sit and sit to lying, total dependence for sit to stand, stand to sit, toilet transfers, not applicable for ambulation and requiring partial to moderate staff assistant in a wheelchair. An interview was completed on 8/21/24 at 9:40 AM with MDS Nurse #1 who reviewed the areas of change from her 5/14/24 quarterly assessment to the most recent quarterly assessment dated [DATE]. She stated a significant change MDS should have been completed rather than a quarterly MDS on 7/29/24 and was definitely needed for Resident #37. An interview was completed on 8/21/24 at 10:00 AM with the Administrator. He reviewed the areas of change in Resident #37 and stated a significant change MDS should have already been completed on Resident #37 and he would see that one was started as of today.

Based on record review and staff interviews, the facility failed to display accurate Posted Nurse Staffing Information for 4 out of 30 days reviewed. The findings included: A review of the Staff Schedule/Assignment Sheet for 07/19/24 revealed 10 Nursing Assistants (NA)s worked from 7:00 AM until 7:00 PM. A review of the Posted Nurse Staffing for the 7:00 AM-7:00 PM shift on 7/19/24 revealed 11 NAs worked. On 07/21/24 during the 7:00 AM until 7:00 PM shift, the Staff Schedule/Assignment Sheet revealed 8 NAs worked and the Posted Nurse Staffing revealed 10 NAs worked. Additionally, the Staff Schedule/Assignment Sheet revealed 3 Licensed Practical Nurses (LPN)s worked and the Posted Nurse Staffing revealed 4 LPNs worked. The Staff Schedule/Assignment Sheet revealed 1 Registered Nurse (RN) worked and the Posted Nurse Staffing revealed 2 RNs worked. During the 7:00 PM until 7:00 AM shift, the Staff Schedule/Assignment Sheet revealed 5 NAs worked and the Posted Nurse Staffing revealed 7 NAs worked. The Staff Schedule/Assignment Sheet revealed 4 LPNs worked and the Posted Nurse Staffing revealed 2 LPNs worked. The Staff Schedule/Assignment Sheet revealed no RN worked and the Posted Nurse Staffing revealed 1 RN worked. On 07/22/24 during the 7:00 AM until 7:00 PM shift, the Staff Schedule/Assignment Sheet revealed 10 NAs worked and the Posted Nurse Staffing revealed 8 NAs worked. Additionally, the Staff Schedule/Assignment Sheet revealed 2 RNs worked and the Posted Nurse Staffing revealed 1 RN worked. During the 7:00 PM until 7:00 AM shift, the Staff Schedule/Assignment Sheet revealed 7 NAs worked and Posted Nurse Staffing revealed 6 NAs worked, and the Staff Schedule/Assignment Sheet revealed 1 RN worked and Posted Nurse Staffing revealed 2 RNs worked. On 07/23/24 during the 7:00 AM until 7:00 PM shift, the Staff Schedule/Assignment Sheet revealed 8 NAs worked and the Posted Nurse Staffing revealed 11 NAs worked. The Staff Schedule/Assignment Sheet revealed 4 LPNs worked and the Posted Nurse Staffing revealed 3 LPNs worked. The Staff Schedule/Assignment Sheet revealed 1 RN worked and the Posted Nurse. Staffing revealed 2 RNs worked. During the 7:00 PM until 7:00 AM shift, the Staff Schedule/Assignment Sheet revealed 6 NAs worked and the Posted Nurse Staffing revealed 5 NAs worked. The assignment sheet revealed 3 LPNs worked and the Posted Nurse Staffing revealed 2 LPNs worked. The Staff Schedule/Assignment Sheet revealed no RN worked and the Posted Nurse Staffing revealed 2 RNs worked. An interview on 08/21/24 at 8:59 AM was conducted with the Human Resource Coordinator. She stated she was responsible for completing the daily staff posting sheet based on the actual working assignment sheet for the day and posting them in a viewable area. She verified that the number of licensed and unlicensed staff and the total hours worked for licensed and unlicensed staff were incorrect for 4 out of 30 days. She verified staffing sheets for 7/19/24, 7/21/24, 7/22/24 and 7/23/24 did not match the staff posting sheets. She then stated for the staffing sheet on 07/19/24 an unlicensed staff was counted twice which made the count incorrect. She explained it appeared on 07/21/24 and 07/22/24 she got the dates mixed up which resulted in the number of licensed and unlicensed staff and the total hours worked to be incorrect. She verified the staff posting sheets compared to the assignment sheets for 07/23/24 did not match and stated she was not sure what happened and why the count was incorrect. An interview was conducted on 08/21/24 at 8:39 AM with the Administrator. He stated he expected the daily nurse staff sheets, and the assignment sheets should accurately reflect the correct number of staff working.

Based on record review, observations and staff interviews, the facility failed to provide care in a safe manner during incontinence care that resulted in a fall with a right hip fracture (Resident #17). This was for 1 of 6 residents reviewed for accidents. The findings included: Resident #17 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, seizure disorder and a history of a stroke resulting in left-sided weakness. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #17 had moderately impaired cognition and was dependent on one staff member for personal hygiene and toileting tasks. A quarterly MDS assessment dated [DATE] indicated Resident #17 was dependent on one staff member for toileting tasks. Resident #17 was care planned on 7/21/23 for an actual fall. The interventions included: - emergency room visit and staff education implemented on 7/21/23. - Concave mattress implemented on 7/26/23. A nursing note dated 7/20/23 at 7:22 PM read a Nurse Aide (NA) reported a witnessed fall while doing personal care with Resident #17. The NA attempted to roll Resident #17 as part of care and was observed rolling out of bed and onto the floor. Resident #17 was complaining of right hip and right head pain. She was alert and oriented. The physician was notified and provided an order to send to the emergency room (ER) for further evaluation. Review of the hospital records from 7/20/23 through 7/26/23 indicated that Resident #17 was seen in the ER following a fall from the bed while she was being changed and was found to have a closed fracture of the right hip. Surgical intervention was completed on 7/21/23. A review of the Summary of Investigation dated 7/21/23 indicated Resident #17's incident occurred at 6:30 PM and that during incontinence care the NA attempted to roll Resident #17 as part of care and rolled out of the bed and onto the floor. She had complaints of right hip and head pain. During the assessment the right hip appeared to be externally rotated and her right leg was shortened. The interventions included sending Resident #17 to the ER, staff education on turning and rolling residents in the bed and initiating a two person assist with incontinence care for Resident #17. On 11/28/23 at 1:23 PM, an interview occurred with Resident #17 who was able to recall the details of the incident on 7/20/23. She verified that prior to the fall from the bed only one NA assisted her with incontinence care. Stated on 7/20/23, the NA was providing incontinence care, rolled her to the right side of her body and she just kept rolling and ended up on the floor. A phone interview occurred with NA #3 on 11/28/23 at 3:24 PM. She explained on 7/20/23 she was providing incontinence care to Resident #17, rolled her to face the window and her back towards the NA. NA #3 stated she had one hand on Resident #17's side and was using the other hand to provide hygiene, when suddenly Resident #17 lunged forward. NA #3 tried to hold onto Resident #17 was but unsuccessful and ended up falling to the floor. NA #3 stated she immediately retrieved the nurse. A phone interview occurred with Nurse #1 on 11/29/23 at 3:07 PM. She recalled Resident #17's fall on 7/20/23 and explained she was retrieved by the NA. When she entered the room, Resident #17 was lying on the floor beside her bed. She was able to recall the aide and resident both stated incontinence care was being rendered when the fall occurred. During the assessment it was noted her leg was turned inwards and appeared shorter than the other one. Resident #17 was complaining of leg pain as well. 911 was called immediately for further evaluation at the ER. The corrective action for the past non-compliance dated 7/20/23 was as follows: NA #3 went into Resident #17's room to change her and when turning Resident #17 away from her she rolled out of bed. Nurse #1 was called to the room to assess Resident #17 who was lying on her right side on the floor beside her bed. The nursing staff called 911 for an ER evaluation. Under further assessment by the ER, Resident #17 was found to have a right hip fracture. The physician, Director of Nursing (DON) and Resident #17's responsible party were notified of the fall and being sent to the ER for evaluation. Identification of Other Residents: On 7/21/23, the DON, clinical supervisor, staff development coordinator and therapy completed a 100% audit of all the residents in the facility to assess if they need to be a one person or two-person assistance for incontinence care and bed mobility. 26 out of 83 residents were deemed to need two-person assistance with Activities of Daily Living (ADLs). On 7/21/23 the MDS Nurse updated the care plans and resident profiles to reflect the residents that needed two-person assistance with ADLs. 100% of all care plans were in compliance for the level of needed assistance. Systemic Changes: Education began on 7/20/23 at 6:55 PM by Nurse Supervisor #1 to NA #3, all the current staff working and the on-coming staff for the 7:00 PM shift regarding bed positioning and safe provision of care. Education needed to be completed no later than 7/21/23 for all licensed nurses and aides, or the staff person would not be allowed to work until the training was completed. Quality Assurance: The DON, nurse supervisor, staff development coordinator and MDS nurse were responsible for the ongoing monitoring of proper rolling procedures and safe provision of care were completed weekly for four weeks and monthly for two months. The monitoring included observations of 4 or more aides on various shifts to include the weekends. Reports were presented to the monthly quality assurance (QA) committee to ensure compliance and corrective action. The date of compliance was 7/21/23. As part of the validation process, the plan of correction was reviewed and verified through review of the audit sheet, the in-service records, and staff interviews. An observation was conducted on 11/29/23 of staff completing incontinence care to Resident #17. Two staff members were present to provide the necessary care. Other observations were conducted on 11/27/23, 11/28/23 and 11/29/23 of staff completing care on residents while they were in the bed. Staff were observed to provide the necessary care with either one or two people as stated in the care plan and resident profiles. Interviews with the staff involved with the incident dated 7/20/23 were completed and with current staff. Interviews revealed they had received in-service education on the provision of safe care with incontinence care. The validation process verified the facility's date of compliance of 7/21/23.

Based on record review, Responsible Party (RP) and staff interviews, the facility failed to notify the resident and/or RP in writing for a transfer to the hospital for 5 (Resident #90, #49, #39, #17, #87) of 6 residents reviewed for hospitalization . The findings included: 1. Resident #90 was admitted to the facility on [DATE]. Review of a quarterly Minimum Data Set, dated dated dated [DATE] indicated Resident #90 was coded for moderate cognitive impairment. Resident #90's medical record revealed she was transferred to the hospital on 9/30/22 and readmitted back to the facility on [DATE]. There was no documentation that a written notice of transfer was provided to the resident and/or RP. Resident #90's medical record revealed she was transferred to the hospital on 3/22/23 and she did not return to the facility. There was no documentation that a written notice of transfer was provided to the resident and/or RP. A telephone interview was completed on 11/27/23 at 2:46 PM with Resident #90's RP. She stated she did not recall receiving anything in writing from the facility about the reason Resident #90 was transferred to the hospital on 9/30/22 and 3/22/23 but was notified in person. An interview on 11/28/23 at 2:20 PM was completed with the Administrator. He stated when a resident was transferred to the hospital the bed hold policy was sent with them, the RP would be notified via phone regarding the transfer and nursing notes would indicate the reason for the transfer. The Administrator stated he was unaware that written notifications regarding the reason for the hospital transfer were required. 2. Resident #49 was admitted to the facility 7/21/22. Review of the quarterly Minimum Data Set, dated dated dated [DATE] indicated Resident #49 was coded for severe cognitive impairment. Resident #49's medical record revealed she was transferred to the hospital on 9/4/22 and readmitted back to the facility on [DATE]. There was no documentation that a written notice of transfer was provided to the resident and/or RP. A telephone interview was completed on 11/29/23 at 9:50 AM with Resident #49's Responsible Party (RP). She stated she did not recall receiving anything in writing from the facility about the reason Resident #49 was transferred to the hospital on 9/4/23 but the facility did call her. An interview on 11/28/23 at 2:20 PM was completed with the Administrator. He stated when a resident was transferred to the hospital the bed hold policy was sent with them, the RP would be notified via phone regarding the transfer and nursing notes would indicate the reason for the transfer. The Administrator stated he was unaware that written notifications regarding the reason for the hospital transfer were required. 3. Resident #39 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set, dated dated dated [DATE] indicated Resident #39 was coded for severe cognitive impairment. Resident #39's medical record revealed she was transferred to the hospital on 11/12/23 and readmitted to the facility on [DATE]. There was no documentation that a written notice of transfer was provided to the resident and/or RP. A telephone interview was completed on 11/29/23 at 11:55 AM with Resident #39's Responsible Party (RP). He stated he did not recall receiving anything in writing from the facility about the reason Resident #39 was transferred to the hospital on 11/12/23 but the facility did call him. An interview on 11/28/23 at 2:20 PM was completed with the Administrator. He stated when a resident was transferred to the hospital the bed hold policy was sent with them, the RP would be notified via phone regarding the transfer and nursing notes would indicate the reason for the transfer. The Administrator stated he was unaware that written notifications regarding the reason for the hospital transfer were required. 40197 4. Resident #17 was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #17 had moderately impaired cognition. Resident #17's medical record revealed she was transferred to the hospital on 7/20/23 and was readmitted back to the facility on [DATE]. There was no documentation that a written notice of transfer was provided to the resident and/or responsible party (RP). The Administrator was interviewed on 11/28/23 at 2:20 PM and stated when a resident was transferred to the hospital the bed hold policy was sent with them, the RP would be notified via phone regarding the transfer and nursing notes would indicate the reason for the transfer. He indicated he was unaware that written notifications regarding the reason for the hospital transfer was required. 5. Resident #87 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #87 had severe cognitive impairment. Resident #87's medical record revealed she was transferred to the hospital on 10/22/23 and did not return to the facility. There was no documentation that a written notice of transfer was provided to the resident and/or responsible party (RP). The Administrator was interviewed on 11/28/23 at 2:20 PM and stated when a resident was transferred to the hospital the bed hold policy was sent with them, the RP would be notified via phone regarding the transfer and nursing notes would indicate the reason for the transfer. He indicated he was unaware that written notifications regarding the reason for the hospital transfer was required.

Based on record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of medications for 2 of 5 residents reviewed for unnecessary medications (Residents #22 and #73). The findings included: 1. Resident #22 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes. The admission MDS assessment dated [DATE] indicated Resident #22 had received 5 days of an insulin injection, however the assessment was not coded for hypoglycemic (medications to treat diabetes) medications or an indication present for its use. On 11/29/23 at 1:30 PM, an interview occurred with the MDS Nurse. She reviewed the MDS assessment dated [DATE] and confirmed she should have marked Resident #22 as receiving a hypoglycemic medication and that there was an indication for its use in his medical record. She felt it was an oversight. During an interview with the Administrator on 11/29/23 at 3:30 PM, he indicated he expected the MDS assessment to be coded accurately. 2. Resident #73 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes. A quarterly MDS assessment dated [DATE] indicated Resident #73 had received 7 days of an insulin injection, however the assessment was not coded for hypoglycemic (medications to treat diabetes) medications or an indication present for its use. On 11/29/23 at 1:30 PM, an interview occurred with the MDS Nurse. She reviewed the MDS assessment dated [DATE] and confirmed she should have marked Resident #22 as receiving a hypoglycemic medication and that there was an indication for its use in his medical record. She felt it was an oversight. During an interview with the Administrator on 11/29/23 at 3:30 PM, he indicated he expected the MDS assessment to be coded accurately.

Based on record review and staff interviews, the facility failed to revise the care plan in the area of planned disposition for 1 of 18 resident's (Resident #16) reviewed. The findings included: Resident # 16 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (irregular heart rate) and history of intracerebral hemorrhage (stroke) with hemiparesis (paralysis of one side). The resident's medical record indicated the resident was transitioned to comfort care 11/2/2023. The resident's active physician orders included atropine for terminal secretions, Ativan for terminal agitation, and morphine for pain. Resident #16's care plan was last revised 11/27/2023. The care plan included a focus for comfort measures dated 10/11/2023. The care plan also included a focus for discharge planning dated 10/4/2023 which included the resident was to be discharged from the facility. Interventions included arrange for home modifications, follow up appointment with primary care provider, and make referrals for home care as needed. On 11/29/2023 at 12:45PM an interview was conducted with the Minimum Data Set (MDS) Nurse. She reviewed Resident #16's care plan and stated she should have revised the care plan. The resident was on comfort measures and there was no intention to discharge him home at that time. She stated it was an oversight and she would update the care plan immediately. During an interview with the Administrator on 11/30/2023 at 8:45AM he stated he believed the failure to revise the care plan was and error and had been updated as of that date.

Based on observations, record review, resident and staff interviews the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented effective procedures and monitor the interventions that the committee put into place following recertification survey dated 4/8/21 for two deficiencies in the area of accurate Minimum Data Set (MDS) coding at F641 and in the supervision to prevent accidents at F689. Also, the recertification survey dated 9/22/22 for one deficiency in the area of care plan revision F657. The continued failure of the facility during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program. Findings included. This tag is cross referenced to: F641- Based on record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of medications for 2 of 5 residents reviewed for unnecessary medications (Residents #22 and #73). During a recertification survey dated 4/8/21, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the activities of daily living (ADLs), bowel and bladder and medications. F657-Based on record review and staff interviews, the facility failed to revise the care plan in the area of planned disposition for 1 of 18 resident's reviewed. During a recertification survey dated 9/22/22, the facility failed to individualize the care plan for a resident reviewed for accidents. F689 - Based on record review, observations and staff interviews, the facility failed to provide care in a safe manner during incontinence care that resulted in a fall with a right hip fracture (Resident #17). This was for 1 of 6 residents reviewed for accidents. During a recertification survey dated 4/8/21, the facility failed to prevent a resident who had cognitive impairment and known wandering behaviors from exiting the facility unsupervised at night. The resident exited the facility unsupervised and self-propelled himself by wheelchair approximately 0.16 miles away from the facility on a roadway that had no sidewalks. An interview was completed on 11/29/23 at 3:20 PM with the Administrator. He was unable to offer any reason for the repeat citation for accurate MDS coding and care plan revision. He also stated the facility completed a complete plan of correction at the time of the incident involving unsafe incontinence care resulting in a fall with injury.

Based on record review, resident, and staff interviews, the facility failed to communicate the facility's efforts to address group concerns verbalized during Resident Council meetings and to resolve repeat concerns for 4 of 4 consecutive months (May 2022, June 2022, July 2022, and August 2022). Findings included: Resident Council minutes dated 05/25/22 indicated residents had voiced concerns related to items listed on the meal ticket was not served, and condiments not provided on the meal trays. There was no evidence of the facility's response to the concerns voiced during the previous meeting had been reviewed or discussed. Resident Council minutes dated 06/23/22 indicated residents had voiced concerns related to Nursing Assistants (NAs) not returning to assist with requests and having more diabetic snacks available. There was no evidence of the facility's response to the concerns voiced during the previous meeting had been reviewed or discussed. Resident Council minutes dated 07/20/22 revealed a repeated concern of items listed on the meal ticket was not served. There was no evidence of the facility's response to the concerns voiced during the previous meeting had been reviewed or discussed. Resident Council minutes dated 08/20/22 indicated residents had voiced concerns related to being hurried by NAs when using the restroom and noodles being served without an accompanying side or entree. There was no evidence of the facility's response to the concerns voiced during the previous meeting had been reviewed or discussed. The facility's concern log revealed no documented concerns from the Resident Council from May 2022 through August 2022. On 09/21/22 at 9:25AM an interview was conducted with the Resident Council group which consisted of 7 of 8 residents that participated in Resident Council regularly (Residents #76, #32, #18, #30, #11, #16 and #42). The group stated they did not receive feedback from staff when group concerns were voiced. They further voiced they have complained multiple times regarding snacks not being delivered or offered to them, call lights not answered in a timely manner, not receiving ice/water consistently, and not being able to choose the time of their scheduled shower. The residents present for the Resident Council interview expressed verbalize the same things every month, but nothing gets resolved. During an interview on 09/20/22 at 4:39PM the Activities Director (AD) revealed that when she received a complaint during the Resident Council meeting, she would write the grievance up with the resident name that first voiced the complaint. The AD further explained she did not document the complaint as a group grievance. The AD would then provide the individual grievance to the department that it related to. The responsible department would address the issues on the grievance and return the grievance forms to the Social Worker. The facility's response to the concerns voiced during the previous meeting were not reviewed or discussed during the following month's meeting. She was not aware of any repeat concerns voiced at the Resident Council meetings. An interview with the Social Worker on 09/21/22 at 2:26PM revealed that if a complaint was made in Resident Council the Activities Director would write the grievance form up with the individuals name who was making the original complaint. She stated if more than one individual was voicing a concern, the AD would write a separate grievance for each person. Group grievances were not captured during the Resident Council meeting. The grievance was then given to the department head that was responsible for the area of concern and then returned to her after completion for filing. She stated there was not a separate binder dedicated to Resident Council meetings, only individual grievances. Interview with the Director of Nursing (DON) and the Administrator on 09/22/22 at 10:31AM revealed that their expectation was for the AD to fill out a grievance for each person that had a complaint/grievance and distribute them to the department head to address. If more than 1 resident complained, then a grievance for each individual resident was to be filled out. The grievances should be resolved and then reviewed at the next Resident Council meeting. They were not aware of any repeat concerns voiced at the Resident Council meetings.

Based on record review, observations and interviews, the facility failed to ensure alternating pressure reducing mattresses were set according to the residents' weights for 3 of 10 residents (Residents #236, #78 and #68) reviewed for pressure injuries. The findings included: 1. Resident #236 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Minimum Data Set (MDS) was not available. Resident #236's baseline care plan dated 9/12/2022 had a focus for pressure injury, stage 3, to the sacrum. The resident's medical record included a visit summary by the Wound Care Physician dated 9/14/2022. The summary indicated Resident #236 had a full thickness injury to the sacrum that measured .05 x .05 x 0.2 centimeters (cm). The etiology of the injury was pressure, and it was stage 3. During a wound care observation on 9/20/2021at 11:50 AM the resident was on an alternating pressure reducing mattress. The mattress was set on 250 pounds (lbs). After the wound care observation, the treatment nurse was interviewed. When asked how the alternating pressure reducing mattress should be set, she stated it should be set to the resident's weight. The treatment nurse observed the mattress to be set at 250 lbs. and stated she thought the resident was 250 lbs. She stated she checked the mattress for function, but she did not check the settings. She further stated the nursing supervisor was responsible for making sure the mattresses were set correctly according to the resident's weight. Resident #236's medical record indicated he was weighed on 9/16/2022 and was 188.7 lbs. On 9/20/2022 at 3:50 PM an interview was conducted with the nursing supervisor. She stated she was responsible for checking the alternating pressure reducing air mattresses for proper settings. She further stated she completed a check weekly. She checked the mattresses last week but had not checked them this week. She did not know why or how the mattress settings got changed. An interview was conducted with the Wound Care Physician on 9/21/2022 at 11:55 AM. He stated the alternating pressure reducing mattresses should be set according to the resident's weight unless the manufacturer's recommendations stated otherwise. On 9/22/2022 at 10:33 AM, an interview was conducted with the Director of Nursing (DON). She stated the staff may have turned the settings up when they provided incontinence care and forgot to place them back on the correct setting when they were done. She stated she expected the alternating pressure reducing mattresses to be set according to the resident's weight. 2. Resident #78 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #78's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Assess for inflation and proper functioning twice a day. Resident #78's weight on 7/13/22 was 145.2 pounds (lbs.). A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #78 had severely impaired decision-making skills. She was coded with one stage 4 pressure ulcer and had a pressure reducing device to the bed. Resident #78's weight on 9/16/22 was 152.0 lbs. On 9/19/22 at 10:00 AM, an observation was made of Resident #78 while she was lying in bed. The alternating pressure reducing mattress machine was set at 350 lbs. per weight setting. The machine had settings of 50 lbs., 100 lbs., 150 lbs., 200 lbs., 250 lbs., 300 lbs., and 350 lbs. and indicated to set according to the resident's weight per pounds. Resident #78 was observed lying in bed on 9/20/22 at 10:00 AM. The alternating pressure reducing mattress machine was set at 350 lbs. On 9/20/22 at 2:45 PM, an interview occurred with the Treatment Nurse and Nurse #6, who stated when they checked the alternating pressure reducing mattresses, they were ensuring the lines were connected and the machine was functioning properly but was unaware of the weight settings. Both nurses verified the weight was set at 350 lbs. and should have been set according to Resident #78's weight. An interview was conducted with the Wound Care Physician on 9/21/22 at 11:55 AM. He stated the alternating pressure reducing mattresses should be set according to the resident's weight unless the manufacturer's recommendations stated otherwise. On 9/22/2022 at 10:33 AM, an interview was conducted with the Director of Nursing (DON). She stated the staff may have turned the settings up when they provided incontinence care and forgot to place them back on the correct setting when they were done. She stated she expected the alternating pressure reducing mattresses to be set according to the resident's weight. 3. Resident #68 was admitted to the facility on [DATE] with multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #68 had severe cognitive impairment and she needed extensive assistance with bed mobility. The assessment further indicated that the resident had stage 3 and unstageable pressure ulcers and she weighed 97 pounds (lbs.). Resident #68 had doctor's orders dated 9/12/22 to clean area to the right hip and coccyx with normal saline, apply calcium alginate and cover with dry dressing daily. Resident #68's care plan dated 9/19/22 was reviewed. One of the care plan problems was unstageable pressure ulcers to the left hip and coccyx. The goals were for the pressure ulcers to decrease in size and not to exhibit signs of infection. Resident #68 was observed in bed on 9/19/22 at 10:47 AM and at 4:05 PM and on 9/20/22 at 9:45 AM. She had an alternating pressure relieving mattress and the weight setting was at 350 lbs. The Treatment Nurse was interviewed on 9/20/22 at 3:45 PM, She stated that the Registered Nurse (RN) Supervisor was responsible for checking the pressure relieving mattress for proper functioning. She reported that Resident #68's pressure relieving mattress was supposed to be set according to the resident's weight. The RN Supervisor was interviewed on 9/20/22 at 3:50 PM. She verified that she was responsible for checking the pressure relieving mattress for proper functioning. She reported that she checks the pressure relieving mattresses weekly but did not get the chance to check them this week. The RN Supervisor indicated that Resident #68's pressure relieving mattress should have been set according to her weight. The Director of Nursing was interviewed on 9/22/22 at 10:38 AM. The DON indicated that she expected the pressure relieving mattress to be set according to the manufacturer's instruction. She stated that Resident #68's pressure relieving mattress should have been set according to her weight. She added that nursing assistants might have turned the knob of the pressure relieving mattress to firm during care and forgot to turn it back to the correct setting.

Based on observation and staff interview, the facility failed to ensure the vent filters and sprinkler pipe under the kitchen exhaust hood were free of grease buildup. The failure had the potential to affect food served to the residents. The findings included: An initial kitchen tour was completed on 9/19/22 at 9:15 AM with Dietary Manager (DM) #1. She stated she was filling in for DM #3 who was out on medical leave. The exhaust hood over the cooking surfaces revealed amber to dark brown grease build up on the vent filters. Also observed on the sprinkler pipe located to the far right of the hood over the fryer was what appeared to be several suspended drops of dark brown grease suspended from the pipe. There was a label on this end of the exhaust hood. DM #1 stated the label indicated the hood was last professionally cleaned in May 2022 and due again November 2022. Another interview was completed on 9/19/22 at 12:15 PM with DM #1. She stated she took down the vent filters and cleaned them since our previous observation. She stated in her facility, she took the vent filters down every 2 weeks and cleaned them whether they were dirty or not because 6 months was too long to go in between cleaning. Another observation was completed on 9/21/22 at 11:12 AM with the Dietary District Manager (DDM). The vent filters were clean and free of obvious grease buildup. The sprinkler pipe appearance over the fryer was unchanged. The DDM stated his contract agency were not allowed to touch the sprinkler pipes or sprinkler heads. He stated the vent filters were professionally cleaned every 6 months and should be cleaned as needed for grease buildup in between professional cleanings. An interview was completed on 9/21/22 at 4:20 PM with the Administrator. He stated the dietary department were contracted and he was not aware that the vent filters and sprinkler pipe over the fryer had significant grease buildup on 9/19/22 but he felt the failure was due to the lack of consistent leadership. He stated he asked his Maintenance Supervisor (MS) to check the exhaust hood and vent filters monthly. An interview was completed on 9/22/22 at 8:20 AM with MS. He stated he added checking the vent filters on the exhaust hood to his weekly computer generated list of items to do to ensure they were clean. MS stated he also cleaned the sprinkler pipe over the fryer as well. A telephone interview was completed on 9/22/22 at 8:32 AM with DM #3. She stated she went out on medical leave on 9/1/22 and prior to her leave, she cleaned the vent filters weekly.

Based on record review, observation and Physician, resident and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedure and monitor interventions the committee put into place following the 4/8/21 recertification and complaint survey, 2/24/21 complaint survey and 8/22/19 recertification and complaint survey. This was for 5 deficiencies that were cited in the areas of Resident self-administration of medication, previously cited on 4/8/21 recertification and complaint survey, and recited on the current recertification and complaint survey of 9/22/22. In addition, Care Plan timing and revision, Respiratory/[CONDITION(S)] care and Food Precurement, Store/Prepare/Serve-Sanitary were also cited during the recertification and complaint survey on 8/22/19 and Treatment/Services to Prevent/Heal pressure ulcers was cited on the complaint survey of 2/24/21 and recited on current recertification and complaint survey of 9/22/22. The duplicate citations during the 3 federal surveys of record showed a pattern of the facility ' s inability to sustain an effective QAPI program. Findings included: 1. F686 - Based on record review, observation and interview, the facility failed to ensure the alternating pressure reducing mattresses were set according to the residents' weights for 3 (Residents #236, #78 & #68) of 10 residents reviewed for pressure injuries. During a complaint survey of 2/24/21, the facility failed to assess and to obtain a treatment order when the pressure ulcer was first identified for 1 (Resident #1) of 3 sampled residents reviewed for pressure ulcers. In an interview with the Administrator on 9/22/22 at 10:23 AM, he stated that the facility had experienced some challenges due to nursing shortages and turnover in management staff, which may have contributed to this repeat citation. 2. F695 - Based on record reviews, observations, resident, staff and Physician interviews, the facility failed to obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This was for 2 of 2 residents reviewed for respiratory care. During the recertification and complaint survey of 8/22/19, the facility failed to administer continuous oxygen as ordered for 1 (Resident #3) of 2 residents reviewed for respiratory care. In an interview with the Administrator on 9/22/22 at 10:23 AM, he stated that the facility had experienced some challenges due to nursing shortages and turnover in management staff. He added that the facility was utilizing agency nurses and nursing aides and he just hired a Staff Development Coordinator (SDC) who would be providing education to the staff. 3. F812 - Based on observation and staff interview, the facility failed to ensure the vent filters and sprinkler pipe under the exhaust hood were free of grease buildup. The failure had the potential to affect food served to the residents. During the recertification and complaint survey of 8/22/19, the facility failed to allow the meal trays to air dry before stacking together and ready for use for 14 meal trays observed. In an interview with the Administrator on 9/22/22 at 10:23 AM, he stated that the facility had a contracted dietary service. They are responsible for the sanitation in the kitchen including vent filters and sprinkle pipes under the exhaust hood. He reported that the Dietary Manager (DM) was on medical leave and there was no consistent DM in the kitchen to monitor. The Administrator indicated that the maintenance director would start to monitor and clean the exhaust hood routinely and as needed. 4. F554 - Based on observations, staff and resident interviews and record review, the facility failed to assess and obtain Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During the recertification and complaint survey of 4/8/21, the facility failed to assess and obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This was for 1 of 1 resident reviewed for self-administration of medications. In an interview with the Administrator on 9/22/22 at 10:23 AM, he stated that the facility had experienced some challenges due to nursing and administrative staff turnover. He added that the turnover in the administrative staff might have contributed to this repeat citation. 5. F657 - Based on record review and staff interviews, the facility failed to review and revise the care plan in the area of falls. This was for 1 (Resident #139) of 11 residents reviewed for accidents. During the recertification and complaint survey of 8/22/19, the facility failed to review and revise the care plan in the area of [CONDITION(S)] medications for 1 (Resident #36) of 5 residents reviewed for unnecessary medications. In an interview with the Administrator on 9/22/22 at 10:23 AM, he stated that the facility had experienced some challenges due to nursing and administrative staff turnover. He added that one of the MDS Nurses acted as the Director of Nursing (DON) temporarily until a full time DON was hired and this might have contributed to this repeat citation.

Based on observations, staff and resident interviews and record review, the facility failed to assess and obtain Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: Resident #23 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Her quarterly Minimum Data Set (MDS) dated [DATE] indicated she was cognitively intact. Review of Resident #23's care plan edited on 7/25/22 read she request to keep her prn inhaler at the bedside. Interventions included to evaluate for her continued ability to self-administer the inhaler at least quarterly. An observation was completed on 9/19/22 at 11:32 AM. Resident #23 was in bed and lying on her over the bed table were observed 2 inhalers ( [MEDICATION(S)] and [MEDICATION(S)]). They were not in original box indicating the prescribers directions for use. Resident #23 stated she was allowed to keep both inhalers at her bedside due to her [CONDITION(S)]. Review of Resident #23's September 2022 Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders for the self-administration of either inhalers. An interview was completed on 9/21/22 at 10:40 AM with MDS Nurse #1. She stated Resident #23 had been assessed previously on 4/7/21 for the self-administration of her [MEDICATION(S)] inhaler but when she went out to the hospital on 9/22/21, the self-administration order was discontinued. MDS Nurse #1 stated previously the process for residents who self-administrated any medication were assessed by the previous Director of Nursing (DON) to ensure the resident was safe to self-administer and aware of the need to safely store the medication. She stated she was uncertain if the current DON was responsible for obtaining the order and completing the self-administration assessment. An interview was completed on 9/21/22 at 2:37 PM with Nurse #8. She stated Resident #23 administered her own inhalers and kept them at her bedside. She stated she was not aware who was responsible to assess and obtain Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] An interview as completed on 9/21/22 at 2:40 PM with the DON. She stated she had been the facility DON since December 2021 and was informed yesterday by MDS Nurse #1 that the previous DON completed the self-administration assessments and obtained the Physician order. She stated she had not been doing it. An interview was completed on 9/22/22 at 10:30 AM with the Administrator and the DON. Both stated it was their expectation that a self-administration assessment be completed anytime a resident request to self-administer any medication, routinely reassess and obtain a Physician order. An interview was completed on 9/22/22 at 10:50 AM with the Medical Director. He stated it was his expectation that the facility complete and routinely reassess and obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record reviews, resident and staff interviews, the facility failed to provide treatments as ordered by the physician for a non-pressure related surgical wound on the left hip for 1 of 2 residents reviewed for wounds (Resident #236). The findings included: Resident #236 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Minimum Data Set (MDS) was not available. Resident #236's baseline care plan dated 9/12/2022 had a focus for pressure injury, stage 3, to the sacrum, deep tissue injury to the right great toe, and non-pressure related surgical wound to the left hip. The resident's active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #236's September 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 9/8/2022 (7:00 PM to 7:00 AM) 9/9/2022 (7:00 PM to 7:00 AM) 9/10/2022 (7:00 PM to 7:00 AM) Review of nursing progress notes did not indicate Resident #236 refused wound care treatment on 9/8/2022, 9/9/2022 or 9/10/2022. On 9/19/2022 at 10:56 AM an interview was conducted with Resident #236. He stated wound care to his left hip was not completed twice daily. Attempts to contact Nurse #10, assigned to Resident #236 on night shift 9/8/2022 were not successful. Nurse #10 documented she did not complete wound care because wound care order did not specify what strength of Dakins solution to use on the wound. On 9/21/2022 at 1:28 PM a telephone interview was conducted with Nurse #9. She stated she was assigned to Resident #236 on 9/9/2022 and she did not complete the wound treatment to the left hip because there was no clarification to what strength of Dakins solution to use on the wound. She further stated she did not call anyone or look at the resident's discharge summary for clarification. Attempts to contact Nurse #7, assigned to Resident #236 on night shift 9/10/2022 were not successful. Nurse #7 documented she did not complete wound care due to waiting on clarification. On 9/22/2022 at 10:33 AM an interview was conducted with the Director of Nursing (DON). She stated to her knowledge there was only one strength of Dakins solution on the treatment cart. She further stated she expected nursing staff to call her or the treatment nurse immediately if wound care orders needed clarification.

Based on record review, observations, and staff interviews, the facility failed to obtain a Physician's order for a resident's use of continuous oxygen (Residents #33 and #68). This was for 2 of 2 residents reviewed for respiratory care. The findings included: 1. Resident #33 was initially admitted to the facility on [DATE] with the most recent readmitted [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Minimum Data Set (MDS) assessment, dated 7/7/22, indicated Resident #33 had severe cognitive impairment. Review of the nursing progress notes revealed on 8/21/22, Resident #33 had low oxygen saturations and was started on oxygen at 2 liters flow by nasal cannula. On 8/22/22 Resident #33 was sent to the emergency room (ER) for further evaluation of shortness of breath and increased fatigue and was admitted to the hospital and readmitted to the facility on [DATE]. Review of the August 2022 physician orders included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was dated 8/21/22 and discontinued on 8/29/22. There were no orders for oxygen at 2 liters from 8/29/22 to 8/31/22. Review of the hospital discharge summary dated 8/29/22 revealed Resident #33 would be on 2 liters of oxygen due to [CONDITION(S)]. A nursing progress note dated 9/4/22 indicated Resident #33 was transferred to the hospital for a condition unrelated to her [CONDITION(S)] and was readmitted to the facility on [DATE]. Review of the hospital discharge summary dated 9/9/22 indicated Resident #33 was on 2 liters of oxygen due to her [CONDITION(S)]. A review of the September 2022 physician orders did not include an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #33's medical record revealed physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . In an observation on 9/19/22 at 9:40 AM, Resident #33 was lying in bed with oxygen running at 2 liters via concentrator. Resident #33 was observed lying in bed watching TV on 9/20/22 at 3:05 PM. Oxygen was being used at 2 liters via a concentrator. In an interview on 9/20/22 at 3:50 PM, the Clinical Care Coordinator (CCC) stated oxygen could be initiated as needed per standing orders when a resident was in need, however the physician should be notified after oxygen was started and an order written [MEDICAL RECORD OR PHYSICIAN ORDER] . After reviewing Resident #33's medical record, the CCC confirmed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #68 was admitted to the facility on [DATE] with multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #68 had severe cognitive impairment. Review of Resident #68's doctor's orders revealed that there was no order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] A nurse's note dated 9/9/22 at 6:59 PM revealed that Resident #68's oxygen saturation was 83% at bedtime and oxygen at 2 liters (L) per minute was administered via nasal canula (written by Nurse # 4). Nurse #4 was interviewed on 9/21/22 at 11:18 AM. She verified that she was assigned to Resident #68 on 9/9/22 and remembered starting the oxygen due to low oxygen saturation. Nurse #4 reported that the facility has a standing order to start the oxygen at 2L per minute. She also indicated that she should have written the order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #68 was observed in bed on 9/19/22 at 10:47 AM and at 4:05 PM on oxygen at 3L/ minute via nasal canula. On 9/20/22 at 3:40 PM, MDS Nurse #1 observed and verified that Resident #68 was on oxygen at 3L per minute. Interview with the Registered Nurse (RN) Supervisor was conducted on 9/20/22 at 3:50 PM. She stated that the facility has a standing order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN Supervisor reviewed Resident #68's doctor's orders and verified that that was no order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing (DON) was interviewed on 9/22/22 at 10:38 AM. The DON stated that nurses were expected to write an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record reviews and resident, family and staff interviews, the facility failed to provide a written grievance response summary for 5 of 8 residents reviewed for grievances (Residents #33, #62, #23, #36 and #68). The findings included: A review of the facility grievance policy, dated 11/28/16, included, in part, the resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. Such report will be made orally by the administrator, or his or her designee. The resident will be offered a copy of the written grievance decision. 1. Resident #33 was originally admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #33 had severe cognitive impairment. Review of the facility grievance logs from November 2021 until September 2022 indicated one grievance was initiated on 7/18/22 for Resident #33, by the responsible party (RP), regarding dissatisfaction with the room. The form indicated the Social Worker (SW) spoke with the family member with a resolution on 7/19/22 and was signed by the Administrator on 7/19/22. The form indicated a verbal resolution was provided. There was no indication a written summary was provided, offered, or requested by/to the RP. On 9/21/22 at 9:41 AM, an interview was conducted with the SW, who stated she logged all the grievance forms, and concerns were investigated by the appropriate department head. She went on to explain after the department head completed the investigation they would call/or speak with the person filing the grievance and provided the resolution verbally. A written copy was only provided to the ones that requested it, but she couldn't remember anyone that had requested a copy recently. A phone interview occurred with Resident #33's RP on 9/21/22 at 3:22 PM, who stated she had received verbal resolution of the past grievance concern but had not been offered or provided a summary in writing. The Administrator was interviewed on 9/22/22 at 10:33 AM and stated he was unaware a written summary of the grievance was not being provided at all times. The Administrator added, it was his expectation for the facility to adhere to the regulatory guidance regarding written grievance response summaries. 2. Resident #62 was admitted to the facility on [DATE]. A quarterly MDS assessment dated [DATE] indicated Resident #62 was cognitively intact. Review of the facility grievance logs from November 2021 until September 2022 indicated three grievance forms were initiated by the RP for Resident #62 on 3/17/22 regarding missing items, facility communication and room changes. The forms indicated the appropriate department heads spoke with the RP on 3/21/22 regarding the resolutions and were signed by the Administrator on 3/21/22. The forms indicated only a verbal resolution was provided. There were no indications written summaries were provided, offered, or requested by/to the RP/resident. On 9/21/22 at 9:41 AM, an interview was conducted with the SW, who stated she logged all the grievance forms, and it was investigated by the appropriate department head. She went on to explain after the department head completed the investigation they would call/or speak with the person filing the grievance and provided the resolution verbally. A written copy was only provided to the ones that requested it, but she couldn't remember anyone that had requested one recently. On 9/21/22 at 2:00 PM, an interview occurred with Resident #62 who stated he had not received anything in writing regarding the concerns his RP had voiced. A phone interview occurred with Resident #62's RP on 9/21/22 at 3:19 PM, who stated she could only recall getting verbal notification of the grievance resolutions. The Administrator was interviewed on 9/22/22 at 10:33 AM and stated he was unaware a written summary of the grievance was not being provided at all times. The Administrator added, it was his expectation for the facility to adhere to the regulatory guidance regarding written grievance response summaries. 3. Resident #23 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Her quarterly Minimum Data Set, dated dated dated [DATE] indicated she was cognitively intact and exhibited no behaviors. Review of the facility grievance list included written intakes on behalf of Resident #23 on 7/26/22, 8/2/22 and 9/11/22. The grievance form indicated Resident #23 was provided verbal investigation findings and actions but nothing was provided in writing. An interview was completed on 9/20/22 at 4:30 PM with Resident #23. She confirmed the Social Worker (SW) completed grievances on her behalf for the dates listed above. Resident #23 stated she did not receive anything in writing about her grievance, but the SW did follow up with her verbally. An interview was completed on 9/21/22 at 9:41 AM with the SW. She stated she was responsible for keeping up with and assigning the grievances to the appropriate department head to investigate and intervene. After the investigation, the department head would follow up with the person filling the grievance and if the person filing the grievance wanted a copy of the investigation findings, action/resolution, a copy the grievance form was given to him/her. The SW stated she did not provide a copy of the grievance investigations with resolutions to Resident #23. An interview was completed on 9/22/22 at 10:30 AM with the Administrator. He stated he thought the SW was providing a written response to each grievance, but he recently found out she only provided the written resolution if it was requested. 4. Resident #36 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #36's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact. The facility's grievance log for February 2022 through August 2022 revealed Resident #36 filed the following grievances: On 2/24/2022 Resident #36 filed a grievance regarding food. She stated the food was bland and did not have any seasoning. She also stated dietary had failed to provide snacks for residents. On 3/28/2022 Resident #36 filed a grievance regarding food. She stated the meat served to her was tough and dry. On 5/25/2022 Resident #36 filed a grievance regarding condiments with meals. She stated the kitchen did not put condiments on the meal trays for residents. Meals were served without any condiments. An interview was conducted with Resident #36 on 9/19/2022 at 11:14 AM. She stated she did not get a written resolution for the grievances she filed regarding food and the food had not changed nor had the facility provided snacks as requested. On 9/21/2022 at 9:41 AM an interview was conducted with the Social Worker (SW). She stated she maintains the grievance log and all the grievance forms. The grievance form was given to the appropriate department head to investigate and resolve. After the investigation, the department head contacted the person filling the grievance. If the person filing the grievance wanted a copy of the investigation and findings, action/resolution, a copy of the grievance form was given to them. She did not recall anyone requesting a copy of the grievance form. On 9/21/2022 at 9:58 AM an interview was conducted with the Director of Nursing (DON). She stated the SW gave her grievance forms. She investigated the grievance. After the investigation, she would call the person who filed the grievance and discuss the result of her investigation and what actions were taken. The DON did not provide a written copy of the grievance to the complainant and did not know regulations stipulated a written copy should have been provided. 5. Resident #68 was admitted to the facility on [DATE] with multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #68 had severe cognitive impairment. Review of the facility's grievance log revealed that Resident #68's family member had reported 5 grievances in the last 4 months. The grievance reporting forms revealed that on 5/23/22, a family member had reported a grievance regarding lack of activities of daily living (ADL) care, on 7/1/22 regarding food/dietary concerns, on 8/30/22 regarding lack of ADL care, 9/2/22 regarding lack of ADL care and on 9/15/22 regarding lack of ADL care. The grievance reporting forms dated 5/23/22, 8/30/22 and 9/2/22 revealed that investigation findings, action/resolution and the grievance decision were reported/given to the person filing the grievance verbally on 5/25/22, and 9/4/22. The grievance reporting forms dated 7/1/22 and 9/15/22 revealed that investigation findings, action/resolution and the grievance decision were reported to the person filing the grievance on 5/25/22, and 9/4/22. The report did not indicate whether the forms were reported/given verbally or in writing. A family member of Resident #68 was interviewed on 9/21/22 at 9:36 AM. The family member stated that she had reported grievances to the facility staff on 5/23/22, 7/1/22, 8/30/22, 9/2/22 and 9/15/22. She indicated that a staff member had called and told her what actions were taken to correct her grievances. She stated that she had never received any responses in writing regarding her grievances and she would prefer to have a copy of the grievance report with the resolution. The Social Worker (SW) was interviewed on 9/21/22 at 9:41 AM. The SW stated that she was responsible for the grievance and keeps all the grievance forms. She reported that the grievance form was given to the department head (depends on the type of grievance) to investigate and to resolve the grievance. The department head would call the person filing the grievance and discuss the resolution. After the investigation, the completed form was returned to the SW for filing. If the person filing the grievance wants a copy of the grievance form, a copy is provided. The Director of Nursing (DON) was interviewed on 9/21/22 at 9:58 AM. The DON stated that the SW was responsible for the grievance. The SW gives her the grievance form if the grievance was related to nursing. She then investigates and takes action to resolve the grievance. She calls the person filing the grievance. She submitted back the completed grievance form to the SW. The Administrator was interviewed on 9/22/22 at 10:23 AM. The Administrator stated that he expected the SW to provide a copy of the completed grievance form to the person filing the grievance. He indicated that he was not aware that the SW was not providing a written copy of the grievance form with the resolution to the person filing the grievance.

Based on record review and staff interview, the facility failed to ensure the nurse staffing data that were posted daily were accurate for 7 of 30 days reviewed. Findings included: The daily nurse staffing data, and the daily nursing assignments were reviewed from 8/20/22 through 9/20/22 with the Human Resources (HR) staff. The daily staffing data, and the daily nursing schedule did not match on 7 (8/27/22, 8/28/22, 9/3/22, 9/4/22, 9/6/22, 9/17/22 and 9/18/22) of 30 days reviewed. 8/27/22 -2 Registered Nurses (RNs) on nurse staffing data - 1 RN on schedule 8/28/22 - 2 RNs on nurse staffing data - 1 RN on schedule 9/3/22 - 2 RNs on nurse staffing data - 1 RN on schedule 9/4/22 - 2 RNs on nurse staffing data - 1 RN on schedule 9/6/22 - 2 RNs on nurse staffing data - 1 RN on schedule 9/17/22 - 2 RNs on nurse staffing data - 1 RN on schedule 9/18/22 - 2 RNs on nurse staffing data - 1 RN on schedule The HR staff member was interviewed on 9/22/22 at 8:40 AM. She stated that she was responsible for completing and posting the nurse staffing data daily except on Saturday and Sunday. She indicated that she completes the nurse staffing form for the weekend and the RN Supervisor was supposed to check for accuracy before posting. She verified that the nurse staffing data on 8/27/22, 8/28/22, 9/3/22, 9/4/22, 9/6/22, 9/17/22 and 9/18/22 were not accurate on the number of RNs in the building. The Administrator was interviewed on 9/22/22 at 10:23 AM. He reported that currently, he did not have a weekend RN Supervisor. He will ensure that the RN working on the weekend will be responsible for checking the nurse staffing data for accuracy before posting.

Based on record review, observations, and staff interviews, the facility failed to have accurate medical records for 3 of 10 residents reviewed for wound care (Resident #286, #236 and #68). The findings included: 1. Resident #286 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The baseline care plan dated 9/9/22 included surgical wound to right groin. Resident #286's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Pack the wound with Dakin's (a solution with anti-infective properties) 0.5% soaked gauze and cover with a dry dressing twice a day. The September 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - Day shift (7:00 AM to 7:00 PM) on 9/13/22, 9/15/22 and 9/16/22. - Evening shift (7:00 PM to 7:00 AM) on 9/9/22 and 9/11/22. Review of the nursing progress notes from 9/8/22 until 9/21/22 revealed Resident #286 did not refuse surgical wound care. A phone interview was completed with Nurse #5 on 9/21/22 at 11:25 AM, who scheduled for the day shift on 9/16/22. She explained wound care had been completed after the medication pass and Resident #286 had accepted. Nurse #5 stated she had forgotten to document the wound care as completed on the MAR. On 9/21/22 at 1:00 PM, an interview occurred with Nurse #6, who was scheduled for the day shift on 9/13/22 and 9/15/22. She reviewed the missing documentation for surgical care to Resident #286 and stated she recalled completing the wound care but had forgotten to document as completed on the MAR. On 9/21/22 at 1:23 PM, a phone interview was conducted with Nurse #9 who had been scheduled for the evening shift on 9/9/22. She was able to recall the surgical wound to Resident #286's groin area and could not remember the resident refusing wound care. She verified the date in question and stated she forgot to sign the wound care as completed on the MAR. A phone interview took place on 9/22/22 at 7:45 AM, with Nurse #7 who had been scheduled for the evening shift on 9/11/22. She was able to recall completing Resident #286's wound care after the medication pass, but must have forgotten to document the surgical wound care as completed on the MAR. The Director of Nursing was interviewed on 9/22/22 at 10:33 AM, and indicated she expected the nursing staff to complete wound care as ordered ensuring it was documented as completed or refused by the resident. 2. Resident #236 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Minimum Data Set (MDS) was not available. Resident #236's baseline care plan dated 9/12/2022 had a focus for pressure injury, stage 3, to the sacrum, deep tissue injury to the right great toe, and non-pressure related injury to the left great toe. The resident's active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He also had an active order dated 9/8/2022 to apply absorbase ointment (skin protectant and barrier cream) to the resident's sacrum twice daily. Resident #236's September 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nursing progress notes did not indicate Resident #236 refused wound care treatment on 9/10/2022. On 9/22/2022 at 9:08 AM an interview was conducted with the Director of Nursing. She stated she was assigned to Resident #236, day shift on 9/10/2022. She stated she completed the wound treatments but did not document them on the resident's MAR. It was an oversight. She further stated she expected wound care treatments to be completed or documented as completed. 3. Resident #68 was admitted to the facility on [DATE] with multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #68 had severe cognitive impairment. Resident #68 had doctor's order dated 8/12/22 to paint deep tissue injury (DTI) to right 5th toe with [MEDICATION(S)] daily, on 8/19/22 to clean left dorsal foot with normal saline, apply xeroform and cover with transparent dressing daily, on 9/1/22 to paint left 1st toe with [MEDICATION(S)] daily and on 9/8/22 to clean right posterior heel wound with normal saline, apply calcium alginate (used to treat wounds with moderate to heavy exudates), cover with silicone foam dressing daily. Review of the September 2022 Treatment Administration Records (TARs) revealed that there was no nurse's initial to indicate that treatment was provided to Resident #68's pressure wounds on 9/9/22, 9/10/22, 9/12/22 and 9/16/22. The TARs revealed that Nurse #5 was assigned to Resident #68 on 9/9/22, 9/10/22 and 9/12/22 and the Treatment Nurse was assigned to the resident on 9/16/22. Nurse #5 was interviewed on 9/21/22 at 11:26 AM. She indicated that she was aware that nurses were responsible to provide the treatment when the Treatment Nurse was not available to provide the treatment. She verified that she was assigned to Resident #68 on 9/9/22, 9/10/22 and 9/12/22. She reported that she provided the treatment but missed to initial the TARs. The Treatment Nurse was interviewed on 9/21/22 at 11:30 AM. She reported that she was assigned to work on the floor on 9/16/22 and was assigned to the resident. She reported that she provided the treatments but forgot to the sign the TARs. The Director of Nursing (DON) was interviewed on 9/22/22 at 10:23 AM. The DON stated that she expected nursing to put their initials on the TARs to indicate that treatments were provided.

Based on record review and interviews with family, Adult Protective Services (APS) Social Worker, Medical Director, and staff, the facility failed to verify a resident ' s discharge location and also failed to assess the home environment to ensure it was safe and provided the level of care required to meet the resident ' s needs resulting in a cognitively impaired resident being discharged to his home where he resided without supervision. Resident #129 was discharged on [DATE] and on 3/12/21 a home visit was conducted by APS who assessed the resident to not have the capacity to live alone and he was subsequently sent to the hospital where he remained as of 4/8/21. This was for 1 of 2 discharged residents (Resident #129) reviewed. Immediate Jeopardy began on 3/11/21 when Resident #129 was discharged to his home where he resided without supervision. The Immediate Jeopardy was removed on 4/8/21 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems put into place related to the discharge planning process are effective and to complete staff training. The findings included: The hospital discharge summary dated 3/2/21 indicated Resident #129 was admitted to the hospital on 2/11/21 after being found by his family member unresponsive at his home. His initial diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Throughout his hospital stay he experienced episodes of confabulation (the replacement of a gap in a person's memory by a falsification that he or she believed to be true), disorientation, and agitation. He was assessed by neurology and deemed to have a neurocognitive disorder. Resident #129 was being discharged to the facility as his Responsible Party (RP) was no longer able to care for him at home due to [CONDITION(S)]. Resident #129 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note completed by the Clinical Care Coordinator (CCC) dated 3/2/21 indicated Resident #129 was admitted to the facility. He was alert and oriented to self only. An admission assessment dated [DATE] completed by the CCC indicated Resident #129 ' s current health problems included, in part, memory loss and balance problems. He utilized a walker and wheelchair. Resident #129 ' s mental status was assessed as alert and oriented to self only. He was noted with anxiety and restlessness. A physician history and physical dated 3/4/21 indicated that Resident #129 was admitted to the facility from the hospital as his RP believed the resident was no longer able to take care of himself at his home and that he required long term placement. A 5-day Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #129 ' s cognition was moderately impaired. The care plan for Resident #129 included a problem area of Resident #129/Resident #129 ' s RP requested resident to remain in the facility for long term care. This area was initiated on 3/5/21. The goal area (initiated 3/5/21 with a target date of 6/5/21) indicated Resident #129 was to remain in the facility for long term care. The interventions, also implemented on 3/5/21 included, in part, involve resident and family in care planning. Nursing notes dated 3/6/21 and 3/7/21 completed by Nurse #1 indicated Resident #129 was alert and oriented to self only. He was noted with wandering by self-propelling his wheelchair throughout the 7:00 AM to 7:00 PM shift. Nurse #1 indicated that safety precautions and redirection were needed related to his confusion. A nursing note dated 3/9/21 at 8:38 PM completed by Nurse #2 indicated that at approximately 7:40 PM she was informed that a resident headcount needed to be completed related to a call to the facility from a 911 dispatcher that a male was reportedly seen in a wheelchair down the street from the facility. A headcount was performed, and Resident #129 was not in the facility. The 911 dispatcher was informed that the male seen down the street from the facility was a facility resident. At approximately 7:50 PM a police officer (Police Corporal #1) called the facility and stated that he was picking up Resident #129 to bring him back to the facility. At 8:02 PM the police officer arrived at the facility with Resident #129 who was in his wheelchair. He had no signs or symptoms of acute distress or pain. He was assisted to his room by staff and was placed on one to one (1:1) monitoring for the remainder of the shift. A police report completed by Police Corporal (PC) #1 indicated on 3/9/21 at 7:41 PM he responded to a call received by 911 regarding a phone call about a sighting of an elderly male in a wheelchair headed away from the facility. PC #1 wrote that he went to the location Resident #129 was spotted and spoke with him. Resident #129 advised that he was leaving a Christmas party and was headed home. The facility was phoned, and they completed a headcount and discovered Resident #129 was missing. PC #1 wrote that he took Resident #129 back to the facility. He indicated he spoke with the facility Administrator who stated that Resident #129 ' s family would be contacted and the facility would try to get him discharged home with family. PC #1 indicated he reported the incident to Adult Protective Services (APS). A progress note dated 3/9/21 at 10:48 PM completed by the Administrator indicated he spoke with Resident #129 ' s RP to notify of his unsupervised exit. A note dated 3/11/21 at 8:50 AM completed by Social Worker (SW) #1 indicated Resident #129 was to discharge home that afternoon with his RP. She wrote that he was to be evaluated by Physical Therapy/Occupational Therapy/and Speech Therapy to receive home health nursing for wound care, medication management, and education, and SW for community resources. A physician ' s discharge summary note dated 3/11/21 indicated Resident #129 was seen for discharge home to family. Resident #129 was noted to be ambulatory in wheelchair throughout his stay at the facility. He recently had an unsupervised exit from the facility in which the police found him in the street on a road near the facility. A nursing note dated 3/11/21 at 3:38 PM completed by Nurse #1 indicated Resident #129 was discharged home. He was picked up by his RP and medications were sent home with the resident. A note dated 3/11/21 at 3:43 PM completed by SW #1 indicated APS were notified for suspicion of lack of care and supervision for Resident #129 following statements from his RP made when picking him up for discharge. APS informed the facility they had an active case for Resident #129, and they would send a SW out for a home visit. An Emergency Department (ED) note dated 3/12/21 indicated Resident #129 was recently admitted to the hospital (2/11/21) and discharged to a facility (3/2/21). APS SW reported that he was seen at his home on 3/12/21 and was assessed to not have the capacity to live independently. The APS SW reported that there was an issue with Resident #129 being discharged from the facility inappropriately. A hospital note dated 3/13/21 indicated during Resident #129 ' s 2/11/21 - 3/2/21 stay at the hospital he was seen by neurology and deemed to have a neurocognitive disorder. Neurology assessed him with poor insight and cognitive dysfunction and noted concern about his ability to return home alone safely and recommended 24 hour supervision. Resident #129 ' s RP reported that he was able to get out of the facility on 3/9/21 and then he was discharged home on 3/11/21. The RP reported that she picked him up from the facility, took him home, settled him in, and left. She further reported that on the morning of 3/12/21 she spoke with APS SW who was checking on Resident #129 and she informed her that Resident #129 was sent home from the facility independently. The APS SW had Resident #129 picked up by Emergency Medical Services (EMS) brought to the ED and she instructed that he was to stay in the hospital until long term placement was able to be arranged. This hospital note additionally indicated that Resident #129 ' s RP was not able to care for the resident as she worked, her spouse had medical issues, and she also cared for another family member with medical issues. It was noted that due to that combination, the RP was unable to take on someone else in her home. When Resident #129 was asked what had been going on and why he was at the hospital he reported a confabulated accounting that included, in part, They brought me here to the hospital, then to an airport onto a helicopter down to the beach. Luckily I have had some experience dealing with the Italian medical society. They knew who I was so it made it go smoothly. If they needed something I gave it to them. An Adult Protective Services Notice to Administrator letter received by the facility on 3/23/21 completed by Department of Social Services (DSS) APS SW indicated a protective services report had been received and evaluation for Resident #129. On the date of 3/9/21 DSS received concerns about maltreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] - Evidence of neglect was found. - The need for protective services was substantiated. A note dated 3/25/21 completed by SW #1 indicated a follow up call was made to Resident #129 ' s RP to follow up on the resident but the RP was unable to be reached. A hospital note dated 4/6/21 indicated Resident #129 remained in the hospital (admitted [DATE]) and discharge planning was in process with a local facility that had a secured memory care unit. A phone interview was conducted with the APS SW on 4/6/21 at 8:20 AM. She indicated that an APS report was initially made by the local police department related to Resident #129 ' s unsupervised exit from the facility on 3/9/21. She stated that on 3/11/21 she received a report from the facility that Resident #129 was discharged from the facility on this date (3/11/21) and they were concerned the family member he was discharged to may not have been able to care for him. The APS SW spoke about Resident #129 ' s history indicating that in September 2020 he was found by a family member in his home (where he lived independently) with all 4 stove burners on and he was sleeping. She further reported that on 2/11/21 Resident #129 was admitted to the hospital after being found by his family member unresponsive at his home. She indicated he was in the hospital until 3/2/21 when he was admitted to the facility. The APS SW stated that she completed a home visit with Resident #129 on 3/12/21. She reported that Resident #129 was alone in his home and he was experiencing delusions. She indicated she strongly felt this was an unsafe living environment for Resident #129 and she contacted EMS for hospital evaluation where he was evaluated and admitted . She revealed he was still in the hospital as of 4/6/21. The APS SW further revealed that she substantiated the allegation of neglect based on the totality of the unsupervised exit on 3/9/21 and subsequent discharge to an unsafe environment 2 days later on 3/11/21. She reported that the facility claimed that his RP said she would be providing care for him. She indicated that she spoke to his RP and she indicated she had never told the facility she was going to provide care for him. She added that the hospital discharge summary from 3/2/21 on the date of admittance to the facility indicated that Resident #129's family member was no longer able to care for him at home due to his [CONDITION(S)] and this why was he was placed at the facility. A phone interview as conducted with Nurse #1 on 4/6/21 at 1:12 PM. She indicated she worked with Resident #129 during his stay at the facility and that he was alert and oriented to self only with cognitive impairment and delusional thoughts. She reported that she was assigned to Resident #129 on the date of his discharge on 3/11/21. She indicated that she was informed by the Administrator that Resident #129 was discharging home and would be staying with his family. Nurse #1 indicated that on 3/11/21 Resident #129 ' s RP came to the facility to pick the resident up and as she was going through his medication list and orders with the RP she indicated that Resident #129 was going home by himself and she would not be with him to administer his medications. Nurse #1 reported that after Resident #129 left with his RP she went to talk to SW #1 and SW #2 about his discharge arrangements as she had not felt comfortable with Resident #129 going home to live alone without supervision. She stated that she shared with SW #1 and SW #2 that Resident #129 ' s RP indicated the resident was going to be living alone unsupervised and they informed her they would contact APS. A phone interview was conducted on 4/6/21 at 9:18 AM with Resident #129 ' s RP. She reported that during Resident #129 ' s hospitalization from [DATE] through 3/2/21 she informed the hospital staff that she was unable to care for Resident #129 at home and this was why he required facility placement. Resident #129 ' s RP revealed that on the night of 3/9/21 she was awakened from her sleep by a phone call from the facility Administrator stating that Resident #129 had gotten out of the facility unsupervised that evening but was now back at the facility. She reported that the Administrator informed her that the facility couldn ' t keep him (Resident #129) because they couldn ' t have residents exiting the facility unsupervised. She stated that she believed she informed the Administrator that she was not able to care for Resident #129 at her home and that he would be residing alone in his home if he was discharged . The RP stated that the Administrator said someone would call her tomorrow to discuss a plan. She indicated that the next day (3/10/21), one of the facility SWs (unable to recall which one) called her and told her they needed to do discharge planning and asked her when she could pick Resident #129 up. She indicated that she thought this meant she had to pick him up as soon as possible so she informed them she could pick him after work the next day. Resident #129 ' s RP stated that she was not asked if she was taking Resident #129 home with her. She revealed that the facility was aware that she could not care for the resident herself as this was the reason he was placed at the facility when he was discharged from the hospital (3/2/21). She stated that she felt she had no other option but to take him home to live by himself. She explained that she worked full time and her husband and herself were already taking turns providing care to another family member with dementia who lived with them. Resident #129 ' s RP indicated that on 3/11/21 after work she went to the facility and picked up Resident #129. She reported that 3 staff members (names unknown) brought him out to car and she said to them that he was going home to live by himself and they acted they like they were surprised by that information. Resident #129 ' s RP stated that she took him to his home and dropped him off. She revealed that the next day (3/12/21) a SW from APS contacted her and said that Resident #129 was not safe at home by himself and that was when he was sent back to the hospital where he still remained. During a phone interview with SW #1 on 4/6/21 at 9:50 AM she stated that she started orientation as the SW on 3/8/21 and that she was being trained by the outgoing SW (SW #2). She reported on 3/10/21 during the morning meeting, Resident #129 ' s unsupervised exit from the facility that occurred the previous night (3/9/21) was discussed and it was decided that he needed a discharge plan as this facility was not able to provide the level of care he needed as evidenced by him getting out of the facility without staff ' s knowledge. She said 1:1 was provided for a shift and then q 15 minute observations were conducted after the unsupervised exit, but that this was not an intervention that could continue indefinitely. SW #1 stated that after the morning meeting she called Resident #129 ' s RP and SW #2 was listening in by speaker phone. She informed Resident #129 ' s RP the facility couldn ' t provide the care Resident #129 needed and they needed to have a discharge plan. She reported that Resident #129 ' s RP seemed agreeable and stated that she could pick him up the following day (3/11/21) after she got out of work. She was asked if it was discussed where Resident #129 was going to reside at in the community and she stated that she assumed Resident #129 ' s RP was going to take him to her home to provide care. She revealed she had not verified where Resident #129 would be residing when speaking with his RP on 3/10/21. She was asked who she thought was going to provide care for Resident #129 when his RP was working. She revealed that she was aware his RP worked and that she assumed there was a caregiver in the home as his RP had another relative who had dementia living with her. She further revealed that she had not completed an assessment of the home environment to ensure it was safe and provided the level of care required to meet Resident #129 ' s needs. SW #1 was asked if she was aware the hospital discharge summary dated 3/2/21 revealed that Resident #129 was discharged to facility placement as his RP was no longer able to care for him at home. She indicated that she was unaware of that information. This phone interview with SW #1 continued. She stated that on 3/11/21 after Resident #129 was picked up at the facility, Nurse #1 came into her office and reported that his RP stated that he was going to his own home to live alone. She indicated that this was a concern as he was not safe to live alone so she and SW #2 phoned APS and requested a safety check for Resident #129. She reported that APS told her they already had an active case open and they would send a SW out to his home. During a phone interview with SW #2 on 4/6/21 at 1:00 PM she stated that she worked at the facility for about a month and her last day was 3/12/21. She reported on 3/10/21 during the morning meeting, Resident #129 ' s unsupervised exit from the facility that occurred the previous night (3/9/21) was discussed and the Administrator informed SW #1 and herself that he spoke with Resident #129 ' s RP last night (3/9/21) after the incident and he told her that the facility was going to have to find somewhere else for him to stay or he would have to be discharged home. She was asked why the facility was no longer able to care for Resident #129 and she stated that she was unable to answer this question as this was management ' s decision. SW #2 reported that after the morning meeting (3/10/21) the Administrator told her and SW #1 to contact Resident #129 ' s RP and discuss discharge plans. She indicated SW #1 contacted Resident #129 ' s RP by phone and she listened in on speaker phone. SW #2 indicated that SW #1 informed Resident #129 ' s RP that they needed to discuss discharge planning. She stated that the RP had not seemed surprised by this information. She indicated SW #1 asked the RP if she was able to come get Resident #129 and if so when would she be able to do this. She reported that Resident #129 ' s RP said she would pick him up the following day (3/11/21) after she got out of work. SW #2 indicated that she assumed from the conversation that Resident #129 ' s RP was unhappy that he was able to get out of the facility unsupervised so she wanted him to be discharged . SW #2 was asked if it was discussed where Resident #129 was going to reside at in the community and she stated that she assumed Resident #129 ' s RP was going to take him to her home to provide care. She revealed it had not verified where Resident #129 would be residing when SW #1 spoke with his RP on 3/10/21. She was asked who she thought was going to provide care for Resident #129 when his RP was working. She revealed that she was aware his RP worked and that she assumed there was a caregiver in the home as his RP had another relative who had dementia living with her. She further revealed that she had not completed an assessment of the home environment to ensure it was safe and provided the level of care required to meet Resident #129 ' s needs. SW #2 was asked if she was aware the hospital discharge summary dated 3/2/21 revealed that Resident #129 was discharged to facility placement as his RP was no longer able to care for him at home. She indicated that she was unaware of that information. This phone interview with SW #2 continued. SW #2 confirmed SW #1 ' s statement that on 3/11/21 after Resident #129 was picked up at the facility by his RP, Nurse #1 came into their office and reported that his RP stated that he was going to his own home to live alone. She indicated that this was a concern as he was not safe to live alone so she and SW #1 phoned APS and requested a safety check for Resident #129. She reported that APS told her they already had an active case open and they would send a SW out to his home. An interview with the Administrator on 4/7/21 at 11:10 AM confirmed he phoned Resident #129 ' s RP after his unsupervised exit from the facility on the night of 3/9/21. He informed her the facility could not keep him and she had 2 options: 1) take him home with her; 2) transfer to another facility with a secured unit without a guarantee that there would be an opening in this county. The Administrator indicated that she spoke about her living situation and informed him that she and her husband both worked opposite shifts and that she also cared for another family member who had dementia. The Administrator stated that during this phone call the RP stated that she would just take him home. The Administrator was asked if Resident #129 ' s RP could have felt like she had no choice but to take him home and he acknowledged that this was possible. The Administrator revealed he was unaware that SW #1 and SW #2 failed to confirm Resident ' s #129 ' s discharge location. He stated that the SWs should have verified the discharge location that Resident #129 was going to be staying at. The Administrator acknowledged his awareness the SWs failed to complete an assessment of the discharge home environment to ensure it was safe and provided the level of care required to meet Resident #129 ' s needs. The Administrator was asked if he was aware the hospital discharge summary dated 3/2/21 revealed that Resident #129 was discharged to facility placement as his RP was no longer able to care for him at home. He was unable to recall if he was aware of that information. The Administrator was asked why the facility discharged the resident and he stated that he was afraid Resident #129 would get out of the facility again and he had not had the ability to provide him 1:1 care indefinitely. He explained that the only way to ensure Resident #129 had not exited the building unsupervised again was to have someone with him at all times. An interview was conducted with the facility ' s Medical Director on 4/8/21 at 10:45 AM. He stated that Resident #129 was cognitively impaired and he required 24 hour care. He stated that Resident #129 was not safe to live alone and/or to live in a home environment without a care giver present at all times. He reported that the facility had a responsibility to ensure the environment a resident was being discharged to was assessed for safety and for the ability to meet the resident ' s needs. The Administrator and DON were notified of the Immediate Jeopardy on 4/7/21 at 2:40 PM. On 4/8/21 at 12:03 PM the facility provided the following credible allegation of Immediate Jeopardy removal: #1 Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Facility failed to ensure Resident #129 was discharged to a safe environment. Resident #129 had a Minimum Data Set assessment (MDS) completed on 3-5-21. His BIMS (Brief Interview for Mental Status) score was calculated at 10, which is considered moderately Impaired. Resident #129 discharge plan was initiated on 3-10-21 by the Social worker. During this process, the social worker called the sister to ask questions on what address the resident would be going to, who would be providing supervision for resident #129, what home health agency they would like to use, what equipment that would be needed and who would be there to let home health and equipment company in at the address. The social worker failed to verify that the address that was given was the sister ' s address and not Residents #129 old home address. The home environment was not assessed for safety because the social worker assumed that the address given was the sister ' s address where 24 hour supervision would be given. Resident # 129 was discharged home on 3-11-21. The Social worker contacted Adult Protective Services (APS) on 3-11-21 to notify them that Resident #129 sister made a comment on discharge that Resident #129 would be discharging to his home alone. The local APS social worker went to perform a safety check on 3-12-21. APS found the resident alone at his residence experiencing delusions and EMS was called to take the resident to the hospital. Resident is still at the hospital at this time. On 4-8-21 the discharge planner at the local hospital for Resident #129 was contacted by our admission coordinator. The discharge planner stated that the temporary guardian was working on resident #129 insurance authorizations to discharge him to a local facility in the area with a locked secured unit. Per the discharge planner the local facility has made an offer pending insurance authorization. The facility Admission coordinator notified the discharge planner for Resident #129 that the facility would accept the resident back at our facility if unable to place at the other local facility with the locked unit. The Social worker performed an audit on 4-7-21 on all residents that were discharged home for the past 30 days to ensure that no other residents were affected by the alleged noncompliance. The social worker looked to see if follow up calls were made and received, were there any concerns from the RP or resident, did home health arrive as ordered, and was equipment delivered as ordered and if anyone living environment was unsafe. No other residents were found during this audit to be affected by the alleged noncompliance. The alleged non-compliance resulted from failure to follow up with the sister of Resident #129 to ensure that the sister would be taking the resident home with her and providing 24 hour care as needed and not following up to ensure the resident was going to the sisters address instead of his old address. This also included the failure to assess the safety of the home environment he was being discharged to. #2 Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. The Social Worker and all licensed nursing staff will be educated by 4-8-21 by the Staff Development Coordinator (SDC), Director of Nursing (DON) and RN Supervisor on what constitutes an unsafe discharge and what steps must be taken to ensure that an unsafe discharge does not occur. All discharges will be discussed in our clinical meeting Monday through Friday. This clinical meeting will be made up of the Social Worker, SDC, Director of Nursing (DON), Therapy Manager, Minimum Data Set (MDS) nurses #1, and #2, Administrator and RN Supervisor. Any discharges occurring on Saturday and Sunday, the RN Supervisor will ensure that safe discharge occurs. The Social worker will be educated by the SDC by 4-8-21 on steps to ensure a safe discharge which includes : Ensure that resident caretakers at the home will be there for the appropriate time frame for the care that is needed and to ensure that all aspects of the discharge is followed up on, including the correct address, the caregivers ' ability to provide the required care for the resident, that equipment has been delivered, follow up doctor ' s appointments have been made, Home health has been ordered if needed and to ensure that resident will have the appropriate care when they return home. To ensure that this alleged noncompliance will not occur the following items will be put in place. The Social worker will have a discharge meeting with the Resident Responsible Party (RP) or the Resident 48 hours before discharge to arrange a safe discharge home and to ensure the home environment is safe. Once the resident is discharged the social worker will have 72 hours to call the resident or RP at discharge location to ensure that all items needed are there, that the home environment is still safe and that resident is safe at location. This will be documented in a progress note in resident file. TITLE OF THE PERSON RESPONSIBLE FOR IMPLEMENTING THE CREDIBLE ALLEGATION FOR IMMEDIATE JEOPARDY REMOVAL. The Administrator and the Director of Nursing will be ultimately responsible to ensure the implementation of credible allegation to remove this alleged immediate jeopardy. Immediate Jeopardy Removal Date: 4-8-21 The facility alleges the removal of Immediate Jeopardy on 4/8/21. On 4/8/21 the credible allegation of Immediate Jeopardy removal was validated by onsite verification. Record review and SW #1 interview verified an audit was completed on 4/7/21 for all residents discharged home in the past 30 days to ensure follow up calls were made and received, all discharge needs were met, and that the home environments were safe. An interview with the Administrator verified this facility would accept Resident #129 back if the placement arranged by the local hospital was not successful and/or if Resident #129 ' s guardian wished for him to return to this facility. This interview with the Administrator also verified that all discharges would be discussed in the clinical meeting Monday through Friday. This clinical meeting would be made up of the Social Worker, SDC, Director of Nursing (DON), Therapy Manager, Minimum Data Set (MDS) nurses #1, and #2, Administrator and RN Supervisor. For any discharges occurring on Saturday and Sunday, the RN Supervisor would ensure that safe discharge occurred. A review of inservices and inservice sign in sheets as well as staff interviews verified education was provided on 4/8/21 to the SW and all licensed nursing staff on what constitutes an unsafe discharge and what steps must be taken to ensure that an unsafe discharge does not occur. This also verified the SW was educated on 4/8/21 on the steps to ensure a safe discharge occurred which includes: 1) Ensure that resident caretakers at the home will be there for the appropriate time frame for the care that is needed; 2) Ensure that all aspects of the discharge are followed up on; and 3) Ensure the resident will have the appropriate care when they return home. The aspects of discharge that required follow up on included the correct address, the caregivers ' ability to provide the required care for the resident, that equipment has been delivered, follow up doctor ' s appointments have been made, and home health has been ordered if needed. Any licensed nursing staff not inserviced by 4/8/21 were required to be educated prior to working on the floor. The facility ' s IJ removal date of 4/8/21 was validated.

Based on record review, observation, and interview with the Medical Director, Police Corporal, and staff, the facility failed to prevent a resident who had cognitive impairment and known wandering behaviors from exiting the facility unsupervised at night. On 3/9/21 Resident #129 exited the facility unsupervised and he self-propelled himself by wheelchair approximately 0.16 miles away from the facility on a roadway that had no sidewalks. This was for 1 of 3 residents reviewed who experienced wandering behaviors. Immediate Jeopardy began on 3/9/21 when Resident #129 exited the facility unsupervised at night. The Immediate Jeopardy was removed on 4/8/21 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. The findings included: Resident #129 was admitted to the facility on [DATE] with diagnoses that included metabolic [CONDITION(S)] (a disturbance of brain function), dementia, depression, and [CONDITION(S)]. The hospital discharge summary dated 3/2/21 indicated that throughout Resident #129 ' s stay at the hospital he experienced episodes of confabulation (the replacement of a gap in a person's memory by a falsification that he or she believed to be true), disorientation, and agitation. He was noted to require facility placement due to [CONDITION(S)]. A nursing note completed by the Clinical Care Coordinator (CCC) dated 3/2/21 indicated Resident #129 was admitted to the facility. He was alert and oriented to self only. An admission assessment dated [DATE] completed by the CCC indicated Resident #129 ' s current health problems included, in part, memory loss and balance problems. He utilized a walker and wheelchair. Resident #129 ' s mental status was assessed as alert and oriented to self only. He was noted with anxiety and restlessness. A 5-day Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #129 ' s cognition was moderately impaired. He was assessed with no [CONDITION(S)], behaviors, or wandering. Resident #129 required supervision of 1 for bed mobility, transfers, and toileting, and supervision with set up help only for locomotion on the unit. He had no functional impairment with range of motion, and he utilized a wheelchair. A nursing note dated 3/6/21 completed by Nurse #1 indicated Resident #129 was alert and oriented to self only. He was noted with wandering by self-propelling his wheelchair throughout the 7:00 AM to 7:00 PM shift. Nurse #1 indicated that safety precautions and redirection were needed related to his confusion. A nursing note dated 3/7/21 completed by Nurse #1 indicated Resident #129 was alert and oriented to self only. He was noted with wandering by self-propelling his wheelchair throughout the 7:00 AM to 7:00 PM shift. Nurse #1 indicated that safety precautions and redirection were needed related to his confusion. A nursing note dated 3/9/21 at 8:38 PM completed by Nurse #2 indicated that at approximately 7:40 PM she was informed that a resident headcount needed to be completed related to a call to the facility from a 911 dispatcher that a male was reportedly seen in a wheelchair down the street from the facility. A headcount was performed, and Resident #129 was not in the facility. The 911 dispatcher was informed that the male seen down the street from the facility was a facility resident. At approximately 7:50 PM a police officer (Police Corporal #1) called the facility and stated that he was picking up Resident #129 to bring him back to the facility. At 8:02 PM the police officer arrived at the facility with Resident #129 who was in his wheelchair. He had no signs or symptoms of acute distress or pain. He was assisted to his room by staff and was placed on one to one (1:1) monitoring for the remainder of the shift. A Safety Event – Elopement/Wandering form with an event date of 3/9/21 at 7:40 PM and a completion date of 3/10/21 at 1:02 AM was completed by Nurse #2. This form indicated that Resident #129 eloped from the facility on 3/9/21. Nurse #2 wrote that at 7:41 PM the facility was notified by 911 dispatch that a man (Resident #129) was seen at/near a roadway adjacent to the facility. Resident #129 was noted with no injuries. Nurse #2 indicated on the form that Resident #129 had exhibited the following behaviors prior to the elopement: - Resisting redirection from staff - Verbalizing statements about leaving - Wandering with no rational purpose and attempting to open doors - Resident verbalized statements regarding going to see his family Nurse #2 indicated that the immediate measures taken were 1:1 care to be followed by q (every) 15 minute checks. A typed statement dated 3/9/21 completed by the Administrator indicated he interviewed the nurse assigned to Resident #129 at the time of his unsupervised exit from the facility on 3/9/21. The statement read, [Nurse #2] stated that she heard a door alarm go off around 7:20pm but it only stayed on for a short period and it went back off. She stated she did not stop her [medication] pass because the alarm went back off and she thought it was the pharmacy coming in. She was performing her [medication pass] on the lower 300 hall during this time. [Nurse #2] took the call from police that notified her of a missing resident. This statement included no signature from Nurse #2. A phone interview was conducted with Nurse #2 on 4/6/21 at 12:10 PM. She stated that she worked with Resident #129 during the second shift on the day of his admission (3/2/21) and then once again on the night of his unsupervised exit from the facility. She stated that Resident #129 was alert and oriented to self only. She indicated that he was not oriented to time, place, or situation. She reported that on 3/2/21 Resident #129 repeatedly self-propelled his wheelchair to the double doors that separated his hall from the 300 hall, and he was trying to open them. He was difficult to redirect and became agitated when it was explained to him that this was the quarantine hall (400 hall) and he needed to remain on this hall. Nurse #2 indicated that the NA and nurse who were assigned to Resident #129 ' s hall were also assigned to part of the 300 hall. She reported that there were double doors that were kept closed that led into Resident #129 ' s hall from the 300 hall as Resident #129 resided on the quarantine hall (400 hall). She stated that Resident #129 ' s hall was not visible from the 300 hall due to the double door closure. Nurse #2 stated that on the night of the incident (3/9/21) she was working the 7:00 PM to 7:00 AM shift and she had not laid eyes upon Resident #129 until after he was returned to the facility by the police (approximately 8:02 PM). She explained that she began her medication pass on the 300 hall and had not entered Resident #129 ' s hall. She verified she had not known he was missing until the 911 dispatcher phoned the facility and informed them an elderly male in a wheelchair was spotted heading away from the facility around 7:40 PM. She reported that this was when the facility staff completed a headcount and she realized Resident #129 was missing. Nurse #2 had not recalled hearing an alarm going off indicating that an exit door was opened. She revealed that Resident #129 was dressed in a gown with pants, a shirt, and a jacket over top of the gown when he was returned to the facility by the police. Nurse #2 indicated that she was not entirely surprised that he got out of the facility since he was able to move about independently and he had spoken to her about his family when she worked with him. She further indicated that it was not safe for Resident #129 to be out of the facility without supervision. A police report completed by Police Corporal (PC) #1 indicated on 3/9/21 at 7:41 PM he responded to a call received by 911 dispatch regarding a phone call they received about a sighting of an elderly male in a wheelchair headed away from the facility. PC #1 wrote that he went to the location Resident #129 was spotted and spoke with him. Resident #129 advised that he was leaving a Christmas party and was headed home. The facility was phoned, and they completed a headcount and discovered Resident #129 was missing. PC #1 wrote that he took Resident #129 back to the facility. He indicated that he spoke with the nurse, Nurse #2, who was assigned to Resident #129 at that time (2nd shift from 7:00 PM to 7:00 AM) on 3/9/21. She informed PC #1 that she received a report on her assigned residents around 7:00 PM from the nurse who had worked the previous shift (3/9/21 7:00 AM to 7:00 PM) and she then began passing medications to residents on the 300 hall. She stated that around 7:20 PM she heard a facility door alarm going off during her medication pass. Nurse #2 indicated that Nurse #4 checked the main entrance/exit door of the facility when the alarm went off. PC #1 wrote that he then spoke with Nurse #4 who reported that she was in the copier room (near the main entrance of the facility) when the alarm went off and she stuck her head out of the copier room door and had not seen anything or anyone. She indicated the alarm went off for about 3 seconds and then shut off. Nurse #4 stated that she had not heard the front door open or close and had not seen anyone pass her to get to the front entrance/exit of the facility. PC #1 wrote that he spoke with the Administrator and he reported a staff member was assigned to be with Resident #129 at all times. PC #1 additionally wrote that he reported the incident to Adult Protective Services (APS). During a phone interview with PC #1 on 4/6/21 at 11:00 AM he stated that a passerby noticed Resident #129 on a roadway adjacent to the facility in his wheelchair on the night of 3/9/21 and the passerby phoned 911 around 7:40 PM. He reported that he went to the location Resident #129 was spotted at and he observed him seated in his wheelchair on the roadway. He stated that Resident #129 told him he was just leaving a Christmas party and he lived in the area and was headed home. PC #1 indicated this was a windy 2 lane roadway with no shoulder (strip of pavement on the exterior the lanes) on each side, and no sidewalks. He further indicated that it was dark outside. PC #1 reported that he took Resident #129 him back to the facility arriving there at approximately 8:00 PM. A typed statement dated 3/9/21 completed by the Administrator indicated he interviewed the Nursing Assistant (NA #2) assigned to Resident #129 at the time of his unsupervised exit from the facility on 3/9/21. The statement read, [NA #2] stated that [Resident #129] was [sitting] in his wheelchair watching TV at 7:10pm [and] this was the last time she put eyes on [Resident #129] before incident. She stated she was doing [Activities of Daily Living] care on another resident around 7:20pm and she heard a wired alarm go off for around 5 seconds and it turned off. She did not come out of the room to check because the alarm went off so fast she thought it was pharmacy. The statement included no signature from NA #2. A phone interview was conducted with NA #2 on 4/6/21 at 12:30 PM. NA #2 reported that she worked with Resident #129 for the first time during the second shift (7:00 PM to 7:00 AM) on 3/9/21. She confirmed she was assigned to him during the time of his unsupervised exit from the facility. NA #2 stated that on 3/9/21 at approximately 6:45 PM during a round she completed with NA #1, the NA who was completing her 7:00 AM to 7:00 PM shift on 3/9/21, she observed Resident #129 seated in his wheelchair in his room watching television. She revealed that she had not seen Resident #129 again until he was returned to the facility by the police around 8:00 PM. The typed statement dated 3/9/21 completed by the Administrator that indicated he interviewed NA #2 and she reported that she last saw Resident #129 at 7:10 PM was reviewed with NA #2. She revealed she had never seen this typed statement before, she had not reported this information to the Administrator, and that this was not accurate information. She explained that she spoke with the Administrator on 3/9/21 after the incident, but she had not said that she saw Resident #129 at 7:10 PM. NA #2 reiterated that she last saw Resident #129 at approximately 6:45 PM. She explained that the NA and nurse who were assigned to Resident #129 ' s hall were also assigned to part of the 300 hall. NA #2 reported that there were double doors that were kept closed that led into Resident #129 ' s hall from the 300 hall as Resident #129 resided on the quarantine unit. She stated that Resident #129 ' s hall was not visible from the 300 hall due to the double door closure. NA #2 reported that she recalled a facility door alarm going off sometime after 7:00 PM while she was providing care to a resident on the 300 hall and she revealed she had not responded to the alarm. She indicated that by the time she completed care the alarm had ceased sounding and she assumed it was a pharmacy staff member who entered one of the facility doors and manually shut the alarm off. NA #2 was asked if it was a normal occurrence for the pharmacy staff to come into the facility, set off the alarm, and then shut the alarm off. She indicated that this happened several times when she was working. NA #2 revealed that Resident #129 was dressed in a gown with pants, a shirt, and a jacket on over top of it when he was returned to the facility by the police. She indicated that he had independently dressed himself over top of the gown. A typed statement dated 3/9/21 completed by the Administrator indicated he interviewed Nurse #4 working at the time of Resident #129 ' s unsupervised exit from the facility. The statement indicated that Nurse #4 was making copies in an office near the front door at the time the alarm sounded. Nurse #4 admitted to hearing the alarm but stated that it was very short and very faint. She reported that she had not seen any residents coming up the 300 hall or toward the hall to the front entrance/exit door when she was making copies. Nurse #4 indicated that she had not visually observed Resident #129 on 3/9/21 until after he was returned to the facility by the police. This statement included no signature from Nurse #4. A phone interview was attempted with Nurse #4 on 4/6/21 at 2:38 PM but she was unable to be reached. An Additional Nursing Admission Data form completed by the CCC with an observation date of 3/2/21 at 2:39 PM and a completion date of 3/10/21 at 8:46 AM indicated Resident #129 had no wandering behaviors. Under the question that asked for specific information or interventions related to wandering behaviors the CCC wrote, Not reported from hospital nurse. A clinical observation form dated 3/10/21 completed by the Director of Nursing (DON) with an observation time of 8:00 AM and completion time of 3:51 PM indicated Resident #129 rested in bed all night and was up in his chair at the time of the observation. He was assessed with no distress or pain. The DON wrote that Resident #129 was able to recall leaving the facility last evening and he stated, He didn ' t know why he did that. A note dated 3/11/21 at 8:50 AM completed by Social Worker (SW) #1 indicated Resident #129 was to discharge home that afternoon with his Responsible Party (RP). A Facility Reported Incident (FRI) with an investigation end date of 3/11/21 was completed by the DON and the Administrator for an allegation of neglect related to Resident #129 ' s unsupervised exit from the facility on 3/9/21. This investigation included a letter dated 3/15/21 completed by the Administrator which indicated that Resident #129 would not state how he got out of the facility. The investigation concluded through staff interviews that a door alarm went off for approximately 5 seconds when Resident #129 exited the facility unsupervised on 3/9/21. The door alarm required the activation of a kill switch that was accessed by removing the cover over the switch which manually shut the alarm off. The facility believed Resident #129 was watching and waiting for the shift to change so he could exit the facility by a door located on his hall that led to the outside. This required Resident #129 to remove the cover over the kill switch of the door, flip the switch to turn off the door alarm, prop the door open with his foot, flip the switch back on to reset the alarm, and then replace the cover prior to exiting the facility. The facility unsubstantiated the allegation of neglect stating that, Resident did not present as an elopement risk during his stay [at the facility]. Included in this FRI was a plan of correction implemented by the facility that listed the following actions and monitoring: Actions: - The key code on all doors in the facility were changed by 9:45 PM on 3-9-21 by the Maintenance Director. - Facility staff conducted a full census bed count on 3-9-21, all residents were accounted for. - All staff were educated on the facility ' s Elopement Policy by 3-10-21 by the Administrator, Director of Nursing and/or Staff Development Coordinator - All kill switches were rewired on 3-10-21 to alarm if anyone cuts them off and back on. The alarm would continue to alarm until someone entered the key code in to reset door. - Elopement assessment was completed on 3-10-21 for Resident #129 and all residents previously identified as exit seekers. - Resident #129 ' s information and picture was added to the elopement book. All other residents previously identified as exit seekers were in the elopement book. - Elopement care plan was added on 3-9-21 for Resident #129 Monitoring: - An audit tool was developed by the Quality Assurance and Performance Improvement (QAPI) team to monitor for and ensure that all door kill switches were fully functioning. - The Maintenance Director would monitor all kill switches for function and alarm daily for two weeks and then weekly. - Key codes would be changed monthly by the Maintenance Director The above plan of correction had not addressed the failure to provide any form of supervision, because could not be seen from the quarantine hall (400 hall) to the 300 hall. On 4/5/21 at 11:00 AM the 300 hall was observed to have closed double doors that separated this hall from the 400 hall, which was where Resident #129 had resided. There was no ability to see Resident #129 ' s hall from the 300 hall when the double doors were closed. The hall Resident #129 resided on was observed to have an exit door that led to the outside. During an interview with the Administrator on 4/7/21 at 11:10 AM he reported that Resident #129 was alert and oriented to self with intermittent confusion. He stated that Resident #129 tended to be more oriented during the day with increasing confusion as the day progressed. The Administrator revealed that on the day of his admission Resident #129 stated that he had just come from a party, which was inaccurate as he was transferred to the facility from the hospital. He further revealed that he heard Resident #129 talking about his family on multiple occasions and self-propelling his wheelchair throughout the hallway he resided on. He stated that Resident #129 was very intelligent, and that staff had observed him tinkering with light switches located on his hall. He reported that the Activities staff provided him with puzzles and other items to keep him busy. The Administrator reported that he was unaware of any instances in which Resident #129 tried to exit the facility prior to 3/9/21 indicating that this was why the allegation of neglect was unsubstantiated by the facility. The facility ' s investigation of Resident #129 ' s 3/9/21 unsupervised exit from the facility that revealed the resident got out of the building through an exit door that led to the outside that was located on the hall he resided on was reviewed with the Administrator. He explained that based on the investigation, Resident #129 flipped the kill switch which was located near the exit door and that this switch turned off the door alarm. He confirmed the facility ' s plan of correction was focused on the functioning of this door alarm. He stated that all exit doors in the facility were rewired so that so that a numerical code had to be entered for the alarm to turn off. The Administrator was asked if any procedures were changed and/or if any education was provided to address the failure to provide any form of supervision, monitoring, and/or observation of Resident #129 and the other residents on the hall he resided on from 6:46 PM through 7:41 PM on 3/9/21. He revealed that no changes were made, and no education was completed related to this failure to provide supervision, monitoring, and/or observation of Resident #129 and the other residents on the hall he resided on. The Administrator confirmed the staff interviews that indicated the NA and nurse who were assigned to Resident #129 ' s hall were also assigned to the 300 hall. He additionally confirmed that the double doors between Resident #129 ' s hall and the 300 hall were kept closed which resulted in the inability to see the hall Resident #129 resided on from the 300 hall. The Administrator revealed that the facility initiated discharge for Resident #129 on 3/10/21 and he was discharged to the community on 3/11/21. The Administrator was asked why the facility discharged the resident and he stated that he was afraid Resident #129 would get out of the facility unsupervised again and that he had not had the ability to provide him 1:1 care for him indefinitely. He explained that the only way to ensure Resident #129 had not exited the building unsupervised again was to have someone with him at all times and that the facility was not able to staff someone for 1:1 care indefinitely. The facility ' s exterior surroundings were observed with the Administrator on 4/7/21 at 12:30 PM and the area included a large pond on the left side of the facility (when facing the facility) and on the right, back, and front of the facility were wooded areas. The section of the road Resident #129 was found by PC #1 was a 2 lane windy road with no visible pavement markings separating the lanes, no shoulder, and no sidewalk. This road was bordered by a downward sloping grassy area on each side and the speed limit was 35 miles per hour. The distance to the location Resident #129 was found at by the police was measured with the Administrator and was found to be approximately 0.16 miles from the door he exited the facility from. The Administrator revealed that it was not safe for Resident #129 to be out of the facility unsupervised. On 3/9/21, the date of Resident #129 ' s unsupervised exit from the facility, the sunset was at 6:21 PM (https://sunrise-sunset.org) and the temperature at 7:53 PM was 60 degrees (www.wunderground.com) in the city Resident #129 was located in. A phone interview was conducted with Nurse #1 on 4/6/21 at 8:47 AM. She indicated she worked with Resident #129 during his stay at the facility and that he was alert and oriented to self only. She reported that Resident # 129 self-propelled his wheelchair throughout the hall he resided on and on one occasion when she was working with him he went to the double doors that separated his hall from the 300 hall and opened them. She indicated she redirected him back to his hall as he was supposed to remain on that hall (400 hall) as it was the quarantine unit. A phone interview with Nurse #3 on 4/6/21 at 10:21 AM confirmed Resident #129 was alert and oriented to self only. He self-propelled his wheelchair throughout his hall consistently during the day. Nurse #3 reported that on one occasion when she was working with Resident #129, he went to the exit door located on his hall and was pressing on that door which caused the alarm to go off. She indicated she was on the hall at that time and she was able to redirect him before he was able to open the door completely. She was asked if she reported this to the DON or Administrator and she stated she had not thought to report it because he had not gotten out. A phone interview with NA #1 on 4/6/21 at 10:43 AM indicated that Resident #129 was able to self-propel his wheelchair up and down the hall he resided on. She indicated that one time when she was working with Resident #129 he opened the double doors that separated his hall from the 300 hall, and he was self-propelling his wheelchair down the 300 hall when she saw him and redirected him back to his hall. She reported that Resident #129 was alert but was oriented to self only. She explained that he was always talking about different things and she provided an example that one second, he was be talking about his family and the next second he was talking about a being on a farm. During a phone interview on 4/6/21 at 3:55 PM with the DON she acknowledged that Resident #129 had wandering behaviors, but she had not considered these to be exit seeking behaviors. She explained that she thought he was just exploring his new environment and was curious. She reported that she was unaware he was observed pressing on the exit door located on his hallway by Nurse #3. She reported that she thought Resident #129 was alert and oriented explaining that on one occasion when she was providing him with wound care, he was telling her how to complete the wound care. She revealed that she had not known he was disorientation to place, time, and situation (as indicated by nursing documentation and staff interviews). The facility ' s investigation of Resident #129 ' s 3/9/21 unsupervised exit from the facility that revealed Resident #129 got out of the building through an exit door that led to the outside that was located on the hall he resided on was reviewed with the DON. She verified the investigation indicated that Resident #129 flipped the kill switch which was located near the exit door and that this switch turned off the door alarm. She confirmed the facility ' s plan of correction was focused on the functioning of this door alarm. She explained that all exit doors in the facility were rewired so that a numerical code had to be entered for the alarm to turn off. The DON was asked if any procedures were changed and/or if any education was provided to address the failure to provide any form of supervision, monitoring, and/or observation to Resident #129 and the other residents on the hall he resided on from 6:46 PM through 7:41 PM on 3/9/21. She indicated that no changes were made, and no education was completed related to this failure to provide supervision, monitoring, and/or observation of Resident #129 and the other residents on the hall he resided on. The DON confirmed the staff interviews that indicated the NA and nurse who were assigned to the hall Resident #129 resided on were also assigned to the 300 hall. She additionally confirmed that the double doors between Resident #129 ' s hall and the 300 hall were kept closed which resulted in the inability to see Resident #129 ' s hall from the 300 hall. The DON revealed that the nurse and NA assigned to those halls could have planned things out better so that one person started their shift working on the 300 hall and worked their way up and the other started their shift working on Resident #129 ' s hall and worked their way down. She acknowledged that it would have taken Resident #129 some time to put clothing on over top of his gown and to then disarm the kill switch and exit the facility. An interview was conducted with the facility ' s Medical Director on 4/8/21 at 10:45 AM. He stated that Resident #129 was cognitively impaired. He reported that he was able to answer questions that related to the present time, but if he was asked to go back and forth between the present and past he confabulated information. The Medical Director provided an example stating that when he saw Resident #129 after his unsupervised exit from the facility the resident said he was banging on the door to get back into the facility, but it was known that this was not true because the police brought him back. Resident #129 had not recalled the police bringing him back and he said he had not remembered how he got out. The Medical Director stated that Resident #129 was fixated on wanting to go home and that every time he spoke to the resident he talked about going home with his family. He indicated that based on this fixation of wanting to go home, his cognitive impairment, and his wandering behaviors he was at risk of an unsupervised exit from the facility. The Medical Director revealed that the facility had not provided the necessary supervision to Resident #129 on 3/9/21 when he exited the facility unsupervised. He stated that he was aware that the NA and nurse assigned to the hall Resident #129 resided on were also assigned to the 300 hall and that there was no visual line of sight from one hall to the other when the double doors between these halls were closed. He indicated that there needed to be some type of rotation with the nurse and the NA so that there was someone on both halls at regular intervals. He added that the residents on the hall Resident #129 had resided on were newly admitted residents and that the facility staff were just getting to know them which made the supervision and monitoring of these residents even more important. The Administrator and DON were notified of the Immediate Jeopardy on 4/7/21 at 2:40 PM. On 4/8/21 at 3:48 PM the facility provided the following credible allegation of Immediate Jeopardy removal: #1 Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #129 was admitted to the facility on [DATE] with diagnoses that included metabolic [CONDITION(S)], dementia, depression, and [CONDITION(S)]. Resident #129 ' s baseline cognitive status was alert and oriented to self only with periods of disorientation to place, time, and situation. Resident #129 was able to propel throughout the unit, at times requiring redirection to his room. An elopement assessment was not conducted upon admission, per policy. On the evening of 3/09/2021 at 7:41 PM, facility staff received a phone call from 911 dispatch that a resident from the facility was found on a street near the facility. Facility staff conducted a full census bed count immediately. All residents were accounted for except for Resident #129. Resident #129 was returned to the facility by Police at 8:01 PM. Upon return to the facility, Resident #129 was assisted to his room by Nurse #2. Nurse #2 performed a comprehensive assessment of Resident #129. Resident #129 did not have any observed injuries or other adverse findings. Resident was alert and oriented to person. Resident #129 was immediately placed on 1:1 monitoring for the remainder of the shift, and then 15-minute monitoring checks to ensure resident safety. There were no additional attempts to exit the facility without supervision. The resident representative and physician were notified of the incident by facility nursing staff on 3/09/2021 at 10:48 PM by the administrator and hall nurse. According to Nurse #2 and CNA #2, a 5 second alarm had sounded at 7:20 PM. Neither Nurse #2 nor CNA #2 checked to see if a resident had exited one of the doors. The resident was last observed at 6:45 PM by Nurse Aide # 2. An Elopement assessment was completed on Resident #129 on 03/10/2021 by The Staff Development Coordinator (SDC), Director of Nursing (DON) and RN Supervisor. It was determined that Resident #129 was at continued risk for elopement. Resident #129 ' s picture and name was added to the elopement book. The elopement book contains enlarged photographs and names of residents at risk for elopement. This book is maintained at the nursing station and front desk at the facility. A Resident experiences wandering care plan was added on 3/09/2021 by the MDS Coordinator. Th [TRUNCATED]

Based on record review, Physician and staff interview, the facility failed to have an adequate indication for the use of the as needed (PRN) [MEDICAL CONDITION] medication, failed to try non-pharmacological intervention prior to administering a PRN [MEDICAL CONDITION] medication and failed to identify the use of the [MEDICAL CONDITION] medications as a possible cause of the falls, sleepiness and decreased po (per Orem) intake for 1 of 3 sampled residents reviewed for unnecessary medication (Resident #1). Resident #1 was administered [MEDICATION NAME] (a drug used to reverse opioid overdose) due to increased lethargy and was sent to the hospital due to unresponsiveness. Resident #1 expired on [DATE] and the cause of death was [MEDICAL CONDITIONS]. Findings included: Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #1 had severe cognitive impairment with behaviors of rejection of care, verbal and physical behavioral symptoms and wandering. The assessment further indicated that Resident #1 needed supervision with transfers and ambulation. The assessment also revealed that Resident #1 had 1 fall prior to admission and had no falls since admission to the facility. The assessment also indicated that Resident #1 had received an antipsychotic medication for 1 day, antianxiety medication for 2 days and antidepressant medication for 3 days during the assessment period. Resident #1's care plan dated [DATE] was reviewed. The resident was care planned for the use of the [MEDICAL CONDITION] medications (antianxiety and antidepressant medications) and for physical behavioral symptoms of wandering into other resident's rooms, removing stop signs and fidgeting other resident's belongings and for verbal behavior of yelling at staff. The goals included resident will not exhibit signs of drug related sedation, drowsiness/over-sedation, disturbed balance/gait/positioning ability, [MEDICAL CONDITION] or [MEDICATION NAME] symptoms. The approaches included attempt non-pharmacological interventions, monitor drug use effectiveness and adverse consequences, monitor mood and response to medication, assess/record effectiveness of drug treatment, monitor and report signs of sedation, [MEDICAL CONDITION] or [MEDICATION NAME] symptoms and provide care, activities and daily schedule that resembles the resident's prior lifestyle. Review of the admission doctor's orders dated [DATE] revealed that Resident #1 did not have orders for [MEDICAL CONDITION] medications. On [DATE] at 6:29 PM, a nurse's note (written by Nurse #3) indicated that Resident #1 was admitted to the facility. He was confused and was combative towards the staff during care. On [DATE] at 2:04 PM, the nurse's note (written by Nurse #2) revealed that Resident #1 was observed rummaging through items on medication cart and wandering into other residents' rooms. The resident was resistant to redirection at times. On [DATE] at 3:28 AM, a nurse's note revealed resident up in wheelchair (w/c) propelling self-short distances before getting up and pushing w/c or leaving w/c and walking throughout facility. Resident frequently becomes very agitated when attempting to be redirected. Resident grabs staff's arms and squeezes/shakes them and refuses what staff requested of him. At times resident is easier to redirect without becoming aggressive. Snacks offered and resident took the tissues and crackers, sat on the floor, tore tissues into pieces, took crackers apart and laid them in an orderly fashion on the floor to use the tools to fix the bushings that had gone bad on his friend's car (another resident's w/c). Resistant to having blood sugar taken. Attempted times 5 before successful. Another male resident encouraged resident to take his bedtime medications with success. Resident wearing pull up and taking self to bathroom. Resident observed sitting on shower chair urinating then turning around and wiping the seat off with his hands, then began assessing shower seat for mechanical problems. Resident was in bed multiple times for short periods of time. Resident going into other resident's rooms and quickly became agitated and aggressive when being directed out of rooms. Resident requires much observation due to poor safety awareness and impulsive behavior. Resident attempted to exit facility several times without success. Resident refusing grippy socks or shoes preferring to be barefoot. Educated resident about the dangers of falling. Resident stated a verbal understanding but pushed this nurse in the chest and stated, get out of here! I put my wife in here! (opening closet door in room). Attempts made to start a conversation to reorient resident as to wife's whereabouts and try to get him to rest in bed. Resident continued to look for wife in linen cart and under bed. Several staff members attempting to keep resident calm. Medicated times 2 per prn orders of 25 milligram (mg) [MEDICATION NAME] (a pain reliever), somewhat effective results noted. Resident was pushing w/c in hallway, shaking arms in the air and speaking loudly and crying, unable to distinguish words. Resident appeared to be adjusting to new environment when in his room with bathroom light on. Best outcomes appear to be slowly approaching resident with snack/drink already in hand prior to initiating any conversation and try to distract/redirect with questions about vehicle repair. Will continue to monitor progress in adjustment to new environment. On [DATE] at 8:00 AM, a nurse's note (written by Nurse #2) revealed resident observed in room [ROOM NUMBER] going through items in drawers. This nurse attempted to redirect resident and inform him that he was not in his room. Resident states, this is my room. This nurse pointed out pictures on the wall to show resident that room belongs to someone else. Resident became agitated and yelled this is my stuff d-----. This nurse sat with resident in room until he was able to be redirected to his own room. This nurse noted that resident had removed the stop sign from doorway of 101 and placed it into the trash can. Resident was back in his room at this time. Will continue to monitor and redirect as needed. On [DATE] at 12:45 PM, a nurse's note (written by Nurse #2) indicated that this nurse has observed resident on 6 occasions, lower self to the floor and sit. Resident has laid on floor in the middle of 200 hall during one instance. Other instances, resident observed leaning under wheelchair and recliner in room. When asked why he sat on floor, resident states I gotta fix it. This nurse observed resident messing with wheelchair legs/bars. This nurse observed resident as he stood up from floor each time independently. Resident also continues to wander into other resident's rooms. This nurse continues to redirect resident as needed. On [DATE], there was a doctor's order for [MEDICATION NAME] (an antianxiety drug) 0.5 mgs by mouth PRN every 6 hours for metabolic [MEDICAL CONDITION]. On [DATE] at 1:49 PM, a nurse's note (written by Nurse #2) indicated this nurse walked past sunroom and observed resident outside in courtyard dragging patio furniture inside. Resident redirected and brought inside. Resident was sitting at front desk at this time. New order for [MEDICATION NAME] 0.5mg by mouth every 6 hours PRN for anxiety or behaviors and Trazadone (antidepressant drug) 50 mg by mouth at bedtime for sleep. The Medication Administration Record (MAR) indicated that Resident #1 was administered [MEDICATION NAME] 0.5 mgs by mouth on [DATE] at 6:23 PM by Nurse #2 due to inappropriate wandering in facility and throwing objects. On /[DATE] at 3:30 PM, Nurse #2 was interviewed. She stated that she administered [MEDICATION NAME] to Resident #1 since he went to other resident's room and was messing with the resident's [MEDICAL CONDITION] tubing. Nurse #2 indicated that she redirected the resident after she found him in another resident's room and brought him to the nurse's station and had given him his harmonica to play. The nurse's note did not indicate that non-pharmacological intervention was tried prior to administering a PRN [MEDICATION NAME]. On [DATE] at 6:44 PM, a nurse's note (written by Nurse #2) revealed that Resident #1 was observed standing in room [ROOM NUMBER] opening drawers. This nurse approached resident and redirected him. Resident brought to nurse's station with this nurse and given his harmonica. Resident playing harmonica at the nurse's station at this time. The Medication Administration Record (MAR) indicated that Resident #1 was administered [MEDICATION NAME] 0.5 mgs by mouth on [DATE] at 8:31 AM by Nurse #1 due to inappropriate wandering in facility and throwing objects and was effective. On [DATE] at 9:53 AM, Nurse #1 was interviewed. She stated that she administered the PRN [MEDICATION NAME] to Resident #1 due to wandering to other resident's rooms. She also indicated that the resident could not be redirected due to the confusion. The nurse's note did not indicate that non-pharmacological intervention was tried prior to administering a PRN [MEDICATION NAME]. On [DATE] at 12:37 AM, a nurse's note revealed that Resident refused his medications upon multiple attempts. This nurse observed resident lowering self- down to floor in hallway. Resident attempted to spread out a sheet on floor and lay down. This nurse assisted resident up and into room [ROOM NUMBER]. At approximately 9:30 PM this nurse observed resident attempting to go into other resident's rooms. Re-directed resident as needed. Wander guard is intact to resident's ankle. On [DATE], there was a doctor's order for [MEDICATION NAME] 0.5 mgs intramuscular (IM) and [MEDICATION NAME] (an antipsychotic drug) 5 mgs IM for restlessness and agitation x (times) 1 dose. The Medication Administration Record (MAR) indicated that Resident #1 was administered [MEDICATION NAME] 5 mgs IM on [DATE] at 1:00 PM by Nurse #1. The MAR did not indicate if the medication was effective or not. On [DATE] at 9:53 AM, Nurse #1 was interviewed. She remembered administering the [MEDICATION NAME] IM to Resident #1, but she could not remember the exact incident. She stated that she should have documented it in her notes the indication for the PRN [MEDICATION NAME]. When asked if she had tried non-pharmacological approach prior to administering [MEDICATION NAME], Nurse #1 stated that Resident #1 could not be redirected at all, he was so confused. Nurse #1 also stated that she didn't know why she documented no behavior on the behavior monitoring for [DATE]. On [DATE] at 3:01 PM, a nurse's note (written by Nurse #1) revealed Resident with increased behaviors, trying to ambulate without assistance, and trying to put self on the floor. Attending Physician here to assess resident and new orders at this time to administer [MEDICATION NAME] 0.5 mg IM and [MEDICATION NAME] (antipsychotic drug) 5mg IM x 1 dose. The Medication Administration Record (MAR) indicated that Resident #1 was administered [MEDICATION NAME] 0.5 mgs IM on [DATE] at 3:30 PM by Nurse #1. The MAR did not indicate if the medication was effective or not. On [DATE] at 9:53 AM, Nurse #1 was interviewed. She remembered administering the [MEDICATION NAME] IM to Resident #1, but she could not remember the exact incident. She stated that she should have documented it in her notes the indication for the [MEDICATION NAME]. When asked if she had tried non-pharmacological approach prior to administering the [MEDICATION NAME], Nurse #1 stated that Resident #1 could not be redirected at all, he was so confused. Nurse #1 also stated that she didn't know why she documented no behavior on the behavior monitoring for [DATE]. The Behavior monitoring documented on the MAR on [DATE] between 12:45 PM to 2:45 PM indicated that Resident #1 did not have any behaviors. The nurse's note did not indicate that non-pharmacological intervention was tried prior to administering the [MEDICATION NAME] and [MEDICATION NAME] injection. On [DATE], there was a doctor's order for [MEDICATION NAME] 1 mg by mouth twice a day and [MEDICATION NAME] 5 mgs IM every 8 hours PRN for restlessness and agitation. On [DATE] at 4:23 PM, a nurse's note (written by Nurse #1) revealed that the attending physician was in the building with new orders to start [MEDICATION NAME] 1mg po BID and [MEDICATION NAME] 5mg IM every 8 hours PRN. On [DATE] at 9:53 AM, Nurse #1 was interviewed. Nurse #1 stated that Resident #1's behaviors were mostly crawling on the floor, combative at times during care and wandering to other resident's rooms. He also would try to ambulate without assistance. A psychiatric note dated [DATE] was reviewed. The note revealed that Resident #1 was referred due to agitation, aggression and dementia versus [MEDICAL CONDITION]. The note indicated the staff reported that Resident #1 slept well last night but has not every night and was crawling on the floor and into another resident's room. He was reaching for things and was high risk for falls in his broda chair and family plan to take him home once stabilized. He was combative with agitation and aggression requiring [MEDICATION NAME] and [MEDICATION NAME] IM. Resident was dozing in his broda chair in his room, having eaten 25% of breakfast but wakes to loud voice. He was able to answer some questions appropriately and was oriented to person and time. He reported feeling sad at times, sleeping at night and was not really agitated or nervous. Nursing notes were reviewed for chronic behavior/mood issues with none reported. For agitation and aggression with impulsivity, will add [MEDICATION NAME] (used to treat [MEDICAL CONDITION] activity and [MEDICAL CONDITION] disorder) with titration. Increasing [MEDICATION NAME] for [MEDICAL CONDITION] and will add [MEDICATION NAME] po PRN. It does appear that he was waxing and waning with [MEDICAL CONDITION] and will try to calm his impulsivity but not sedate him but realize that he will be sleepy for a couple of days with changes and plan to discontinue scheduled [MEDICATION NAME] when able if [MEDICATION NAME] if effective. Plan for [MEDICATION NAME] 250 mgs po 3 times a day for impulsivity/aggression with [MEDICAL CONDITION], increase [MEDICATION NAME] 100 mgs at bedtime for [MEDICAL CONDITION] and PRN [MEDICATION NAME] 0.5 mgs every 6 hours as needed for agitation/[MEDICAL CONDITION] x 14 days. On [DATE] at 2:55 PM, a nurse's note revealed that Resident #1 was seen by a psychiatric Nurse Practitioner with new orders for [MEDICATION NAME] 250 mgs 3 times a day, [MEDICATION NAME] 0.5mg every 6 hours PRN and increase [MEDICATION NAME] to 100 mg at bedtime. Resident #1's laboratory works were reviewed. Resident #1 was admitted to the facility on [DATE] with NA (Sodium) level of 137 (normal value ,[DATE]); Chloride level of 103.5 (normal value ,[DATE]); Blood Urea Nitrogen (BUN) level of 15 (normal value ,[DATE]) and creatinine level of 1.08 (normal value 0XXX,[DATE].27). On [DATE], NA level was 144, Chloride level of 104, BUN level of 27 and creatinine level of 1.68. On [DATE] at 3:29 PM, a nurse's note (written by Nurse #1) indicated that the Nurse Practitioner (NP) had reviewed the laboratory results for Resident #1. New order to encourage po fluids 240 cubic centimeter (cc) 3 time a day between meals for increased creatinine level and to repeat BMP on [DATE]. On [DATE] at 3:05 PM, a nurse's note (written by Nurse #2) indicated that at approximately 2:30 PM, a therapist reported while walking down 100 hall, the therapist heard a thud. Resident observed sitting on floor holding head. Vital signs and neuro status were within normal limits. Range of motion at baseline. Resident complained of headache. A small skin tear noted to right thumb. On [DATE], the laboratory results were reviewed. The NA level was 137, Chloride was 99, BUN was 21 and creatinine was 1.57. On [DATE] at 4:10 PM, a nurse's note (written by Nurse #2) revealed that the laboratory results were reviewed and the Nurse Practitioner (NP) was notified of white blood cell count (WBC) of 13.4 and status [REDACTED]. On ,[DATE] at 2:06 PM, a nurse's note revealed that an interdisciplinary team (IDT)/Clinical at- risk meeting was conducted. Resident #1 was discussed in IDT meeting secondary to fall. Will continue to provide interventions to reduce injury from falls and will continue to monitor. On [DATE] at 12:55 PM, the Director of Nursing (DON)was not available, so the MDS Nurse was interviewed. The MDS Nurse reported that the IDT, consist of the department heads, meets once a week on Thursdays to discuss, falls, pressure ulcer, weight loss, and [MEDICAL CONDITION] medications. She stated that on [DATE], the IDT had met and discussed Resident #1's fall that occurred on [DATE]. She indicated that the team did not discuss the use of the [MEDICAL CONDITION] medication for Resident #1 that day. She indicated that falls, decreased po intake and sleepiness were possible adverse drug reaction of [MEDICAL CONDITION] medications but she didn't think that the resident's fall, decreased po intake and sleepiness were due to the [MEDICAL CONDITION] medications. On [DATE] at 5:48 PM, a nurse's note revealed Resident #1 status [REDACTED]. The urine culture result dated [DATE] was reviewed and the result no growth. On [DATE], a Nurse Practitioner note revealed that Resident #1 was out of bed sitting in his wheelchair. There was some difficulty with arousal, but he was able to drink some fluids. The chest x-ray result dated [DATE] did not show acute findings. On [DATE] at 12:41 PM, a nurse's note (written by the DON) revealed that family members were at window of sunroom to visit resident. Resident was very sleepy and was not responding as family beat on the window. Family brought food and staff will attempt to feed as resident is more awake. On [DATE] at 4:09 PM, a nurse's note indicated that this nurse was called to nurse's station. Resident #1 observed on floor in front of nurse's station. A small bump noted to right side of forehead. On [DATE] at 6:34 PM, a nurse's note indicated that Resident#1's family member had called and was requesting that the resident be seen by the facility doctor. The note indicated that the resident was encouraged po fluids throughout the shift with little intake. The laboratory results dated [DATE] revealed NA level of 150, Chloride level of 115.7, BUN of 53 and creatinine level of 2.18. Review of the Medication Administration Records (MAR) revealed that Resident #1 had received the [MEDICATION NAME] 1 mgs po twice a day (scheduled at 8 AM and 8 PM) from [DATE] (8 PM dose) through [DATE] (8 AM dose) except on [DATE] at 8 PM dose due to lethargic. On [DATE] at 3:22 PM, a nurse's note (written by Nurse #3) indicated that Resident #1 was assisted to broda chair this AM before breakfast. He was resistive to staff when staff provided care requiring assist of two. Multiple attempts made to fed breakfast. Took a couple bites and became agitated. The Physician came to assess the redness to the resident's left forearm (LFA). Resident's eyes were closed. This nurse discussed decreased activity after scheduled medications with the physician. The physician would change [MEDICATION NAME] to PRN. Staff assisted resident to bed and this nurse called to room. Resident was noted pale, with pupils non-responsive, blood pressure (B/P) of ,[DATE] and oxygen saturation of 88%. Oxygen was administered and the physician was called to resident's room. [MEDICATION NAME] was ordered and administered. Laboratory results from this AM brought into room showing WBC 27,000. ,[DATE] NS was ordered and started 22 gauge to LFA. Urinalysis and chest X-ray were completed on [DATE] with negative results. B/P ,[DATE] and oxygen saturation 96% on 2 liters per minute (L/MIN). Due to poor response to fluids and inability to locate infection the resident was sent to hospital. On [DATE] at 12:05 PM, Nurse #3 was interviewed. She stated that she was assigned to Resident #1 on [DATE] when the resident was sent to the hospital. She indicated the morning of [DATE], the resident was combative during care and she administered the morning dose of [MEDICATION NAME]. Later that day, she was called to the resident's room and she found the resident very lethargic. She called the Physician who came to assess the resident. The Physician had ordered to administer [MEDICATION NAME] and the resident was sent to the hospital. Resident #1's meal intake records were reviewed. On [DATE], Resident #1 had ,[DATE]% intake for breakfast, lunch and dinner. On [DATE], there was no documentation of meal intake. On [DATE], he had ,[DATE] % intake for breakfast, and he refused lunch and dinner. On [DATE], there was no meal intake documented for breakfast and lunch and he had ,[DATE]% intake for dinner. On [DATE], he had ,[DATE]% meal intake for breakfast and dinner and no documented meal intake for lunch. On [DATE], he refused breakfast, ,[DATE]% intake for lunch and no documented intake for dinner. On [DATE], there was no documented intake for breakfast, had ,[DATE] % intake for lunch and ,[DATE] % intake for dinner. On [DATE], he had ,[DATE]% for breakfast, ,[DATE] % for lunch and dinner. On [DATE], he had refused breakfast and lunch and had ,[DATE] % dinner. On [DATE], he had ,[DATE]% intake for breakfast and refused lunch. The emergency medical services (EMS) records dated [DATE] were reviewed. The records revealed that Resident #1 was initially assessed by the EMS staff on [DATE] at 2:46 PM as being unresponsive, pale and with blood pressure of ,[DATE], pulse of 100, respiration of 14 and oxygen saturation of 98%. The 4-lead electrocardiogram (ECG) showed [MEDICAL CONDITION]. The assessment at 2:53 PM revealed that Resident #1 was unresponsive, pale, and with periods of apnea. At 3:22 PM, a bag valve mask (BVM) (also known as Ambu bag is a handheld device used to provide positive pressure ventilation to patient who are not breathing or not breathing adequately), a flow rate of 25 L/min was provided. The EMS narrative note indicated that at the facility, EMS assessed Resident #1, he was unresponsive, and the nursing home (NH) staff stated that we gave him [MEDICATION NAME] because we think we gave him too much [MEDICATION NAME]. Resident was loaded onto the stretcher and moved to the ambulance. Resident was found to be hypotensive, still completely unresponsiveness. Intravenous (IV) was in place from the NH. Normal Saline (NS) was hooked to that IV and was run with a pressure infuser. Resident had a weak carotid pulse. He was placed on Trendelenburg position ( the body is laid supine or flat on the back on ,[DATE] degree incline with the feet elevated above the head). The resident had short periods of apnea; he was placed on oxygen. Another IV was obtained if needed. In route to the hospital, resident remained unconscious, blood pressure improved. Approximately 5 minutes from the hospital, the resident had a significant period of apnea and he was ventilated with a BVM and was successful. The hospital emergency department records dated [DATE] were reviewed. The records revealed that on EMS arrival, Resident #1 had some periods of apnea and he was bagged on the ambulance ride. He did get some rounds of [MEDICATION NAME] without improvement by EMS and NH staff. Per NH staff, they believed the resident got too much [MEDICATION NAME]. On arrival to the emergency room (ER), the resident was somnolent but breathing on his own. He was moving all extremities. He was non-verbal. He was provided respiratory support with repositioning and non-rebreather mask. Flumazenil (used to treat drowsiness by sedatives following surgery or drug overdose) was considered given likely benzodiazepine overdose however the risk of withdrawal [MEDICAL CONDITION] outweighs the benefits of this medication currently. If the resident begins to have apneic spells again or other complication, we will reevaluate the need of this drug. The active problems included metabolic [MEDICAL CONDITION] due [MEDICAL CONDITIONS], dehydration, infection, worsening kidney function and other factors including [MEDICATION NAME] use. On [DATE] at 3:30 PM, Nurse #2 was interviewed. She was assigned to Resident #1 on [DATE], [DATE], [DATE], and [DATE] on first shift. The Nurse stated that Resident #1 was pleasantly confused and easy to redirect during the day and was agitated during the evening. He would sit on the floor, hit, cursed, wandered to other resident's rooms and mess with their stuff. He was a mechanic and he would sit on the floor trying to fix the wheelchairs and beds. He was ambulatory and was able to feed himself. He plays his harmonica. On [DATE] at 4:01 PM, Nurse Aide (NA) #1 was interviewed. She stated that Resident #1 was confused and was resistive to care. She was assigned to him when he had a fall on [DATE]. He tried to walk and fall. NA #2 indicated that she could not remember him well, she could not remember his status on admission or if there were any decline in his physical or mental condition. On [DATE] at 4:05 PM, NA #2 was interviewed and stated that she could not remember him well. Resident #1 had been at the facility for short period of time. On [DATE] at 4:10 PM, Nurse #3 was interviewed. She was assigned to Resident #1 on [DATE], [DATE] and [DATE] on first shift. Nurse #2 stated that the resident was able to walk on admission but unsteady. He was confused, agitated and wandered in and out of other resident's rooms. He was on broda chair prior to discharge. Nurse #3 stated that she didn't notice a big change in resident's condition until [DATE]. On [DATE] at 9:53 AM, Nurse #1 was interviewed. She was assigned to Resident #1 on [DATE], [DATE], [DATE] and [DATE] on first shift. Nurse #1 stated that Resident #1's behaviors were mostly crawling on the floor, combative at times during care and wandering to other resident's rooms. He also would try to ambulate without assistance and would sit on floor. She stated that she had seen the resident standing by the bed but not walking. Nurse #1 reported that the resident was in the wheelchair or broad chair when out of bed. She indicated that she had monitored resident's behavior and adverse reaction of the [MEDICAL CONDITION] medications and documented on the MAR. On [DATE] at 10:22 AM, the MDS Nurse was interviewed. She stated that the indications for the use of the [MEDICAL CONDITION] medication for Resident #1 were agitation, aggression, and combativeness. She stated that trying to ambulate without assistance and trying to put self on floor were not acceptable indication for the use of the [MEDICAL CONDITION] medications. She also indicated that nurses were expected to try non-pharmacological interventions prior to administering PRN [MEDICAL CONDITION] medications like redirection and keeping him in commons areas and document in the resident's medical record. On [DATE] at 11:10 AM, the Physician was interviewed. He stated that Resident #1 had a lot of behaviors at the hospital and when he was admitted to the facility. He wandered to other resident's rooms, resistive to care, combative, and trying to pull the [MEDICAL CONDITION] tubing of another resident. He remembered starting the [MEDICATION NAME] 0.5 mgs as PRN and then 1 mg twice a day scheduled. He expected the staff to monitor the resident for sedation and to hold the [MEDICATION NAME] when the resident was showing signs of sedation. The Physician also stated that the staff had called him on [DATE] when the resident could not be redirected and was very combative and he ordered [MEDICATION NAME] and [MEDICATION NAME] IM. He added that he would not order [MEDICATION NAME] and [MEDICATION NAME] PRN for behaviors like ambulating without assistance and trying to put self on floor. The Physician indicated that he knew the staff were trying non-pharmacological approaches prior to administering PRN [MEDICAL CONDITION] medications but he expected them to document the approaches tried or attempted in the resident's medical records. The Physician stated that when a resident had experienced falls, decreased po intake and sleepiness, he would consider infection first and he would order laboratory works, urinalysis and culture, chest x-ray and blood works. He also stated that the use of [MEDICAL CONDITION] medications should also be considered as possible cause of falls, decreased po intake and sleepiness but you have to look at the whole picture. The Physician reported that when he saw the resident on [DATE], there was a change in resident's condition from his visit on [DATE]. The resident was groggy, he ordered [MEDICATION NAME] to try to wake him up, but that didn't work so he sent the resident out to the hospital. On [DATE] at 12:05 PM, a follow up interview was conducted with Nurse #3. She stated that she was assigned to Resident #1 on [DATE]. The NA was having difficulty in getting him to eat and drink. He would eat a bite or two and his alertness comes and goes. On [DATE] at 11:55 PM, interview with the Activity Director was conducted. She stated that Resident #1 was pleasantly confused on admission. He loved to play his harmonica. Due to the pandemic, she provided 1:1 activity to residents. She read devotions, paint nails, and crafts. She provided blocks to Resident #1 to fidget on. The Activity Director indicated that Resident #1 was a mechanic and his wife said to give him something to fidget on. She revealed that she had not provided any activities to him since he was asleep every time, she visited him in his room. She tried to visit different times of the day, but he was asleep.

Based on observation, record review, resident and staff interviews, the facility failed to properly secure 1 of 3 residents (Resident #1) with a lap belt, in the transportation van, resulting in a fractured tibia and fibula. The immediate jeopardy began for Resident #1 on 5/28/13 and was identified on 6/6/2013 at 3:00 pm. Immediate Jeopardy was removed on 6/8/13 at 2:08 pm, after the Credible Allegation was validated through staff interviews, record review and observations. The facility will remain out of compliance at a level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy), to complete implementation of system changes and monitoring the corrective actions stated in the credible allegation. The findings included: The facility's 11/6/12 Transportation Policy read, " All passengers must be facing forward and secured by using 4 point tie down for wheelchairs and seat belts must in use for all passengers and drivers. " The facility's van used a " Sure-Lok " securement system for transport of wheelchairs. In the undated " Sure-Lok, Training Guide, it relayed the following information: ? That the driver " Conducts a visual inspection of the vehicle interior as well as the wheelchair securement components. Make sure each securement station has four securement straps, a lap belt and shoulder strap. " ? In the section titled, " Securing the occupant " , it read to " Start by attaching the lap belt. Place the ends of the lap belt around the passenger. Thread them down through the opening between the side panel or the seat back and the seat cushion. Remember to position the lap belt around the occupant's pelvic zone near the hip, with the buckle of the lap belt placed opposite to the side where the shoulder belt is attached to the wall. The last belt to attach before you're on your way is the shoulder belt. Bring the triangular fitting of the shoulder belt over the passenger's shoulder, past the collar bone, and diagonally across the upper chest. Attach it to the stud of the lap belt latch plate. Pull on the loose end through the adjuster to achieve firm yet comfortable tension. ? Sure-Lok recommends that every securement station be equipped with a complete Sure-Lok Occupant Restraint System consisting of lap and shoulder belts for use by the occupant. " Resident #1 was originally admitted to the facility on 10/18/11 and then re-admitted on [DATE] with the following cumulative Diagnoses: [REDACTED]. On his admission Minimum Data Set (MDS), dated [DATE], he was assessed as being cognitively intact. The nurse's notes revealed that on the morning of 5/28/13, Resident #1 was out of the building for a medical procedure. On 6/7/13, the Maintenance Director provided a copy of the van's driver log, which indicated that on 5/28/13, the vehicle was operated by Driver #1. Driver #1 had completed a " Pre-Trip Checklist " , that day, verifying that each securement station was properly equipped with four securement straps, a lap belt, and a shoulder belt. A " Resident Incident/Accident " form, dated 5/28/13 at 2:10 pm, stated that Resident #1 reported that he slid out of his wheelchair in the van. The fall was noted to be unwitnessed and Resident #1 had complained of pain to his left leg. He was transported to the hospital. On 6/4/13 at 4:28 pm, Resident #1 was interviewed. He shared that on 5/28/13, he was at the local hospital outpatient clinic waiting for Driver #1 to return to pick him up from a medical procedure. He stated that she arrived at 2:00 pm and assisted him in his wheelchair, with getting on the facility ' s van. He was raised into the van using an electric lift, with his wheelchair brakes locked. He was the only occupant on the van, and was positioned at the rear of the van, but placed in the middle. He stated that Driver #1 used the straps from the floor of the van to secure the wheels. Then he recalled her using a long belt, attached to the van's sidewall, pulled across his waist and fastened down to the floor. He shared that he only had one belt placed on him and that he was not provided a lap belt, to fit across his pelvis. Once the belt was in place, Resident #1 denied unfastening it during the trip. He mentioned that there had been instances in the past when he was on the van, that the drivers couldn't get the straps to pull out or retract. Next he recalled that the driver had exited the outpatient parking lot, onto a main road, when she slammed on her brakes. He stated that the back wheels of his chair, lifted off the floor, " as if popping a wheelie " and the cushion that he was sitting on, allowed him to slide out of his wheelchair, although the shoulder belt remained fastened. He commented that the belt, had a large give away and did not tighten or lock, when he slid forward and fell on the floor. As he fell , his left leg went up under his body, bending backwards, until he landed on top of his leg. He stated, " When I fell , it sounded like a loud clap, I heard the snap. Five years ago, I broke my right leg and the sound of the snap was familiar. " He reported to the driver that he suspected that his leg was broken and asked her to take him back to the hospital. He commented that he could feel pain from the point of breakage, all the way up to his hip. Resident #1 stated that he was initially taken to the hospital, per his request, but returned to the facility on [DATE] at 3:00 pm and had a mobile x-ray performed there. Results from the x-ray confirmed a fractured tibia and fibula. The Nurse's Notes from 5/28/13 indicate that he was transported back to the hospital later that evening, where he was admitted for treatment. The Hospital Discharge Summary 5/30/13 stated that Resident #1 was not a candidate for surgery, due to many other complicating health conditions; therefore his fractured left leg was splinted and treated with prescription pain medications. On 6/5/13 at 1:19 pm, Driver #1 was interviewed by telephone. She shared that she had driven for the facility for two years and received training from the Maintenance Director on how to lock the seatbelts on the van. She shared that when a passenger was placed on the van, she always makes sure that they are locked down, using 4 locks on the floor, locking the wheelchair brakes and using safety belt to lock around the wheelchair. She also shakes the chair, gently, to make sure that it is stable and secure. Driver #1 stated that she picked up Resident #1 in the facility's van on 5/28/13 at 2:00 pm. She brought him on the van, using the electric lift and secured his wheelchair on the floor track and used a shoulder belt to secure him in his wheelchair. He was holding a sandwich and had placed a cup of ice next to him, when she returned to her seat to pull off. The Driver stated that while operating the vehicle, she maintained a quiet environment, free of distractions. She traveled going about 25 mph (miles per hour) on a road with light traffic, approximately 100 yards from the lot, onto a main road, when she recalled hearing Resident #1 yell. The driver shared that prior to him yelling, she did not hit her brakes or come to any quick stops. She recalled that she looked in her rearview mirror and noticed that Resident #1 had fallen out of his chair. She pulled off the road, climbed in the back of the van, to investigate what happened. She stated that his seat belt was on when they left the parking lot, but after he fell , she didn ' t see it on him. She reported that she found him with his buttocks resting on his foot pedals and his legs extended. She stated that she did not find the wheelchair turned over, that it's position was still locked. He told her, that he thought that his leg was broke. She asked him if he wanted to go to the emergency room , and he responded yes; so she transported him there. On 6/7/13 at 5:21 pm, during a follow up interview with Driver #1 at the facility, she stated the van was not equipped with a lap belt, that only shoulder belts were used to secure residents in their wheelchairs. The " Sure-Lok " system, allows the driver to secure the shoulder belt to a fastener on the right front passenger side, or on the left rear passenger side. On 5/28/13, she secured Resident #1's shoulder belt on the floor to the front of his wheelchair. However, after Resident #1 left the emergency room , following the accident, she stated that she wheeled him back to the van, and secured his shoulder belt to the rear of the wheelchair. The Maintenance Director was interviewed on 6/5/13 at 10:35 am. He stated that the facility only used one van, which they had operated since 2006. He commented that the van had been serviced recently, but did not have any problems with it's Sure-Lok securement system. A copy of the maintenance invoices were reviewed and did not illustrate a problem with the van safely operating. He shared that when the corporate office purchased the van, they gave him training materials (videos and handouts) which he used to train the drivers how to operate the lift and secure residents. The van, he stated had never been equipped with seat belts that fit across the lap, commenting that this was viewed as a physical restraint. The van only had shoulder belts which were looped through the armrest of the wheelchair, then secured to the floor. He produced paperwork to document that Driver #1 had training from him on 7/30/10, 3/9/12 and more recently on 5/29/13. He shared that during the training, the driver was observed during a return demonstration of the lift operation and securement procedures. On 6/5/13 at 4:20 pm, the Maintenance Director and an employee, demonstrated how to secure a resident in a wheelchair, during transport. The van did not contain a lap seat belt; only a shoulder belt was used and it did allow the employee to lean forward, to extend her upper body, over her knees. In the event of an accident, the Maintenance Director explained that the belt should lock. The chair fit securely on the floor tracks and the brakes were locked during securement. When the Maintenance Director was asked if he could lift the secured chair off the ground, the back wheels rose up to an inch. The manufacturers video, that was viewed earlier that day by the surveyor and maintenance director, stated that a secured chair, shouldn't move more than 2 inches side to side, front to back. The Maintenance Director then demonstrated using two shoulder belts to secure a resident, locking one belt in the front and the other in the back, creating a criss-cross pattern of belts across the employee's chest. The employee was asked to lean forward in the wheelchair and she could only move about four inches, never extending past her knees. The Maintenance Director stated that two belts are rarely used, but he has recommended to the drivers to use them on residents who may be combative, in a bariatric chair or he stated if the resident was non-compliant, with seat belt use. On 6/6/13, the transportation appointment book was reviewed. Residents, who were identified by the facility on 6/4/13, to be alert and oriented, and who had transportation services within the last quarter, were selected for interview. On 6/6/13 at 10:20 am, Resident #2 was interviewed. He was recently transported by Driver #2 and stated that he was secured with only one belt, placed across his shoulder,then secured to the floor in front of the wheelchair. On 6/6/13 at 10:30 am, Resident #3 was interviewed. She stated that in March, 2013 she was transported to the dentist and only a shoulder strap was used to secure her in her wheelchair. Driver #2 was interviewed on 6/7/13 at 5:17pm. She stated that she worked as one of the primary drivers for the facility and she been employed there for about five months. She stated that she had never had a lap belt available to secure residents in wheelchairs. She commented that only shoulder belts were used and that she had transported residents in reclining chairs in the van as well. She stated that when she secured the shoulder belt, she always fastened it to the rear of the wheelchair. If a resident was agitated, she had used two shoulder belts to secure them in the wheelchair. She was unaware of any resident unfastening seatbelts or falling during transport while she operated the van. During an interview with the Administrator on 6/6/13 at 3:20 pm, he commented that the facility had never encountered any problems with residents getting injured, using the current system in place. He shared that only one belt was used on the van, a shoulder belt, and that using two belts, especially on an alert and oriented resident, would be a restraint. He was unaware that the Maintenance Director recommended the use of two belts, if the resident was combative or used a larger chair. The Administrator was notified of the Immediate Jeopardy on 6/6/13 at 3:00 pm. The facility provided a Credible Allegation of Compliance on 6/8/13 at 2:08 pm. The allegation of compliance indicated: Credible Allegation of Compliance: ? All in house transportation was suspended from 5/28/13 to 5/29/13, then again the evening of 6/6/13. The maintenance director did a complete inspection which included a check of all tie downs, hydraulic lift, brakes, tires, fire extinguisher, shoulder strap seatbelts and the tracks on the floor that the tie downs fasten to on 5/28/13. ? The driver (#1) was drug tested on [DATE], per our investigative procedure. The driver performed return demonstration correctly for the maintenance director using a fell ow employee as a resident. A demonstration trip of approximately 1 ? miles was completed on 5/28/13 without incident and in compliance with proper securement procedures. ? The transportation policy was reviewed and revised to include all carry-on items are to be secured at the front of the van out of reach of the residents upon being placed on the van on 5/29/13. The residents were educated on these changes on 5/29/13 by the Administrator and the van drivers were educated on 5/29/13 by the maintenance director. ? All drivers will be required to perform a return demonstration as evidenced by raising the resident in the lift and properly securing the tie down straps and the lap and shoulder belts. This will be done every 6 months to ensure continued compliance. ? The manufacturers video, which demonstrated securing residents in wheelchairs, while traveling on the facility's van, was viewed by all drivers on 6/8/13. ? The van was modified to include pelvic/lap seatbeats as of 6/7/13. ? On 6/8/13, the facility assured that 100% of the current drivers had been in-serviced regarding revised transportation policy which included acceptable wheelchairs for transport, example standard, bariatric and high-back wheelchairs, since previously the facilty would transport a resident in reclining wheelchairs, with only a shoulder belt in place. ? All new van drivers will be educated with written and audiovisual material and perform a return demonstration prior to driving the van. Others with Potential to be effected: ? The Administrator interviewed 100% of all residents (22 residents) who had been transported with the facility van over the last 30 days, on 6/6/13 and 6/7/13. The interviews revealed that none of the residents experienced any issues with the van transportation. Measures and Systemic Changes ? The facility investigation began on 5/28/13 and ended on 5/31/13, included obtaining statements from the resident and driver involved in the incident. ? A drug test was performed on driver #1 on 5/28/13. The driver was suspended from driving the van on 5/28/13 until 5/31/13 pending drug test results and appropriately performing a return demonstration. ? A transportation audit tool was developed to include the following: ? Were proper techniques used to place the resident into the van? ? Were proper techniques used to secure resident, example attach seat belts, tie downs, etc.? ? Were proper techniques used to operate the hydraulic lift on the van? ? Were proper techniques used to unload the resident from the van? ? Is there documentation that the employee has been educated regarding proper use of the equipment/van? ? Transportation staff audited daily x 5 days then weekly for 4 weeks, then monthly for two months. These audits will be completed by the Maintenance Director, Administrator and or Director of Nursing. This observation will include each van driver. Continuing audit will be based on the results of previous audits. The transportation policy was revised to include checking all carry-on items with the van driver when entering the van. These items will be secured at the front of the van by the driver and out of reach of the residents during transport. ? On 5/28/13, then again from 6/6/13, all in house transportation services were suspended until re-education and return demonstration of proper securing techniques were performed by employees that drive the van. Monitoring ? The Administrator developed a monitoring tool to audit transportation staff for compliance with proper securing techniques. This was initiated on 5/28/13 and will continue daily over the next 4 days, then weekly for the next 4 weeks, then monthly for 2 months. The observations will include all van drivers. Continuing audits will be determined by results of the prior audits. ? Results of the Quality of Care compliance audits will be reviewed, analyzed and discussed by the Quality Assurance Committee monthly for input and recommendations. If any concerns or problems are identified system changes will take place. The Quality Assurance committee will monitor monthly for no less than 3 months. Ongoing audits will be determined by the results of the prior audits. The credible allegation was verified 6/8/13 at 2:08 pm, as evidenced by review of the 6/8/13 revised transportation policy, verifying in-service attendance sheets on the new policy and interviewing residents and staff, observations of van drivers, as well as the Maintenance Director, safely securing residents in wheelchairs on the van and verifying the installation of new shoulder and pelvic/lap seatbelts on the van. Review of in-service records for the new Transportation and Quality Care Policies, indicated participation by 80% of nursing, housekeeping, dietary, transportation and therapy staff. Remaining staff will be in-serviced before resuming duties.