Every finding on record at Perimeter Rehabilitation Suites by Harborview

Based on record review, resident and staff interviews, and facility policy review, the facility failed to develop a comprehensive Care Plan for four of four residents (Resident (R) 13, R29, R114, and R242) reviewed for activities and one of four residents (R117) reviewed for Pre-admission Screening and Resident Review (PASARR). The Care Plan failed to address activity needs and interventions for R13, R29, R114, and R242 and failed to address a diagnosis of post-traumatic stress disorder (PTSD) and related interventions. These failures placed the residents at risk for unmet physical and psychosocial care needs and the inability to meet their maximum practicable level of functioning.Findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 03/01/2025, revealed, The care planning process will include an assessment of the resident's strengths and needs . and incorporate culturally competent and trauma-informed care as indicated . All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record . The comprehensive care plan will describe . The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . [and] Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations. Review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2025 indicated .The RAI consists of three basic components: The Minimum Data Set (MDS) Version 3.0, the Care Area Assessment (CAA) process and the RAI Utilization Guidelines.This process is designed to assist the assessor to systematically interpret the information recorded on the MDS. Once a care area has been identified or triggered, nursing home providers use current, evidence-based clinical resources to conduct an assessment of the potential problem and determine whether or not to care plan for it. The CAA process helps the clinician to focus on key issues identified during the assessment process so that decisions as to whether and how to intervene can be explored with the resident.The RAI process, which includes the Federally mandated MDS, is the basis for an accurate assessment of nursing home residents. The MDS information and the CAA process provide the foundation upon which the care plan is formulated. There are 20 problem-oriented CAAs, each of which includes MDS-based trigger conditions that signal the need for additional assessment and review of the triggered care area. 1. Review of R13's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE] with diagnoses including encephalopathy, respiratory failure, dementia, malnutrition, and dysphagia. Review of R13's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/02/2026 and located under the MDS tab of the EMR, revealed a score of ten out of 15 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. He was assessed to exhibit moderate mood symptoms of depression. The MDS documented it was very important for R13 to participate in religious and group activities. Review of the Care Area Assessment indicated additional activities assessment was indicated due to R13's Little interest or pleasure in doing things - symptom presence. The CAA directed staff to proceed to care planning for activities needs and interventions. Review of R13's EMR under the Care Plan tab revealed there was no Care Plan addressing his activity needs, goals, or interventions. During a concurrent interview on 03/18/2026 at 7:57 AM, MDS Coordinator 1 (MDSC1) and MDSC2 confirmed that once a care area has been triggered in the CAA and directed the staff to develop a Care Plan, the Care Plan was to be developed. The [NAME] President of Clinical Reimbursement (VPCR) stated the activities staff was responsible for the activity Care Plan. 2. Review of R29's admission Record, located under the Profile tab of the EMR, revealed he was admitted to the facility on [DATE] with diagnoses including stroke, epilepsy, hemiplegia and hemiparesis, muscle weakness, respiratory failure with tracheostomy, and gastrostomy tube. Review of R29's admission MDS with an ARD of 01/29/2026 and located under the MDS tab of the EMR, revealed he was unable to complete the BIMS and staff assessed him with short-and long-term memory problems and severely impaired cognition. R29's activities interests were unable to be assessed due to his inability to respond. Review of the CAA indicated additional activities assessment was indicated due to R29's Staff assessment of daily and activity preferences did not indicate that resident prefers participating in favorite activities. The CAA directed staff to proceed to care planning for activities needs and interventions. Review of R29's EMR under the Care Plan tab revealed there was no Care Plan addressing his activity needs, goals, or interventions. During a concurrent interview on 03/18/2026 at 7:57 AM, MDSC1 and MDSC2 confirmed that once a care area has been triggered in the CAA and directed the staff to develop a Care Plan, the Care Plan was to be developed. The VPCR stated the activities staff were responsible for the activity Care Plan. During an interview on 03/18/2026 at 2:21 PM, the Activities Assistant (AA) confirmed R13 and R29 did not have an activities Care Plan. The AA stated she had been serving as the Activity Director since the previous director left the position; however, she had not yet been trained in care planning and was not involved in developing the Care Plan. During an interview on 03/19/2026 at 4:30 PM, the Administrator stated the MDSC would be completing the activity Care Plan, as the MDSC was expected to ultimately ensure the Care Plan was complete. 3. Review of Resident (R)242's admission Record found under the Profile Tab of the EMR indicated an admission date of 10/07/2025 with diagnoses of type 2 diabetes, multiple sclerosis, dementia, post-traumatic stress syndrome, and major depressive disorder. Review of R242's MDS CAA Triggers Summary found under the MDS Tab of the EMR with an ARD of 10/10/2025 and signed on 10/20/2025 indicated R242's activity triggering condition was little interest or pleasure in doing things and would be addressed the care plan. Review of R242's CAA Summary, found under the MDS Tab of the EMR, with an ARD of 10/10/2025 indicated that Activities triggered with a yes for care plan decision. Review of R242's Care Plan, found under the Care Plan Tab of the EMR, with an admission date of 10/07/2025 indicated that there was no care plan for activities. During an interview on 03/19/2026 at 10:53 AM, MDSC1 stated that they realized on 03/18/2026 that a care plan had not been completed for R242's activity preferences. During an interview on 03/19/2026 at 2:30 PM, the Director of Nursing (DON) stated that activity preferences needed to be in a care plan to care for the residents. 4. Review of R114's EMR titled admission Record located under the Profile tab of the EMR, indicated the facility admitted the resident on 01/30/2026. Review of R114's admission MDS with an ARD of 02/02/2026 located under the MDS tab of the EMR, indicated the resident had a BIMS score of 12 out of 15, which revealed the resident was moderately cognitively impaired. The assessment indicated that activities were somewhat important. The assessment for mood indicated the resident scored 11 which means the resident had moderate depression. Under the CAA, the resident triggered under activities and directed the staff to develop a care plan. Review of R114's Care Plan located under the Care Plan tab of the EMR, failed to contain evidence that the facility developed a care plan for the resident for activities. During an interview conducted on 03/18/2026 at 7:57 AM, MDSC1 and MDSC2 confirmed that once a care area has been triggered in the CAA and directs the clinician to develop a care plan, the care plan was to be developed. The VPCR was present during this interview. Both MDSC1 and MDSC2 confirmed R114 did not have a care plan developed for activities. Both MDSC1 and MDSC2 stated the resident triggered under activities due to his response to the mood assessment 5. Review of R117's EMR titled admission Record located under the Profile tab of the EMR indicated the facility admitted the resident on 10/08/2024 with a diagnosis of PTSD. Review of R117's EMR titled quarterly MDS with an ARD of 01/11/2026, located under the MDS tab of the EMR, indicated the resident had a BIMS score of 15 out of 15, which revealed the resident was cognitively intact. The resident was identified with a diagnosis of PTSD. Review of R117's EMR titled Care Plan located under the Care Plan tab of the EMR, failed to contain evidence that the resident's diagnosis of PTSD was care planned. During an interview on 03/18/2026 at 7:29 AM, R117 confirmed he had a diagnosis of PTSD and was military related. R117 stated he was currently stable since he was on medication and currently had no triggers. During an interview on 03/18/2026 at 8:21 AM, an interview was conducted with MDSC1 and MDSC2. Both confirmed that there was no care plan in place for R117's diagnosis of PTSD. Both stated they were to speak with the Social Services Director (SSD) since she was responsible for the care plan. During an interview on 03/18/2026 at 2:06 PM, the SSD stated it was important to care plan a resident's diagnosis of PTSD since there were different stressors and different responses. SSD stated it was the MDS team that would develop the care plan for a diagnosis of PTSD. An interview was conducted on 03/19/2026 at 4:06 PM and the following were in attendance: the Administrator, Director of Nursing (DON), Chief Compliance Officer (CCO), and National Director of Risk Management (NDRM). The DON stated a diagnosis of PTSD was to be care planned since the facility wanted to ensure the safety of residents and protect them from reactions to triggers. The DON stated the MDSC were to do the development of the care plans until social services and activities were trained to do so.

Based on observations, staff interviews, record review, and policy review, the facility failed to ensure five of six residents (Resident (R) 11, R13, R29, R190, and R204) reviewed for bed rails out of 196 residents who used bed rails were assessed for safety with and need for bed rails before their use. This deficient practice had the potential to place the residents at risk of injury or entrapment related to bed rail use.Findings include: Review of the facility's policy titled, Bed Rail Safety dated 03/01/25, revealed, As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs: a. Medical diagnosis, conditions, symptoms, and/or behavioral symptoms; b. Size and weight; c. Sleep habits; d. Medication(s); e. Acute medical or surgical interventions; f. Underlying medical conditions; g. Existence of delirium; h. Ability to toilet self safely; i. Cognition; j. Communication; k. Mobility (in and out of bed); l. Risk of falling. The resident assessment must also assess the resident's risk from using bed rails . The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself. 1. Review of R11's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, shortness of breath (SOB), and pneumonia. Review of R11's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/06/26 and located under the MDS tab of the EMR, revealed a score of six out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. He required substantial/maximal assistance with bed mobility and sitting up and was dependent on staff for transfers. Review of R11's Admission/readmission Data Collection, dated 02/03/26, and located under the Assessments tab of the EMR, revealed R11 did not desire to use bed rails. Review of R11's Admission/readmission Nursing Evaluations, dated 02/03/26, and located under the Assessments tab of the EMR, revealed R11 was not using bed rails and did not desire to use them. The assessment documented the use of bed rails would not assist R11 with turning in bed or add to his ability to transfer. The entrapment review was not completed, and the assessment documented bed rails were not indicated at this time. Review of R11's Care Plan dated 02/04/26 and located under the Care Plan tab of the EMR revealed, [R11] has an ADL [activities of daily living] self-care performance deficit r/t [related to] impaired mobility, SOB/chronic respiratory failure. The approaches included, SIDE RAILS: (SPECIFY) Mobility Bars up for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition as necessary to avoid injury. During an observation on 03/16/26 at 3:46 PM in R11's room, R11 was observed in bed with bed rails approximately half the length of the bed in the up position on both sides of the bed. During an observation on 03/19/26 at 10:36 AM in R11's room, the bed rails were again observed on R11's bed in the up position. In a concurrent interview, Unit Manager (UM) 2 confirmed that R11 had bilateral bed rails in the up position but was unsure if they were 1/2 or 1/4 rails as the bed and the rails were provided by hospice. UM2 stated when R11 was first admitted , he was on a facility bed without any bed rails; however, when he was admitted to hospice, the hospice brought in the bed with rails. UM2 stated she was unsure whether an assessment of the appropriateness of and need for the rails needed to be completed when hospice bed rails were implemented. 2. Review of R13's admission Record, located under the Profile tab of the EMR, revealed he was admitted to the facility on [DATE] with diagnoses including encephalopathy, respiratory failure, dementia, malnutrition, and dysphagia. Review of R13's admission MDS with an ARD of 01/02/26 and located under the MDS tab of the EMR, revealed a score of ten out of 15 on the BIMS, indicating moderately impaired cognition. He required substantial/maximal assistance with bed mobility and was dependent on staff for transfers. Review of R13's 12/30/25 Admission/readmission Data Collection, dated 12/30/25 and located under the Assessments tab of the EMR revealed R13 did not desire to use bed rails. Review of R13's Admission/readmission Nursing Evaluations dated 12/30/25 and located under the Assessments tab of the EMR, revealed R13 was not using bed rails and did not desire to use them. The assessment documented the use of bed rails would not assist R13 with turning in bed or add to his ability to transfer. The entrapment review was not completed, and the assessment documented bed rails were not indicated at this time. Review of R13's Care Plan dated 12/31/25 and located under the Care Plan tab of the EMR revealed, [R13] has an ADL self-care performance deficit r/t pain, weakness, impaired mobility, debility, dementia. The approaches included, SIDE RAILS: Mobility bars up for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition as necessary to avoid injury. During an observation on 03/17/26 at 8:51 AM in R13's room, R13 was observed in bed with bed rails approximately half the length of the bed in the up position on both sides of the bed. During an observation on 03/18/26 at 11:10 AM in R13's room, the bed rails were again observed on R13's bed in the up position. In a concurrent interview, UM1 confirmed that R13 had bilateral bed rails in the up position but was unsure if they were 1/2 or 1/4 rails as the bed and the rails were provided by hospice. UM1 stated when R13 was first admitted , he was on a facility bed without any bed rails; however, when he was admitted to hospice, the hospice brought in the bed with rails. UM1 confirmed there was no assessment of the appropriateness of and need for the rails when hospice bed rails were implemented. UM1 confirmed there was no assessment in hospice documentation 3. Review of R29's admission Record, located under the Profile tab of the EMR, revealed he was admitted to the facility on [DATE] with diagnoses including stroke, hemiplegia and hemiparesis, epilepsy, muscle weakness, and respiratory failure. Review of R29's admission MDS with an ARD of 01/29/26 and located under the MDS tab of the EMR revealed he was unable to make himself understood or understand others and had severely impaired cognition. The assessment documented R29 was dependent on staff for all mobility and activities of daily living. Review of R29's Admission/readmission Nursing Evaluations dated 03/09/26 and located under the Assessments tab of the EMR, revealed R29 was not using bed rails and did not desire to use them. The assessment documented the use of bed rails would not assist R29 with turning in bed or add to his ability to transfer. The entrapment review was not completed, and the assessment documented bed rails were not indicated at this time. Review of R29's Care Plan dated 01/20/26 and located under the Care Plan tab of the EMR, revealed, [R29] has an ADL self-care performance deficit r/t weakness, impaired mobility. The approaches included, SIDE RAILS: Mobility bars up for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition as necessary to avoid injury. During an observation on 03/16/26 at 3:33 PM in R29's room, R29 was observed in bed with bed rails approximately a quarter of the length of the bed in the up position on both sides of the bed. During an observation on 03/19/26 at 10:39 AM in R29's room, the bed rails were again observed on R29's bed in the up position. In a concurrent interview, UM2 confirmed that R29 had bilateral bed rails and stated she did not know he had them on the bed. UM2 stated R29 was unable to use the bed rails as he had hardly any movement except for his hands. UM2 stated R29 did not need bed rails and added they may have just been left on his bed from the last resident who used it. During an interview on 03/19/26 at 4:30 PM, the Director of Nursing (DON) stated the assessment should be completed whenever bed rails were implemented and the bed rails should only be used when indicated as necessary and safe in the assessment. The DON stated the facility was responsible for conducting an assessment when hospice brought in a bed with rails. The National Director of Risk Management (NDRM) - concurrent interview with DON - confirmed the staff should have completed the side rail assessment when the resident received a bed with rails. 4.Review of R190's admission Record, located under the Profile tab of the EMR, revealed R190 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis, other lack of coordination, seizures, muscle weakness (generalized), cognitive communication deficit, and major depressive disorder. Review of R190's Care Plan, dated 07/20/23 and located under the Care Plan tab of the EMR, revealed a focus Activities of Daily Living (ADL) self-care performance deficit. Interventions included mobility bars up for safety during care provision, to assist with bed mobility and staff were to observe for injury or entrapment related to side rail use and reposition as necessary to avoid injury. Review of R190's quarterly Minimum Data Set (MDS), located under the MDS tab of the EMR and with an Assessment Reference Date (ARD) of 12/28/25, revealed R190 had multiple sclerosis, depression, seizures, upper and lower extremity impairments on one side, required moderate help with rolling from side to side and from sitting to standing. It was recorded R190 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R190's Quarterly Nursing Evaluation, dated 12/25/25, which included a Side Rail Evaluation, and located in the Assessment tab of the EMR, indicated R190 was not using side rails for positioning, support, or bed mobility and did not express a desire to use side rails. The evaluation did not assess R190 for the use of side rails or the risk of entrapment. The evaluation documented side rails were not indicated. During an observation on 03/18/26 at 10:26 AM, Certified Medication Technician (CMT) 2 confirmed R190's right hand mid-bed side rails on his bed were loose and posed a risk for injury. During an observation and interview on 03/19/26 at 12:31 PM, the Assistant Director of Nursing (ADON) 3 reviewed R190's bed rail evaluation dated 12/22/25 and stated, It says he [R190] doesn't need side rails. He should have an assessment completed. 5. Review of R204's admission Record, located under the Profile tab of the EMR, revealed R204 was admitted to the facility on [DATE] with diagnoses of paraplegia. Review of R204's Care Plan, dated 09/03/24 and located under the Care Plan tab of the EMR, revealed a focus ADL self-care performance deficit. Interventions included mobility bars up for safety during care provision, to assist with bed mobility and staff were to observe for injury or entrapment related to side rail use and reposition as necessary to avoid injury. Review of R204's quarterly MDS, located under the MDS tab of the EMR and with an ARD of 12/19/25, revealed R204 had paraplegia, had no upper and lower extremity impairments, required minimal help with rolling from side to side and from lying to sitting. It was recorded R204 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R204's Quarterly Nursing Evaluation, dated 12/01/25, which included a Side Rail Evaluation, and located in the Assessment tab of the EMR, indicated R204 was not using side rails for positioning, support, or bed mobility and did not express a desire to use side rails. The evaluation did not assess R204 for the use of side rails or the risk of entrapment. The evaluation documented side rails were not indicated. During an observation on 03/18/26 at 10:26 AM, Certified Medication Technician (CMT) 2 confirmed R204 had side rails in use on his bed. During an interview on 03/18/26 at 11:06 AM, Unit Manager (UM) 1 stated, the procedure for bed rails included Complete an assessment, assess restraint, and sign consent. The assessment is completed in the computer. The consent is on paper with signature. Assess for entrapment, look to see if arms or leg stick between rails that could cause injury. Maintenance would install the rails or bring a bed with rails. The assessment would include the size of bed rails. The assessment is in the initial nursing assessment, and is also an individual assessment. It is completed on admission and I believe quarterly. There should bed rail an order. I believe it would be on the care plan. The MDS nurse makes all changed on care plans. During an observation and interview on 03/19/26 at 12:31 PM, the Assistant Director of Nursing (ADON) 3 reviewed R204's bed rail evaluation, dated 12/01/25, and stated It says he [R204] doesn't need side rails. I see side rails more of a risk for entrapment than mobility bars. I go with what the resident is using it for. I don't think they [siderails] have ever been up [for R204]. ADON3 observed the side rails on R204's bed and stated, That is a mobility bar not a side rail. Mobility bars don't have a risk of entrapment. When asked about the difference between a mobility bar and a side rail, ADON3 stated, Physically the bars are the same. I agree there could still be a risk of entrapment with mobility bars as with side rails.

Based on resident, resident guardian and staff interviews, record review, facility policy review, and review of the facility's investigation, the facility failed to ensure three residents (Resident (R) 35, R236, and R5) out of five residents reviewed for abuse were free from abuse out of 51 total residents sampled. R236 crawled into bed with R35 and began to kiss her. In addition, R5 was verbally abused and threatened by a Resident Care Aide (RCA)1. This had the potential for R5 to suffer emotional and psychological harm (Cross Reference F607, F609, F610).Findings include: Review of a facility policy titled Abuse, Neglect and Exploitation dated 07/15/2025 indicated . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Sexual Abuse is non-consensual sexual contact of any type with a resident. 1. Review of R35's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the facility admitted the resident on 09/05/2024 with a diagnosis of dementia without behavioral disturbances. Review of R35's EMR titled quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/08/2025 located under the MDS tab indicated that the resident had a Brief Interview for Mental Status (BIMS) of 15 out of 15 revealed that the resident was cognitively intact. Review of R35's EMR titled Care Plan located under the Care Plan tab dated 09/06/2024 indicated that the resident had impaired cognitive function/dementia related to a stroke. The care plan failed to address that the resident fluctuated with mental status even though her cognition was identified through the BIMS score of 15. Review of R236's EMR titled admission Record located under the Profile tab indicated the facility admitted the resident on 10/26/2023 with a diagnosis of delirium with known psychological disorder. Review of R236's EMR titled quarterly MDS with an ARD of 12/26/2025 located under the MDS tab indicated the resident had a BIMS score of 10 out of 15, which revealed the resident was moderately cognitively impaired. Review of R236's EMR titled Care Plan located under the Care Plan tab dated 11/17/2023 indicated the resident had impaired functional/dementia or impaired thought process related to dementia, with impaired decision making. Review of a document provided by the facility titled Facility Incident Report dated 01/13/2026 indicated that on 01/11/2026 R236 was found in R35's bed. R236 was observed to kiss R35 on the lips. Review of a document provided by the facility titled Abuse-Resident to Resident dated 01/20/2026 indicated that R35 had a BIMS score of 15 which revealed the resident's cognition was intact with occasional confusion. The report indicated R236 had a BIMS score of 10 which revealed that the resident had moderate cognitive impairment. The investigation indicated that staff attempted to interview R35, but she refused. Review of the facility's investigation revealed a written statement from Certified Nurse Aide (CNA) 9, dated 01/11/26, who wrote that she witnessed R236 in the bed of R35, and she asked R236 to get out of R35's bed. Before getting out of bed, R236 kissed R35 on the lips. CNA9 stated that she reported the incident to a nurse. Part of the investigation included police involvement. Per the investigation the police officer attempted to interview both residents and the officer stated they were unsuccessful in obtaining information since both residents were confused. The facility investigation included an interview with R35's roommate, R21. R21 reported that the curtain was pulled between she and R35. R21 reported that she saw R236 and could not see specifically what occurred but overheard smacking noises and stated R236 asked R35 if she wanted more and R35 laughed. The investigation determined that since both residents seemed to enjoy themselves and were not distressed from the interaction, the facility was unable to substantiate resident-to-resident sexual abuse. There was evidence that the facility moved R236 to another room away from R35 on 01/13/0226 and began 30-minute checks on the whereabouts of R236. During an interview conducted on 03/16/2026 at 3:22 PM, R35 stated she did not remember being touched or being with in bed with a male resident while being kissed and stated she felt safe. R35 did not have a resident representative. During an interview conducted on 03/18/2026 at 9:03 AM, the Legal Guardian for R236 stated that this was the first time the resident was involved in a resident-to-resident incident and stated that the resident was not able to consent since he was not capable of signing any paperwork and was not capable of making decisions. During an interview conducted on 03/17/2026 at 4:15 PM, the Administrator stated that sexual abuse did not happen between R35 and R236 but believed that the incident still needed to be reported to the State Survey Agency (SSA). The Administrator stated that neither of the residents were upset after the encounter. The Administrator stated that the room change and the 30-minute checks were implemented by facility protocol. The Administrator stated that both residents were seen by mental health providers to ensure that harm did not occur. The definition of sexual abuse did not align with the regulatory requirements. During an interview conducted on 03/18/2026 at 6:32 AM, the Assistant Director of Nursing (ADON) 1 stated Certified Nursing Assistant (CNA) 9 reported the resident-to-resident incident to Licensed Practical Nurse (LPN)1 immediately after witnessing the incident. ADON 1 stated that R236 was moved to another room and then the 30-minute checks began two days later. ADON1 stated that this was a one-time incident with R35 and R236 and it never happened again. ADON1 stated that he did not believe that it was abuse. ADON1 stated that R35 had days in which she was coherent and there were days that she was not. During an interview conducted on 03/19/2026 at 4:06 PM, the Administrator defined sexual abuse included when a resident was upset and crying and not wanting to be touched. The Administrator stated both R35 and R236 were capable of making their own decisions and did not believe that sexual abuse had occurred. Also present during this interview was the Director of Nursing, Chief Compliance Officer (CCO), and National Director of Risk Management (NDRM). The Administrator stated that consent was determined if both residents were able to make their needs known. The Administrator stated after speaking with the two residents, R35 told the facility to mind your own business. The Administrator stated they interviewed R21 and the roommate reported that they were both laughing and giggling. CCO stated that both R35 and R236 were not deemed incompetent and both he and the Administrator stated that both residents had rights. The Administrator stated that the resident-to-resident was reported to the SSA out of an abundance of caution. 2. Review of R5's admission Record, located under the Profile tab of the EMR, revealed he was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, end stage renal disease, osteoarthritis, neuropathy, chronic obstructive pulmonary disease, Parkinsonism, liver cirrhosis, chronic pain, fatigue, anxiety, seizures, and bilateral leg amputation. Review of R5's admission MDS with an ARD of 04/25/2025 and located under the MDS tab of the EMR, revealed a score of 15 out of 15 on the BIMS, indicating intact cognition. He did not exhibit any behavioral symptoms. Review of R5's quarterly MDS with an ARD of 01/25/2026 and located under the MDS tab of the EMR, revealed a score of 15 out of 15 on the BIMS and no behavioral symptoms. Review of R5's Facility Incident Report Form, dated 07/06/25, and provided by the facility, revealed, During the resident smoke break, [R5] stated he asked the staff member, a RCA [Resident Care Assistant], to roll his wheelchair back towards the door and he said the staff member told him that since he rolled himself out he should roll himself back in. The resident said the staff member called him an expletive. Review of R5's Abuse – Staff to Resident Final Report, dated 07/14/2025 and provided by the Administrator, revealed RCA1 was immediately suspended pending investigation and the police department was contacted and conducted an investigation as well. Interview with R5 confirmed RCA1 refused to assist him to wheel into the building and RCA1 cussed at him and threatened him physically. Interviews with other residents who witnessed the incident confirmed a verbal altercation between R5 and RCA1 and RCA1's refusal to assist R5 with wheeling back into the building. A written statement from RCA1 revealed he confirmed he refused to assist R5 and had cussed at R5. The facility's investigation substantiated the allegation of verbal abuse and RCA1's employment was terminated. During an interview on 03/19/2026 at 10:06 AM, R5 stated about nine months ago, RCA1 refused to assist him to wheel into the facility and they got into an argument. R5 stated RCA1 threatened to pull him out of his wheelchair and stomp on him and also cussed at him. R5 stated, I was so angry, I wanted to kill him . I want him to go to hell. R5 confirmed he had not seen RCA1 since the incident and was waiting for follow-up from the police department. During an interview on 03/19/2026 at 4:30 PM, the Administrator stated R5 reported the allegation of abuse to him, and he immediately conducted an investigation. The Administrator stated he substantiated the abuse occurred due to R5's statement, witness accounts of events, and RCA1's admission of guilt.

Based on staff interviews, record review, and facility policy review, the facility failed to implement their abuse policies for capacity to consent for sexual activity for two residents (Resident (R) 35 and R236), of five, out of 51 sampled residents sampled. In addition, the facility failed to implement their abuse policies by failing to immediately separate both residents and implement supervision. This had the potential for on-going sexual contact. (Refer to F600)Findings include:Review of a facility policy titled Abuse, Neglect and Exploitation dated 07/15/2025 indicated . The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves.Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship. The facility will have written procedures to assist staff in identifying the different types of abuse.mental, verbal abuse, sexual abuse, physical abuse.The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:A. Responding immediately to protect the alleged victim and integrity of the investigation;B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed;C. Increased supervision of the alleged victim and residents;D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator;E. Protection from retaliation;F. Providing emotional support1. Review of R35's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the facility admitted the resident on 09/05/2024 with a diagnosis of dementia without behavioral disturbances.Review of R35's EMR titled quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/08/2025 located under the MDS tab indicated that the resident had a Brief Interview for Mental Status (BIMS) of 15 out of 15 revealed that the resident was cognitively intact.2. Review of R236's EMR titled admission Record located under the Profile tab indicated the facility admitted the resident on 10/26/2023 with a diagnosis of delirium with known psychological disorder.Review of R236's EMR titled quarterly MDS with an ARD of 12/26/2025 located under the MDS tab indicated the resident had a BIMS score of 10 out of 15, which revealed the resident was moderately cognitively impaired.Review of a document provided by the facility titled Facility Incident Report dated 01/13/2026 indicated that on 01/11/2026, R236 was found in R35's bed. R236 was observed to kiss R35 on the lips. Included in the investigation was a document titled Abuse-Resident to Resident dated 01/20/2026, which revealed the facility moved R236 to another room on 01/13/2026 instead of on 01/11/2026 when the resident-to-resident occurred. The facility failed to implement 30-minute checks on 01/11/2026. Police were notified on 01/13/2026 instead of on 01/11/2026 when the resident-to-resident occurred. The report indicated that the police officer attempted to interview both residents and the officer stated they were unsuccessful in obtaining information since both residents were confused. There was no evidence cited in the document that the facility showed that capacity assessments were completed and consent was evaluated by a qualified professional.During an interview conducted on 03/19/2026 at 4:06 PM, the Administrator defined sexual abuse included when a resident was upset and crying and not wanting to be touched. The Administrator stated both R35 and R236 were capable of making their own decisions and did not believe that sexual abuse had occurred. The Administrator stated that both residents consented to the interaction. The facility's misunderstanding of the definition of resident-to resident sexual abuse resulted in failure to initiate capacity and protective interventions.

Based on staff interviews, record review, and facility policy review, the facility failed to ensure an allegation of sexual abuse was reported timely to the Administrator and to the State Survey Agency (SSA) for two of five residents (Resident (R) 35 and R236) reviewed for abuse out of 51 sampled residents. This failure increased the risk of other vulnerable residents being abused. Findings include:Review of a facility policy titled Abuse, Neglect, and Exploitation dated 07/15/2025 indicated .Reporting of all alleged violations, regardless of residents cognitive status, to the Administrator, state agency.regardless of cognitive status.and to all other required agencies within specified timeframes.Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse.1. Review of R35's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the facility admitted the resident on 09/05/2024.2. Review of R236's EMR titled admission Record located under the Profile tab indicated the facility admitted the resident on 10/26/2023.Review of a document provided by the facility titled Facility Incident Report, dated 01/13/2026, indicated that on 01/11/2026, R236 was found in R35's bed. R236 was observed to kiss R35 on the lips.Review of a document provided by the facility titled Abuse-Resident to Resident, dated 01/20/2026, indicated that Certified Nurse Aide (CNA) 9 wrote a statement on 01/11/2026 and indicated she witnessed R236 in R35's bed and R236 kissed R35 when CNA9 directed R236 to get out of R35's bed. CNA9 stated she reported the incident to a nurse (there was no name identified in the investigation). The facility identified Licensed Practical Nurse (LPN)1 as the nurse who received the report from CNA9. There was no information on the reasons for the delay in reporting to the SSA.During an interview conducted on 03/17/2026 at 4:15 PM, the Administrator stated the Assistant Director of Nursing (ADON)1 reported the resident-to-resident incident. The Administrator stated when he was notified of the sexual incident on 01/13/2026 and that was when he reported the resident-to-resident to the SSA. The Administrator stated CNA9 reported the sexual encounter with R35 and R236 to Licensed Practical Nurse (LPN) 1. The Administrator stated that the incident between R35 and R236 was not considered sexual abuse. The Administrator stated once he learned about the resident-to-resident incident he reported the encounter to the SSA out of an abundance of caution.During an interview conducted on 03/18/2026 at 6:32 AM, ADON1 confirmed he learned about the sexual encounter which involved R35 and R236 two days after the incident. ADON1 stated the staff involved were CNA9 and LPN1 and he verbally counseled them both on timely reporting of resident-to-resident incidents. ADON1 confirmed he notified the Administrator of the resident-to-resident incident two days later. ADON1 was unable to identify how he obtained the information regarding R35 and R236 prior to reporting the allegation to the Administrator. During an interview on 03/18/2026 at 3:11 PM, LPN1 stated she was not the nurse that CNA9 reported the resident-to resident to.

Based on record review, staff interviews, and facility policy review, the facility failed to provide the resident's responsible party a written notice of transfer, notice of bed hold practices and complete information on the process to appeal the transfer, including appeal agency contact information for a sample of two of two residents (Resident (R)144 and R238) reviewed for hospitalizations in a total sample of 51 residents. This failure had the possibility to negatively impact residents and their responsible parties due to them not being aware of the reason for a transfer and how to appeal the transfer. Findings include:Review of the facility's policy titled, Transfer and Discharge (including AMA) reviewed 11/01/2025 indicated, .Policy Explanation and Compliance Guidelines:.2. Once admitted , the resident has the right to remain in the facility unless their transfer or discharge meets one of the following specified exemptions: a. The transfer.is necessary for the resident's welfare and the resident's needs cannot be met in the facility.The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. Specific reason of transfer.b. The effective date of transfer.The specific location .to which the resident is to be transferred.d. An explanation of the right to appeal the transfer.e. The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests. F. Information on how to obtain an appeal form.Review of the facility's policy titled, Bed Hold Notice revised 07/01/2025 indicated, Policy: It is the policy of this facility to provide written information to the resident and/or the resident's representative regarding the bed hold practices.at the time of a transfer. Policy Explanation and Compliance Guidelines: 1.at the time of a transfer to the hospital.the facility will provide the resident and/or the resident representative written information that specifies:.b. The reserve bed payment policy. C. The facility policies regarding bed-hold periods to include allowing a resident to return to the next available bed.2. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file and/or medical record.1. Review of R144 's Face Sheet located under the Profile tab of the Electronic Medical Record (EMR) revealed R144 was admitted to the facility on [DATE] with the diagnoses of non-traumatic intracerebral hemorrhage, cerebral edema, pneumonia, osteoarthritis, hemiplegia and hemiparesis affecting the right dominant side, aphasia, and seizures.Review of R144's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/25/2026 located under the MDS tab of the EMR indicated R144 was dependent for all tasks. The MDS revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating R144 was severely cognitively impaired. Review of R144's EMR under the Progress Notes tab indicated a progress note, dated 02/11/2026, .Patient daughter request for patient to be transfer to the hospital. Stating that pt [patient] is getting worse.Also stating that pt having apnea when breathing and pt is not breathing well.Responsible party notified.2. Review of R238's Face Sheet located under the Profile tab of the EMR revealed R238 was admitted to the facility on [DATE] with the diagnoses of non-traumatic subacute subdural hemorrhage, seizures, cerebral infarction, atrial fibrillation, unspecified dementia, malnutrition, and type II diabetes.Review of R238's admission MDS with an ARD of 02/22/2026 located under the EMR MDS tab indicated R238 was dependent for all tasks. The MDS revealed a Brief Interview for Mental Status (BIMS) score of memory problem, severely impaired. Review of R238's EMR under the Progress Notes tab indicated a progress note, dated 02/22/2026, .change in condition.at 11:30 AM family reported resident finger nail beds became blue.his doctor communicated by phone, ordered oxygen 3 L (liters) via nasal cannula.Reason for transfer: further diagnosis and treatment.Responsible party notified. During an interview on 03/19/2026 at 12:40 PM with the National Director of Risk Management (NDRM) revealed they always call the responsible party when a resident was being discharged but we did not send notification in writing. The NDRM explained that a bed hold notification form was sent with the resident to the hospital, but they did not retain a copy of the form in the resident's EMR. NDRM stated, In my 29 years I have never heard of this.During an interview on 03/19/2026 at 4:50 PM with the Administrator revealed he was not aware that the responsible party needed to receive a written notice of transfer and information regarding the bed hold notice upon any resident transfer to the hospital.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to ensure an adequate and ongoing program of activities to meet the needs of one of four residents (Resident (R) 29) reviewed for activities who was dependent on staff for all stimulation and engagement. This failure placed R29 at risk for increased self-injurious behaviors and unmet psychosocial needsFindings include:Review of the facility's policy titled, Activities, dated 01/01/2026, revealed, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being.Review of R29's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE] with diagnoses including stroke, epilepsy, hemiplegia and hemiparesis, muscle weakness, respiratory failure with tracheostomy, and gastrostomy tube. R29 was out of the facility at the hospital from [DATE] through 03/09/2026.Review of R29's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/29/2026 and located under the MDS tab of the EMR, revealed he was unable to complete the BIMS and staff assessed him with short-and long-term memory problems and severely impaired cognition. Per the MDS, R29 had no speech, was unable to make himself understood or understand others, and was totally dependent on staff for mobility and activities of daily living. R29's activities interests were unable to be assessed due to his inability to respond. Review of the CAA indicated additional activities assessment was indicated due to R29's Staff assessment of daily and activity preferences did not indicate that resident prefers participating in favorite activities. The CAA directed staff to proceed to care planning for activities needs and interventions.Review of R29's 03/12/26 Activities assessment dated [DATE] and located under the Assessments tab of the EMR, revealed R29 could not participate in group activities physically or cognitively. R29 was unable to respond and had no one to speak for him. No activity interests were identified in the assessment. The form documented, Resident requires [one-to-one] activities. Reading and music.Review of R29's EMR under the Care Plan tab revealed there was no Care Plan addressing his activity needs, goals, or interventions. Cross reference F656: Comprehensive Care Plan.Review of R29's Individual Activity Participation Records dated January 2026, February 2026, and March 2026 and provided on paper by the Activities Assistant (AA) revealed:-In January, nine one-to-one visits (01/02/2026, 01/05/2026, 01/09/2026, 01/12/2026, 01/13/2026, 01/18/2026, 01/19/2026, 01/23/2026, 01/28/2026) were documented that included reading, spiritual, talking, and sensory activities. However, five of these visits were documented between 01/02/2026 and 01/13/2026, which was prior to R29's initial facility admission.-In February, eight one-to-one visits (02/01/2026, 02/03/2026, 02/05/2026, 02/12/2026, 02/13/2026, 02/15/2026, 02/23/2026, 02/26/2026) were documented that included reading, talking, and sensory activities.-In March, four one-to-one visits (03/04/2026 (x2), 03/12/2026, 03/15/2026) were documented that included reading, religious, talking, and sensory activities. However, two activities were documented on 03/04/2026, which was during the time R29 was out of the facility at the hospital.During an observation on 03/16/2026 at 3:33 PM in R29's room, R29 was lying in bed without any music or television on in his room. There were no items in his hands or near him for sensory stimulation or to keep his hands busy.During an observation on 03/17/2026 at 9:42 AM in R29's room, R29 was lying in bed without any music or television on in his room. There were no items in his hands or near him for sensory stimulation or to keep his hands busy.During an observation on 03/17/2026 at 1:47 PM in R29's room, R29 was lying in bed without any music or television on in his room.R29 had pulled out his tracheostomy tubing. There were no items in his hands or near him for sensory stimulation or to keep his hands busy. In a concurrent interview, Respiratory Therapist (RT) 1 stated R29 would get restless at times and would use his hands to pull on the tubing.During an observation on 03/18/2026 at 7:27 AM in R29's room, R29 was lying in bed without any music or television on in his room. There were no items in his hands or near him for sensory stimulation or to keep his hands busy.During an interview on 03/18/2026 at 2:21 PM, the AA stated she had been serving as the Activity Director since the previous director left and had not yet completed a training course. She stated she did not have corporate assistance with developing an activities program. The AA stated R29 received one-to-one visits by staff since he was unable to participate in group or independent activities. The AA stated staff would read to him or talk to him, play music, or provide hand massage or sensory stimulation. The AA stated the visits should occur two to three times per week. The AA stated R29 did not have a radio in his room, but he would benefit from TV on during the day when staff were not visiting with him for sensory stimulation.During an observation on 03/19/2026 at 10:39 AM in R29's room, R29 was lying in bed without any music or television on in his room. There were no items in his hands or near him for sensory stimulation or to keep his hands busy.During an interview on 03/19/2026 at 12:57 PM, the AA stated she did not know why participation was reflected for R29 on days when he was not in the facility, as another activity assistant completed the participation records. The AA stated since R29 did not participate in activities and only received two to three one-to-one visits weekly, he would benefit from additional in-room stimulation like TV.During an interview on 03/19/2026 at 3:25 PM, the AA stated she was mistaken and she had been the one to complete the participation records. She stated she transcribed the information from other attendance sheets, incorrectly transposing another resident's information. The AA stated she had no additional records of participation for R29.During a concurrent interview on 03/19/2026 at 4:30 PM, the Administrator stated he expected activities staff to keep accurate records of participation including provision of one-to-one activities. The National Director of Risk Management (NDRM) stated the facility could be offering TV shows, music, or additional activities/objects for sensory stimulation and engagement and the staff could be doing more for R29.

Based on staff interviews, record review, and review of the Activities Director (AD) Job Description, the facility failed to ensure that a qualified activity professional was employed. This deficient practice had the potential to affect the 210 residents who resided in the facility. Findings include: Review of a document provided by the facility titled Activities Director job description, undated indicated . The activities program must be directed by a qualified professional who is.a qualified therapeutic recreation specialist or an activities professional who.licensed or registered, if applicable, by the state in which practicing.Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990.Has 2 years of experience in a social or recreational program within the last 5 years.one of which was full-time in a therapeutic activities program.qualified occupational therapist or occupational therapy assistant.Has completed a training course approved by the State. During an interview on 03/18/26 at 2:21 PM, the Activity Assistant (AA) stated she had been serving as the AD since the previous director left and had not yet completed a training course. She stated she did not have corporate assistance with developing an activities program. The AA stated she had not received any training in care planning and had not been involved in developing or revising activity care plans. The AA stated she did not attend Quality Assurance and Performance Improvement (QAPI) meetings and was not involved in any quality improvement projects. During an interview conducted on 03/18/26 at 2:56 PM, the Administrator stated the last day of the former AD's employment was on 08/07/25. The Administrator stated the AA was not the AD. The Administrator stated that the facility had the AA signed up for classes in April to obtain her AD credentials.

Based on observations, interviews, and record review, the facility failed to ensure emergency tracheostomy care supplies were kept within close proximity for one of four residents (Resident (R) 243) reviewed for tracheostomy care. This deficient practice had the potential to place R243 at risk of going without oxygen for over two minutes in the event of tracheostomy failure, which could lead to oxygen deprivation and brain damage. Findings include:Review of Anoxic Brain Injury: How Long Can the Brain Survive Without Oxygen, accessed on 03/23/26 at https://www.spinalcord.com/anoxic-brain-injury#:~:text=How%20Long%20Can%20the%20Brain,the%20potential%20long%2Dterm%20harm, revealed, two minutes without oxygen often leads to the beginning of brain cell damage, loss of consciousness, and cognitive impairment. While one minute may only cause dysfunction, by two to three minutes, brain cells begin to die, making it a critical emergency. Severe, irreversible damage is highly likely around five minutes.Review of R243's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, tracheostomy, quadriplegia, and encephalopathy. Review of R243's Care Plan dated 03/16/26 and located under the Care Plan tab of the EMR revealed, [R243] has a tracheostomy r/t [related to] chronic respiratory failure. The approaches included, Ensure that trach ties are secured at all times . [and] suction as necessary. Review of R243's EMR under the Orders tab revealed the physician's orders, dated 03/13/26, for tracheostomy care, including Trach care daily and PRN [as needed] for disposable: remove and dispose of inner cannula. Replace with new inner cannula . Change trach ties every night shift and as needed . Change respiratory supplies and setup every [Sunday] and as needed . Suction via trach every day and night shift for patency or to keep the airway open . [and] Trach Type: Shiley Flexcuff Trach Size: 4. During an observation on 03/17/26 at 8:46 AM in R243's room, there were no suction machines or tracheostomy supplies observed. R243 had a capped tracheostomy in place. During an interview on 03/17/26 at 2:10 PM and concurrent observation in R243's room, Respiratory Therapist (RT) 1 stated it was important for tracheostomy care supplies, including a suction machine, spare tracheostomy, inner cannula, trach ties, and mask, to be kept accessible in a resident's room so that the nursing staff did not have to go searching for supplies in the event of an emergency. RT1 confirmed there were no tracheostomy care supplies, including a suction machine, spare tracheostomy, inner cannula, trach ties, and mask, in R243's room. RT1 placed the necessary equipment in R243's room from the supply cart, which was kept in the closet across from the nurses' station, approximately a two-minute round trip from R243's room. During an interview on 03/17/26 at 4:14 PM, Unit Manager (UM) 2 stated the nursing staff was responsible for setting up the room of a new admission with tracheostomy supplies if needed. During an interview on 03/17/26 at 4:29 PM, Licensed Practical Nurse (LPN) 6 stated that when R243 was admitted , she was admitted to a shared room, which had been set up with her tracheostomy care supplies. However, R243 was subsequently moved to a private room upon her representative's request, and the supplies must not have been moved as well. LPN6 stated spare trach kits, inner cannulas, mask, and suction should be in the resident's room so it was easily accessible. During an interview on 03/17/26 at 4:53 PM, Regional Risk Nurse (RRN) 1 stated R243's representative was angry about the suction machine being placed in R243's room and asked the staff to remove it from the room. RRN1 stated R243's representative was educated on the importance of having emergency care equipment at the bedside for easy access, but stated there was a suction machine on the crash cart, an approximately two-minute round trip from R243's room. During an interview on 03/19/26 at 4:30 PM, the Director of Nursing (DON) stated she expected staff to ensure tracheostomy care supplies were kept in the resident's room for access during an emergency.

Based on observations, interviews, record review, and policy review, the facility failed to ensure one of one Resident (R) (R43) reviewed for the provision of dental services was provided with routine services out of a survey sample of 51. This deficient practice had the potential to place R43 at risk of infections and pain associated with the lack of routine dental services.Findings include:Review of a facility policy titled Dental Services dated 10/01/25 indicated .It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care .Routine dental services .means the facility will, if necessary or required, assist the resident with making dental appointments. Review of R43's titled admission Record located in the electronic medical record (EMR) under the Profile tab, indicated the facility admitted the resident on 12/26/24. Review of R43's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/21/26 located under the MDS tab indicated the resident had a Brief Interview for Mental Status (BIMS) score of six out of 15, which revealed the resident was severely cognitively impaired. The MDS indicated no broken or missing teeth. Review of R43's clinical record failed to show evidence that the resident received routine dental services within the 14 months of the resident's stay. During an observation conducted on 03/16/26 at 11:09 AM, the resident opened her mouth and exposed her teeth. There was heavy white substance buildup around all of her upper teeth. There was a reddish color to her two front top teeth. During an interview conducted on 03/17/26 at 2:30 PM, the Social Services Director (SSD) and the Regional [NAME] President of Operations (RVPO)1and both confirmed that R43 did not have prior appointments with a dentist for routine dental care during her stay at the facility. An observation was conducted of R43's teeth, and there was a heavy white substance around each of her upper teeth. There was a pink substance on her top two front teeth. Both SSD and RVPO1 verified the observation. The SSD stated that the resident's teeth were in this condition upon admission. The facility failed to provide any additional information for R43 for dental care or the status of her teeth. During an interview conducted on 03/18/26 at 10:17 AM, R43's Family Member (FM)1 stated he was looking for a community dentist to come in and evaluate and treat the resident's teeth. FM1 stated he was not aware that a dentist contracted with the facility could come in and provide routine dental care to the resident. During an interview conducted on 03/19/26 at 4:06 PM, the Chief Strategy Officer stated R43 should be seen annually by a dentist.

Based on observation, record review, resident and staff interviews, and policy review, the facility failed to ensure one of three residents (Resident (R) 13) reviewed for nutrition was served thickened liquids as ordered by the physician. This deficient practice had the potential to place R13 at risk of choking or aspiration of liquids into the lungs Findings include:Review of the facility's policy titled Therapeutic Diet Orders, dated 02/01/26, revealed, All diet orders are to be communicated to the dietary department in accordance with facility procedures. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. Review of R13's admission Record, located under the Profile tab of the EMR, revealed he was admitted to the facility on [DATE] with diagnoses including malnutrition and dysphagia. Review of R13's admission MDS with an ARD of 01/02/26 and located under the MDS tab of the EMR, revealed a score of ten out of 15 on the BIMS, indicating moderately impaired cognition. He required a mechanically altered diet. Review of R13's EMR under the Orders tab revealed a physician's order, dated 01/01/26, for thickened liquids at nectar consistency. Review of R13's Care Plan dated 02/16/26 revealed, [R13] is at risk for alteration in nutritional and hydration status r/t . Adult FTT [failure to thrive], . poor PO [oral] intake, refuses weights, and fracture. The approaches included Diet as ordered. During an observation on 03/18/26 at 8:09 AM in R13's room, R13 was eating breakfast and had a glass of regular (thin) juice, a carton of regular (thin) milk, and a cup of regular (thin) water on his bedside table. Half the liquids had been consumed. R13 stated his liquids were not thickened, but he was drinking them without any trouble. Review of R13's 03/18/26 breakfast tray card revealed he was to receive nectar-thick liquids, including milk and a beverage of choice During an interview on 03/18/26 at 8:11 AM, Licensed Practical Nurse (LPN) 3 confirmed R13 had thin juice, thin milk, and thin water with his meal. She stated she did not know why he was not given nectar-thickened liquids. During an interview on 03/18/26 at 8:41 AM, LPN3 stated R13 was supposed to receive nectar-thickened liquids only, and the thin liquids had been removed and replaced with nectar-thickened liquids. LPN3 stated the juice and milk were provided by the kitchen. During a concurrent interview on 03/19/26 at 4:30 PM, the Director of Nursing (DON) stated that the thin liquids were served from the kitchen. The Administrator stated the kitchen staff should be checking the orders during the tray line to ensure the correct consistency of beverages was served, and the nursing staff serving the meals should be double-checking to ensure the appropriate thickened liquids were served.

Based on record review and staff interviews, the facility failed to ensure the clinical records were complete for one of one resident (R) 79) reviewed out of a total sample of 34 residents. This deficient practice had the potential to create the opportunity for inaccurate medical records to be accessible to staff. Findings include: Review of the facility policy titled Medication Administration with a revision date of 05/01/25, provided by the facility, indicated 20. Sign the MAR after administered. Review of a facility's policy titled Documentation in Medical Record, dated 03/01/25, indicated that .Each resident's medical record shall contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Review of Resident (R)79's admission Record found under the Profile tab of the electronic medical record (EMR) indicated an admission date of 12/27/25 with diagnoses of appendicitis, hemiplegia and hemiparesis, type 2 diabetes, major depressive disorder, and dementia. Review of R79's Medication Administration Record (MAR) found under the Physician's Orders tab in the EMR for 03/01/26 - 03/19/26 indicated no administration documentation for the following medication:The 9:00 PM dose on 03/12/26 for Eliquis (a medication used to thin blood), 5 milligrams (mg), give one tablet by mouth two times a day.On 03/12/26 for Atorvastatin calcium (a medication used to treat high cholesterol) 80 mg one tablet by mouth at bedtime, and for Ezetimibe (a medication used to treat high cholesterol) 10 mg tablet by mouth at bedtime. During an interview on 03/19/26 at 11:40AM, Licensed Practical Nurse (LPN)8 confirmed working on the night shift on 03/12/26. LPN8 stated that the medications were given, and she forgot to go back and click them off in the computer system. LPN8 stated that documentation should have been done before the end of the shift. In an interview on 03/19/26 at 2:30 PM, the Director of Nurses (DON) stated that if it is not documented, it is not done, and timely documentation is emphasized over and over.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to adhere to infection control practices and policies during incontinence care for two of three residents (Resident (R) 172 and R181) observed for incontinence care in the sample of 51 residents. The deficient practice had the potential to place R172 and R181 at risk of cross-contamination and infection.Findings include: Review of the facility's policy titled Perineal Care with a revision date of 01/01/26 provided by the facility indicated that: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. Review of the facility's policy titled Handwashing/Hand Hygiene with a revision date of August 2019 provided by the facility indicated that: 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations; h. Before moving from a contaminated body site to a clean body site during resident care, and j. After contact with blood or bodily fluids. Review of the facility's policy titled, Enhanced Barrier Precautions, revised 03/01/25, provided by the facility indicated, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO] that employs targeted gown and gloves use during high contact resident care activities. Initiation of Enhanced Barrier Precautions. for residents with any of the following: wounds.even if the resident is not known to be infected or colonized with MDRO. Implementation of Enhanced Barrier Precautions: . PPE [Personal Protective Equipment] for enhanced barrier precautions is only necessary when performing high-contact care activities . High-contact care activities include: . Changing linens, changing briefs, . and Wound care. Review of the facility's policy titled, Hand Hygiene, revised 03/01/25, provided by the facility, indicated, The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. 1. Review of R172's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R172 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction, need for assistance with personal care, and a fall from a non-moving wheelchair. Review of the admission Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 01/16/26 showed documentation R172 completed a Brief Interview for Mental Status (BIMS) with a score of 11 out of 15, which indicated R172 was moderately cognitively impaired. Review of R172's Care Plan located under the Care Plan tab in the EMR revealed R172 was on enhanced barrier precautions for potential infection related to wounds. During an observation on 03/18/26 at 6:44 AM, Certified Nurse Aide (CNA) 8 entered R172's room to perform incontinence care. An EBP sign was posted on R172's bedroom door that indicated, Providers and staff must also: wear gloves and a gown for the following high-contact resident care activities.changing linens, providing hygiene, changing briefs, . wound care. CNA8 performed hand hygiene, donned gloves, and performed incontinence care. CNA8 did not wear a gown while performing incontinence care. Midway through care, the Regional Risk Consultant (RRC) instructed CNA8 to put on a gown. CNA8 did not perform hand hygiene during glove changes. CNA8 left the room while wearing the gown and obtained a clean sheet from the linen cart that was outside the room, and deposited R172's soiled brief and linens into the trash bin and linen hamper outside the room without bagging the soiled linens or brief. During an interview on 03/18/26 at 7:24 AM, CNA8 stated, I changed gloves going from soiled to clean. I did not sanitize my hands between glove changes. I should sanitize my hands when I remove gloves. I did not wear a gown in the beginning. During an interview on 03/18/26 at 7:29 AM, the RCC stated, We need to make sure we have everything in the room to start with. We should sanitize our hands anytime we take gloves off. During an interview on 03/19/26 at 12:31 PM, the Assistant Director of Nursing (ADON) 3 stated, For residents with EBP precautions, staff are to put on a gown and gloves. I encourage staff to wash their hands every time they remove or change gloves, before and after providing care. If needing to leave the room, they are to remove the gown. They should have all of their supplies in the room before going in, or ask another staff member to bring the needed supplies, so they don't have to de-gown. Only take what is needed off the linen cart. It is not appropriate to have the linen cart outside the room and grab things off the linen cart while gowned. During an interview on 03/19/26 at 2:00 PM, the Director of Nursing (DON) stated, It was not appropriate for staff to go in and out of the room wearing a gown. Staff should have all of their supplies before going into the room. There is a risk of cross-contamination. The expectation is that staff perform hand hygiene with each glove change. 2. Review of R181's admission Record found under the Profile tab of the EMR indicated an admission date of 05/30/22 with diagnoses cerebrovascular insufficiency, hemiplegia, and hemiparesis affecting the right side, vascular dementia, and major depressive disorder. Review of R181's MDS with an ARD of 12/27/25 found under the MDS tab of the EMR indicated R181 was always incontinent of bowel and bladder. During an observation on 03/17/26 at 1:34 PM of R181's incontinent care, CNA5 donned gloves and provided incontinent care using the same pair of gloves throughout the process. CNA5 wrapped up the urine-soiled brief, applied barrier cream to the perineal area, and put on a new brief without changing dirty gloves and performing hand sanitization. In an interview on 03/17/26 at 1:44 PM, CNA5 stated she did not change gloves, and that handwashing and gloves were put on before she entered the room to provide care.

Based on record review, observation, staff interviews, review of maintenance documentation, and review of facility policy, the facility failed to ensure siderails were securely attached to the bed for one (Resident (R) 190) of six reviewed for side rails out of a sample of 51 residents. The deficient practice had the potential to place R190 at increased risk of injury related to side-rail use. Findings include:Review of the facility's policy titled, Side Rail Safety, revised 03/01/25, indicated, Inspecting and regularly checking the mattress and bed rails for areas of possible entrapment; ensuring the bed frame, bed rail and mattress do not leave a gap wide enough to entrap a resident's head or body, regardless of mattress width, length, and/or depth, checking bedrails regularly to make sure they are still installed correctly, and have not shifted or loosened over time. Review of R190's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R190 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis, other lack of coordination, seizures, muscle weakness (generalized), cognitive communication deficit, and major depressive disorder. Review of R190's Care Plan, dated 07/20/23 and located under the Care Plan tab of the EMR, revealed a focus of R190 had limited physical mobility related to repeated falls, multiple sclerosis exacerbation, history of seizures, weakness, and rib fractures. Interventions included staff were to provide supportive care and assistance with mobility as needed. Review of R190's quarterly Minimum Data Set (MDS), located under the MDS tab of the EMR and with an Assessment Reference Date (ARD) of 12/28/25, revealed R190 had multiple sclerosis, depression, seizures, upper and lower extremity impairments on one side, required moderate help with rolling from side to side, and from sitting to standing. It was recorded that R190 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R190's Care Plan, dated 07/20/23 and located under the Care Plan tab of the EMR, revealed a focus Activities of Daily Living (ADL) self-care performance deficit. Interventions included mobility bars up for safety during care provision, to assist with bed mobility and staff were to observe for injury or entrapment related to side rail use and reposition as necessary to avoid injury. During an observation and interview on 03/18/26 at 10:22 AM, R190's right-hand mid-bed metal rail was observed loose and unable to remain in the proper location. R190 lifted the bed rail and let it fall to the floor. R190 stated he used it to hold on to while turning in bed. During an observation and interview on 03/18/26 at 10:26 AM, Certified Medication Technician (CMT) 2 confirmed R190's right hand mid-bed side rail was loose and posed a risk for injury. During an interview and observation on 03/18/26 at 10:45 AM, the Maintenance Director stated, I try to inspect five-10 beds with bed rails on each floor daily. Each bed is inspected weekly. I have not inspected any beds on the 4th floor today. I looked at the bed in [R190's] room earlier this week. The Maintenance Director inspected R190's right-hand mid-bed rail. The rail was attached with one bolt near the head of the bed, and when the rail was lifted up, it dropped to the floor. The facility was unable to provide documentation of weekly bed inspections completed by maintenance.

Based on observations, record review, interviews, and a review of the policy titled Elopements and Wandering Residents, the facility failed to provide adequate supervision and assistance devices to prevent accidents for one of 52 sampled residents (R) (R49) related to ensuring that R49's unit was secure to prevent elopement. On 12/18/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.On 12/18/2025 at 3:15 pm, the Administrator, Director of Nursing, [NAME] President of Operations, and Chief Compliance Officer were notified that IJ was identified to have existed on 7/1/2025, when Resident (R) (R49) eloped from the facility by exiting the second-floor secured unit. It was determined that the alarms and the delayed egress paddle door were not functioning properly.An Acceptable Removal Plan was received on 12/19/2025. Based on observation, record review, a review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice were removed on 12/19/2025. The facility remained out of compliance while the facility continued management-level staff oversight, as well as continuing to develop and implement a Plan of Correction (POC). This oversight process includes monitoring the physical building for functioning egress doors and assessing and monitoring residents with elopement risk.Findings included:A review of the facility's policy titled Elopements and Wandering Residents, dated 3/1/2022 and revised 7/1/2025, revealed that if the resident is not found indoors or in the vicinity of the building, the Administrator will call the police to act as a liaison to locate the missing resident. A review of the electronic medical record (EMR) revealed that R49 was admitted to the facility on [DATE] with diagnoses of orthopedic aftercare following surgical amputation, cellulitis of the left toe, idiopathic aseptic necrosis of the left toes, vascular dementia, psychotic disturbance, mood disturbance, anxiety, and cognitive communication deficit.A review of R49's physician's orders revealed an order for a wander guard to the right ankle, to check placement each shift on 4/17/2025. A review of R49's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/26/2025 revealed a Brief Interview for Mental Status (BIMS) score of five out of 15, which indicated the resident was severely cognitively impaired. The MDS indicated no upper or lower extremity impairment, and sit-to-stand requires maximum assistance. A review of R49's Elopement Risk Evaluation dated 7/1/2025, revealed the resident scored a 14, which indicated high risk.A review of R49's care plan, dated 4/17/2025, revised on 6/29/2025, revealed R49 was an elopement risk and wanderer, and his safety would be maintained. The Care plan indicated interventions of checking the sensor placement on the leg and function, and to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books. A review of R49's progress notes revealed that on 6/21/2025 at 5:13 pm, R49 was observed ambulating on the unit with an unsteady gait requiring redirection to his wheelchair for safety. R49 was non-compliant with redirection for safety measures due to fall risk multiple times throughout the shift. At times, failed to utilize the wheelchair during the shift, having limited safety awareness. Further review of the progress notes revealed on 7/1/2025 at 2:50 pm, the alarm from the wander guard system went off, and a search within the facility was initiated to see if all residents are present. The resident was nowhere to be found in the unit and in other units after checks. Code Yellow was immediately initiated, and all staff went out to search for the resident. The resident was found at approximately 3:40 pm in the parking garage across the street and was brought back to the facility. R49 was assessed and was not injured. Resident will be on 30-minute checks and room change initiated, will continue plan of care.A review of the Facility Reported Incident (FRI) dated 7/1/2025 provided by the facility revealed that at 2:55 pm, the alarm on the second floor went off. The report concluded that R49 eloped through the exit doors on the second floor. The elopement code was called and performed well; staff performed inside and outside searches, and R49 was found less than an hour after the call. R49 was placed on one-on-one 24 hours after the incident. The report further indicated that a code yellow was implemented after the alarm for the wander guard was sounding and R49 was not in sight. There is no reference to the outside exit discharge door alarm, only the stairway exit door wander guard alarm. Further review of the FRI indicated on 7/1/2025 at 3:15 pm or 20 minutes later, a code yellow was announced over the intercom, alerting all staff that a resident had eloped. Police were notified that a resident was missing from our facility. After the police were contacted, the FRI indicated, management staff and floor employees searched outside the premises.An interview with Licensed Practical Nurse (LPN10) on 12/19/2025 at 10:05 am revealed that she was recently in-service on the issue of elopement. She stated she was present on the day (7/1/2025) that R49 eloped. She indicated that once the Code Yellow was called, staff began looking for R49 inside the building right away. She said it's a big building with lots of places to hide. By the time we got outside, he was gone. She verified that most of the searches for the R49 occurred inside the building, despite the exit door alarm. An observation on 12/18/2025 at 9:05 am revealed the resident was at the door from which he left on 7/1/2025 or near bedroom [ROOM NUMBER], setting off the wander guard alarm. The wander guard range is approximately five feet, meaning the alarm will sound when a sensor is within five feet of the transmitter. Certified Nursing Assistant (CNA)4 was observed with Office Staff (OS2) resetting the code for the stairway exit door near bedroom [ROOM NUMBER]. During an interview on 12/18/2025 at 12:45 pm, CNA4 stated that we were adjusting the door for him. He set off the alarm when he got too close to the door. During an interview with OS2 on 12/18/2025 at 12:49 pm, he stated that this morning, pointing to the door from the dining room corridor when R49 set off the alarm. OS2 stated that he was adjusting the door using the alarm code to stop the wander guard alarm from sounding. He stated that R49 sets the door alarm off all the time. He sets the alarm off near 239 and at the elevator. An observation of the exit doors on the 200 Hall, made on 12/18/2025 at 11:20 am in the presence of the Administrator and Director of Physical Plant Services ([NAME]), revealed the exit door near 239 was on a 15-second delay (no sign of delay time) at the stairwell. The second door at the exit discharge inside the stairway was without a special locking arrangement. This door had a large paddle-type panic bar that read in orange/pink color Emergency Exit Only, Alarm Will Sound, Push Here. The Administrator pushed onto the first stairway door, which released the locking device after sounding a moderately loud alarm in 15 seconds. The second exit inside the stairway or at the exit discharge was opened by pushing the large colored paddle panic hardware. This door did not alarm despite the sign on the paddle. This exit discharge door, being on the second floor, the grade of the building was such that this door emptied onto a sidewalk at ground level. No stairs were required to access this exit door. During an interview with the [NAME] on 12/18/2025 at 11:20 am indicated that this door alarm has not been working for a long time. When asked why the device was not repaired, he stated it's not on my Tels report for routine maintenance and monitoring. Tels' system is a facility-based software program that allows any staff member with access to a computer to request repair of a broken or missing item. It's logged in, maintenance reviews, repairs, and documents repairs. During an interview with the Administrator on 12/18/2025 at 11:20 am revealed that another exit was across from the exit at 239. This door was locked and labeled as NO EXIT. The exit door in bedroom [ROOM NUMBER] had an EXIT sign above it in the corridor and above the stairway door, but the door was locked with a special locking arrangement and did not open or sound an alarm. The exit door near 225, leading to a stairway, opened in 15 seconds with pressure, as did the exit door near 249. The cross corridor exits access doors near 205 also opened in 15 seconds (no sign,) each with special locking arrangements. These two doors were also accessed by using special knowledge or a code. The two elevator doors used for residents also lock when a wander guard sensor is near and alarm when the doors open, as well as the service elevator near bedroom [ROOM NUMBER]. A code pad was also at each elevator.Further interview with [NAME] on 11/19/2025 at 9:30 am revealed that a contractor unlocked the exit discharge door about two weeks ago to work on an exterior wooden fence in the area. He must not have relocked the door when he was finished. When asked by the [NAME] if the contractor had a key, he stated, No, he would have to get the key from the facility and relock through a key with the facility.

Based on record review, interviews, and a review of the policy titled Resident Rights, the facility failed to ensure one of 18 sampled residents (R) (R16) was informed of their rights regarding treatment, financial liability, and resident rights upon admission to the facility. The deficient practice resulted in a resident not having informed consent, not knowing their financial liability, or what their rights were.Findings included:A review of the facility's policy titled Resident Rights dated 2/1/2025, indicated The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Prior to or upon admission, the social service designee, or another designated staff member, will inform the resident and/or the resident's representative of the resident's rights and responsibilities.A review of R16's admission Record in the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including amyotrophic lateral sclerosis, hemiplegia affecting the left nondominant side, dysphagia-oropharyngeal phase, and slurred speech. R16 was discharged home on [DATE].A review of R16's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date of 11/4/2025 revealed a Brief Interview of Mental Status (BIMS) score of 13 out of 15, which indicated she was cognitively intact. Further review revealed that R16 had unclear speech, was sometimes able to make herself understood, and missed some parts of understanding others. A review of R16's admission Agreement form, provided by the facility, which included consent to treat, revealed it was signed electronically by the resident representative on 11/8/2025. A review of R16's Resident Rights form provided by the facility revealed it was not signed. A review of R16's Financial Expectations Worksheet - Insurance Review form provided by the facility revealed it was completed on 11/6/2025 on the same day as the care conference.A review of R16's Insurance Benefits and Co-Pay Due to Facility During Stay form provided by the facility was blank and electronically signed on 11/8/2025.During an interview with Family Member (FM) FM16 on 12/17/2025 at 11:32 am, FM16 stated, admission paperwork was received electronically via email. I refused to sign it because my name was wrong. [R16] is oriented and takes care of everything herself, so I was not sure why she hadn't signed anything. The form was pre-filled out, and I was not able to make changes. The facility had to keep fixing the documents. admission paperwork was first received on 11/7/2025. [R16] said she never signed anything. They fixed my name and sent it back to me on 11/7/2025. The system stopped me from signing since I could not advance the documents without signing due to incorrect information. I never received a corrected form. The immunization records were wrong, along with other information regarding allergies.During an interview on 12/17/2025 at 10:55 am, the Director of Hospitality/Interim Admissions Staff (DOH/IA) stated, Upon admission, admission paperwork is emailed to the resident/representative for signature. Consent to treat should be signed once the resident comes through the door. The DOH/IA was unable to determine when the email was sent due to it was not sent from her email address.During an interview on 12/17/2025 at 11:03 am, the Administrator stated, Nursing has a consent to treat form that should be signed upon admission in the physical chart.During an interview on 12/17/2025 at 1:01 pm, the [NAME] President of Operations (VPO) stated, The resident's consent for treatment and admission packet was not signed at admission. The packet was created on 11/6/2025. The admissions person, who was responsible, resigned from the position at the time of admission. There is no paper consent to treat form signed. There is no documentation that the resident/representative was informed of the resident's rights or benefits and costs.

Based on interviews, record review, document review, and review of the facility's policy titled Abuse, Neglect and Exploitation, the facility failed to protect the rights of one of eight residents (R) (R6) reviewed for abuse. Specifically, to be free from exploitation by a staff member. This failure had the potential to cause emotional distress or financial burden for R6.Findings included:A review of the facility's policy titled Abuse, Neglect and Exploitation dated 7/15/2025 revealed, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. 'Exploitation' means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion.A review of R6's admission Record located in the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, bipolar disorder, anxiety, depression, and a history of physical and sexual abuse.A review of R6's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 9/26/2025 revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. She exhibited some symptoms of depression but no behavioral symptoms. A review of R6's Care Plan, initiated 10/13/2023, revealed, [R6] has self-reported trauma related to her attention-seeking behaviors. Approaches included, Encourage and empower me to be involved in my own care . Encourage me to express my feelings/concerns/thoughts in a safe space . Keeping me informed about changes to my care, life at the facility, etc.During an interview on 12/15/2025 at 11:40 am, R6 stated that Floor Technician (FT) FT1 had exploited her by asking her for money. She stated the staff member no longer worked at the facility, and she felt comfortable and safe in the facility since FT1 had been gone. R6 stated that FT1 texted her requests for money, and she had provided the facility with screenshots of text messages.A review of a Social Services note dated 5/15/2025 revealed, On 5/8 [5/8/2025], resident reported allegations of . misappropriation of funds by a staff member. Allegations were reported to state. SW [Social Worker] interviewed the resident, the resident provided her statement, and the statement was given to Admin [Administrator]. SW informed the resident that an investigation will be done per facility policy. Resident verbalized understanding.A review of the facility's Facility Incident Report Form, the initial report to the State Agency (SA) dated 5/8/2025 in the incident folder revealed, [R6] stated [FT1], a housekeeper, . asked her for money . The staff member was suspended pending investigation. Investigation is ongoing.A review of the facility's Final Report, the follow-up report to the SA, dated 5/15/2025 and provided in the incident folder, revealed the facility's investigation included statements from R6 and her roommate, interviews with other alert and oriented facility residents, and attempted interviews with FT1, with no contact made. The investigation also included screenshots of R6's text messages confirming FT1's requests for money. The allegation of exploitation was substantiated, and FT1 was terminated. A review of FT1's personnel file provided by the Administrator revealed there was no evidence of a criminal background check or reference checks before employment. Cross-reference F606: Not Employ/Engage Staff with Adverse Actions.During an interview on 12/17/2025 at 1:04 pm, the Administrator, who served as the facility's Abuse Prevention Coordinator, stated he had conducted an investigation into R6's allegation and viewed photographic evidence of FT1 requesting money from the resident. The Administrator stated this was exploitation, and the allegation was substantiated as he had proof that it occurred. The Administrator stated FT1 did not respond to calls during the investigation, and he was terminated from facility employment without working again in the building. The Administrator stated resident interviews, and further investigation showed no additional residents had been affected by FT1. The Administrator stated it was against facility policy for staff to request money or gifts from residents, and it was considered exploitation/abuse.

Based on interviews, document review, and review of the policy titled Abuse, Neglect and Exploitation, the facility failed to ensure that one of three staff, Floor Technician (FT) (FT1), completed and documented a criminal background history, including a history of abuse, neglect, or exploitation, before employment. This failure had the potential to contribute to a substantiated allegation of exploitation for a facility resident (R) (R6). Findings included:A review of the facility's Abuse, Neglect and Exploitation policy dated 7/15/2025 revealed, The components of the facility abuse prohibition plan are discussed herein:I. ScreeningA. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property.1. Background, reference, and credentials checks shall be conducted on potential employees,contracted temporary staff, students affiliated with academic institutions, volunteers, andconsultants.2. Screenings may be conducted by the facility itself, a third-party agency, or an academic institution.3. The facility will maintain documentation of proof that the screening occurred.A review of the Final Report dated 5/15/2025 regarding the investigation of an allegation of exploitation by R6, provided in the incident folder, revealed that R6 alleged that FT1 sent text messages to her asking for money. The investigation also included screenshots of R6's text messages confirming that FT1 requested money. The allegation of exploitation was substantiated, and FT1 was terminated.A review of the personnel file for FT1 provided by the Administrator revealed a hire date of 3/27/2024. There was no evidence of a criminal background check or reference checks before employment. The file indicated that two reference checks were attempted on 3/19/2024; however, not completed.During an interview on 12/17/2025 at 1:04 pm with the Administrator, who served as the facility's Abuse Prevention Coordinator, confirmed that he was unable to locate a background check on FT1, and the only evidence of reference checks was the two that were not completed.Cross-reference F602: Free from Misappropriation/exploitation

Based on resident and staff interviews, record review, and a review of the policy titled Abuse, Neglect and Exploitation, the facility failed to ensure an allegation of misappropriation of resident property was thoroughly investigated for two of eight residents (R) (R5 and R28) reviewed for abuse. This failure had the potential to contribute to further misappropriation of property in the facility. Findings included:A review of the facility's policy titled Abuse, Neglect and Exploitation dated 7/15/2025 revealed, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur . Written procedures for investigations include: 1. Identifying staff responsible for the investigation.4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and6. Providing complete and thorough documentation of the investigation. 1. Review of R5's admission Record located under the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to anxiety and bipolar disorder. Review of R5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/19/2025, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. She did not exhibit behavioral symptoms. During an interview on 12/18/2025 at 11:45 am, R5 stated she had $173.00 stolen from her while at the facility. She went on to explain her money was stored in her wallet in her lockbox in her room, with the lockbox key tied around her neck. She stated the key went missing from around her neck and was lying in her wheelchair seat upon her return from a shower the next morning. R5 stated she had reported this allegation to the Administrator on 3/3/2025; however, she was told he could not prove it was stolen. A review of R5's Facility Incident Report Form, the initial report to the State Agency (SA), dated 3/20/2025, and provided by the Administrator revealed, Resident stated she was missing $173.00. The resident stated it was in her lockbox, and when she woke up this morning, it was gone. Police were notified, and an investigation was initiated. A review of the facility's Final Report to the SA, dated 3/26/2025 and provided by the Administrator, revealed the police department determined this was not a criminal case as there was no proof that the money had been stolen. Staff did not know about the money. The resident's room and belongings were searched, but the money was not found. The allegation was unsubstantiated. Attached was one statement written by a staff member, whose signature was illegible, which documented that the staff member did not take R5's member. Interviews with five residents documented that they were asked if money had been taken from them while in the facility. There were no resident interviews regarding R5's money, and the interviews did not include R5's roommate. There were no additional staff interviews included. During an interview on 12/18/2025 at 1:05 pm, the Administrator stated he spoke with more staff members as part of the investigation; however, only one of them wrote a statement, and his interviews were not documented. The Administrator stated, Sometimes we just interview verbally; we do not always document staff statements. The Administrator stated he would have expected R5's roommate to be interviewed as part of the investigation and confirmed she was not. 2. A review of R28's admission Record located under the Profile tab of the EMR revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to epilepsy, traumatic subarachnoid hemorrhage without loss of consciousness, and unspecified fall, sequela. A review of R28's end of Prospective Payment System (PPS) stay MDS with an ARD of 9/17/2025 revealed a BIMS score of five out of 15, indicating severe cognitive impairment. He was recorded to be independent with rolling left/right, sitting to lying, lying to sitting on the side of the bed, and sitting to standing. Since R28's last admission/entry or reentry, he has had one fall with no injury. The MDS indicated R28 was supervision or touch assistance with an ambulance for walking 10 to 150 feet. A review of R28's Situation, Background, Assessment, Recommendation (SBAR), dated 10/6/2025 at 7:05 pm, and located in the EMR under the Progress Notes tab revealed . unwitnessed fall in dining (sic) room at 7:05 pm, injury to back of head, bleeding noted, jerking and foaming at mouth and nose noted. A record review of R28's Post Fall assessment dated [DATE] and located in the EMR under the Assessments tab revealed the facility assessed the resident to have a laceration to the back of the head after the incident, and that the resident was transferred to the hospital. A record review of R28's hospital Discharge summary dated [DATE] and located in the EMR under the Miscellaneous tab revealed the resident had a C3 cervical fracture. A review of R28's Facility Incident Report Form, the initial report to the SA dated 10/9/2025 revealed, Witnessed Fall with Major Injury with No Alleged Abuse.Date and Time of Incident: 10/7/2025 at 7:05 pm.On 10/7/2025, the resident attempted to sit on a chair and missed the handle of the chair, resulting in him falling on the floor. Resident fell in dining (sic) room at 7:05, injury to the back of the head, bleeding noted, pressure applied tothe area, foaming at the mouth and nose.In order to transfer the resident to the hospital.The hospital reached out to the facility on [DATE] and stated the resident obtained a neck fracture. The Facility Incident Report Form dated 10/9/2025 was completed and submitted to the SA after R28's diagnosis of a cervical fracture. This form indicated the resident had a fall on 10/7/2025 that was witnessed. Record review and staff interviewed revealed the resident had an unwitnessed event on 10/06/25 that resulted in a laceration to the back of the head and a discharge to the hospital. The facility failed to ensure the investigation was thorough and corresponded with staff interviews and record review. During an interview on 12/18/2025 at 1:10 pm, Licensed Practical Nurse (LPN) 9 stated that she had heard a thud in the dining room. She said that she and other staff went into the dining room and found R28 on the floor. She stated it was unwitnessed, and the resident was bleeding from the head. LPN9 said the facility called 911 right away, and the resident was picked up by paramedics very quickly. LPN9 stated that she believed R28 was having a seizure, which led to the fall with injury. She said that she completed the SBAR, and then the management team did the reporting and follow-up investigation. During an interview on 12/18/2025 at 4:02 pm, Assistant Director of Nursing (ADON) 2 stated that he was not at the facility but was informed by LPN9 that R28 was found in the day room, foaming at the mouth. ADON2 said that he communicated with LPN9 during the incident. He said the resident was given oxygen, and his neuros were taken. ADON2 said that paramedics came quickly. He said they did a follow-up and found out R28 had a cervical fracture. ADON2 said that he had talked to other residents, but no one could explain what had happened. He said that the facility did not know. ADON2 stated that the Administrator would follow up with any reported events to the SA. During an interview on 12/18/2025 at 4:45 pm, the Director of Nursing (DON) stated that the facility staff called and told her what happened with R28. She stated that the facility reviewed the incident the next day. She said that it was determined that R28 had been in the day room when it happened. She confirmed he was a frequent faller. She said that it looked like R28 might have had seizure activity, but there was no way to know if he had the fall or the seizure first before the injury. During an interview on 12/18/2025 at 5:00 pm, the Administrator stated that when he was notified of a resident going to the hospital, he submitted a Facility Incident Report Form to the SA. The Administrator said that he would use the resident's record and then document what happened in the report. Upon reviewing the resident's record of the incident and the subsequent Facility Incident Report Form submitted to the SA, the Administrator confirmed that they did not correspond. He said he was not sure why he documented the date of the fall as 10/7/2025, and that it was witnessed. He stated that if he had known it was unwitnessed, he would have done an investigation as an injury of unknown origin.

Based on interviews, record reviews, a review of the policy titled MDS 3.0 Completion, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to accurately code the quarterly Minimum Data Set (MDS) assessment for one of 52 sampled residents (R) (R20) related to a urinary tract infection (UTI) that was not coded when a resident returned from the hospital. This failure had the potential to result in incomplete care planning. Findings included:A review of the facility's policy titled MDS 3.0 Completion, revised/reviewed 03/01/24, revealed Policy: Residents are assessed, using a comprehensive assessment process, to identify care needs and to develop an interdisciplinary care plan . Policy Explanation and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State .A review of the Centers for Medicare and Medicaid Services (CMS) LTC RAI 3.0 User's Manual, Version 1.20.1, dated October 2025, Chapter 3 MDS Items, Section I: Active Diagnoses, indicated . Item I2300 Urinary tract infection (UTI): - The UTI has a look-back period of 30 days for active disease instead of 7 days. - Code only if both of the following are met in the last 30 days: 1. It was determined that the resident had a UTI using evidence-based criteria such as McGreer's, NHSN [National Healthcare Safety Network], or Loeb in the last 30 days, AND 2. A physician documented UTI diagnosis (or by a nurse practitioner, physician assistant, clinical nurse specialist if allowable under state licensure laws) in the last 30 days . If the diagnosis of UTI was made prior to the resident's admission, entry, or reentry into the facility, it is not necessary to obtain or evaluate the evidence-based criteria used to make the diagnosis in the prior setting. A documented physician diagnosis of UTI prior to admission is acceptable. This information may be included in the hospital transfer summary or other paperwork .A review of the electronic medical record (EMR), an undated admission Record revealed that R20 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction. A review of R20's SBAR (situation background assessment response) dated 7/23/2025 revealed that the resident's family member called 911 and did not communicate concerns with staff; stated to the EMT [emergency medical technician] that the resident was not responding to her. The EMT transferred the resident via stretcher to the hospital. A review of R20's Hospital Discharge Report dated 8/1/2025 revealed under the Diagnosis and Reason for Visit a diagnosis of UTI and . urine cultures 7/23 (7/23/2025) growing E. coli (group of bacteria that can cause infections in the gut, urinary tract, and other parts of the body) multidrug-resistant sensitive to Meropenem (an antibiotic). Patient treated with 7 days of Meropenem. A review of R20's quarterly MDS assessment, with an Assessment Reference Date (ARD) of 8/2/2025 and located in the EMR under the MDS tab, revealed that under the Infections item I2300 Urinary Tract Infection (UTI) (LAST 30 DAYS) was not marked with an X. During an interview on 12/18/2025 at 12:57 pm, the Resident Assessment Director (RAD), RAD1, confirmed the UTI was not coded on the quarterly MDS assessment for R20 with ARD 8/2/2025. The MDS Director stated R20 was discharged from the hospital on 8/1/2025 and was diagnosed with a UTI based on lab results and treated for it with antibiotics. The MDS Director also stated the MDS Coordinator should have coded the UTI on the MDS since R20 had one in the last 30 days. The MDS Director indicated she did not audit any of the MDS assessments to ensure they were accurately completed by the MDS Coordinators. The MDS Director also indicated that the Regional MDS Coordinator had a couple of calls with her staff monthly related to coding MDS assessments and audited some MDS assessments, but was not aware that any errors in coding UTIs were found at the facility. During an interview on 12/18/2025 at 1:23 pm, RAD2 confirmed he did not code the UTI on the quarterly MDS assessment for R20. The MDS Coordinator stated he was trained to code a UTI if the resident had a UTI while in the facility. The MDS Coordinator stated that he used the RAI Manual when coding the assessments and received training on calls monthly held by the Regional MDS Coordinator. During an interview on 12/18/2025 at 2:34 pm, the [NAME] President (VP) of Clinical Reimbursement stated the MDS Coordinators were trained to code a UTI when the resident was diagnosed and treated for a UTI in the hospital within the last 30 days. The VP of Clinical Reimbursement stated she expected the staff to follow the RAI Manual and accurately code the MDS assessments. The VP of Clinical Reimbursement indicated she had regional MDS coordinators over the facilities, and they had not started auditing MDS assessments for accurately coding the UTIs yet. During an interview on 12/18/2025 at 1:29 pm, the Administrator stated he expected staff to code the MDS assessments correctly according to the RAI Manual.

Based on the interview and record review, the facility failed to assess and provide one of 48 sampled residents (R) (R124) with sufficient fluid intake via gastric tube feeding to maintain proper hydration and health. As a result, R124 was admitted to an acute care hospital on [DATE] and died on [DATE] from septic shock, hypoxic respiratory failure, and non-ST elevation myocardial infarction. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the Immediate Jeopardy (IJ) for F692, F710, and F835 on [DATE] at 3:00 pm. The noncompliance related to the IJ was identified to have existed on [DATE]. Based on observations, record reviews, interviews, and a review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on [DATE]. Findings included:A review of the Notification of Changes Policy dated [DATE] and revised on [DATE] revealed that the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.A review of the Hydration Policy dated [DATE] and revised on [DATE] revealed that the facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health.A review of the Physician Visits and Physician Delegation Policy dated [DATE] and revised on [DATE] revealed that it is the policy of this facility to ensure the physician takes an active role in supervising the care of residents.1. A review of an admission Record revealed R124 was an [AGE] year-old male admitted to the facility on [DATE] with medical history that included, but was not limited to, dementia, dysphagia, gastric tube, sepsis, urinary tract infection, hypovolemia, hyperosmolality, and hypernatremia, chronic obstructive pulmonary disease, essential hypertension, atrial fibrillation, and seizures. A review of a Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of [DATE], revealed R124 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was dependent for all activities of daily living (ADL) care, required PEG-tube feedings, was bedfast, and was non-verbal.A review of R124's Care Plan included a focus area initiated on [DATE], which indicated the resident required tube feeding (PEG) related to dysphagia. Interventions directed staff to observe/document/report as needed (PRN) any symptoms of aspiration-fever, shortness of breath, tube dislodged, infection at tube site, self-extubation, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration date initiated [DATE].A review of physician orders dated [DATE] revealed R124's facility physician (MM) ordered comprehensive metabolic panel (CMP) labs that revealed R124 had an abnormal blood sodium level of 151 mEq/L. (Normal Sodium 136 - 145 mEq/L)A review of the electronic medical record (EMR) revealed the facility's previous Director of Nursing (DON) reviewed R124's CMP labs on [DATE] at 10:43 am. The previous facility's DON did not notify/follow up with physician MM since interventions were not ordered to correct R124's hypernatremia.A review of the EMR revealed the facility's Nurse Practitioner (NP) reviewed R124's CMP labs on [DATE] at 9:31 pm. No record of notifying the resident's physician or ordering interventions.A review of labs ordered from [DATE] through [DATE] (Eight days) revealed, physician MM did not recheck labs or provide orders for intravenous (IV) fluids as an intervention to correct R124's hypernatremia. Record review of hospital CMP labs on [DATE] revealed R124's sodium level was 161 mEq/L. R124 was admitted to the hospital from [DATE] through [DATE] (24 days).A review of the nurse's progress note dated [DATE] revealed R124 was observed in bed using accessory muscles to breathe, and he was unresponsive. R124's oxygen saturation levels were out of range (no value documented). Oxygen 100% was applied with no improvement. Physician MM was notified, and they gave orders to send R124 to the hospital.A review of hospital CMP labs on [DATE] revealed R124's sodium level was 161 mEq/L. Record review of hospital Medication Administration records revealed R124 was hospitalized for 24 days and administered continuous IV fluids for severe dehydration, weakness, and acute respiratory failure. The resident was discharged from the hospital and returned to the facility on [DATE].A review of facility readmission CMP labs ordered by physician MM on [DATE] revealed R124's sodium level was 142 mEq/L on [DATE].A review of nursing notes dated [DATE] at 2:46 pm revealed, Note Text: (Nurse) Writer called physician MM concerning resident weight. Physician MM stated that she does not totally agree with fluctuating weight. Physician MM recommends that the resident (R124) be re-weighed tomorrow and that RD follow up with weights and tube feeding. Physician MM was made aware of the lab results of [DATE] of hemoglobin of 8.2 compared to 9.5 on [DATE]. Physician MM stated no new orders at this time based on the normal value of MCV, Albumin of 2.3, and per physician MM, the RD can review and recommend supplements. The Responsible Party (RP) was made aware.A review of the facility Registered Dietitian (RD) notes dated [DATE] at 8:48 am revealed, Nutrition Note: [AGE] year-old male recently readmitted from hospital. Upon readmission resident was triggered with significant weight gain, since they had been triggered with significant weight loss. The team reweighed the resident today. Current wt 145.4 lbs. Tube feeding (TF) infusion meets residents' increased needs. (R124) The resident has multiple wounds. Reviewed lab results [DATE]. See RD recommendations below:Height (HT): 71 (5 ft'9 in)Weight (WT): 145.4 lbs.Body Mass Index (BMI): 20.2Significant Weights: [DATE] readmission wt: 159 lbs./-8.5%A review of R124's hospital records on [DATE] revealed a discharge weight of 163 lbs. R124's had a weight loss of 11.6%; 17.6 lbs. in six days.A review of R124's labs revealed that physician MM did not order any new labs related to R124's change in condition noted by the RD on [DATE], nor after the resident was re-weighed on [DATE]. Weight Results: [DATE] at 10:00 am 145.4 lbs. via mechanical lift.A review of R124's labs revealed that Physician MM did not order any new labs related to R124's change in condition noted by the RD on [DATE].A review of nurse progress notes revealed on [DATE], R124 was observed in bed using accessory muscles to breathe, and he was unresponsive. R124's oxygen saturation levels were out of range. (No value documented) 100% oxygen was applied with no improvement. R124's physician, MM, was notified, and they gave orders to send R124 to the hospital.A review of Emergency Medical Services reported R124's oxygen saturation levels were 85% on 15 Liters of oxygen on [DATE].A review of hospital diagnosis for R124 on [DATE] includes hypoxemic respiratory failure, aspiration pneumonia, urinary tract infections (UTI), adult failure to thrive, dehydration, atrial fibrillation, and metabolic dysfunction.A review of R124's Death Certificate lists cause of death as septic shock, hypoxic respiratory failure, and non-ST elevation myocardial infarction. R124 was pronounced dead at the hospital on [DATE] at 7:04 am.During an interview on [DATE] at 12:06 pm, Physician MM confirmed the abnormal CMP lab findings were not addressed in her assessment, and IV fluids should have been immediately started on [DATE]. Also, Physician MM confirmed misinterpreting new hospital discharge nutrition orders provided on [DATE], requiring 8 to 10 glasses of water to be administered daily via R124's tube feedings. These orders were not implemented, nor was clarification requested. These failures resulted in two preventable hospitalizations on [DATE] and [DATE].During an interview on [DATE] at 1:09 pm, the interim DON stated that it is her responsibility to hold nursing staff and the physicians accountable for completing their job duties. The interim DON also stated that audits will be conducted by checking the admissions, pulling out records, and completing the audit check to make sure that nothing is missed. Interim DON further stated that audits for labs will be performed on a weekly or daily basis, depending on what might be going on at that time in the facility.The facility implemented the following actions to remove the IJ: 1. R124 was discharged from the facility. 2. The Chief Clinical Officer (CCO) immediately met with the Administrator and DON to determine the root cause of the deficiencies. We reviewed all policies related to the IJs received; Hydration policy, Physician Visits and Physician Delegation policy, and Notification of Changes policy, and determined that the root cause of the deficient practice was that we failed to follow our policies. The policies did not require updating. 3. On [DATE], the DON and Assistant DONs began reviewing resident admission orders and labs for the past two weeks to ensure that any hydration and enteral hydration orders were ordered correctly and abnormal labs from the last two weeks had physician notification and were addressed to provide adequate hydration as needed. This will be completed by [DATE]. 4. The CCO on [DATE] in-serviced the Administrator, DON, and Assistant DON on the Physician Visits and Physician Delegation policy and Notification of Changes policy, and Hydration policy to ensure that review of labs, notification to providers is done timely and correctly to provide for the hydration and health of the residents. 5. On [DATE] the CCO, DON, Assistant DON and/or Staff Development Coordinator began in-servicing all Licensed nursing staff (Registered Nurses (RNs), Licensed Practical Nurses (LPNs) on the Hydration policy and ensuring all Labs are reviewed with documented notification to the provider when abnormal labs are received, proper hydration is provided to the residents and orders are transcribed correctly with clarification from the provider as needed. At this time, the following Licensed Nursing Staff have been in-service. (10 of 10 RNs, 29 of 36 LPNs) 39 of 46 (85%) of nursing staff were educated. Any Licensed Nursing staff (RNs, LPNs) who have not already completed the in-service will be educated before working their next shift by the DON, Assistant DON, CCO, or the Staff Development Coordinator. 6. On [DATE], the CCO in-serviced the DON and the Assistant DON on the process of reviewing Labs and admission orders in Morning Clinical Meetings, Monday through Friday. In the Morning Clinical, the DON and Assistant DON will review all labs from the previous day and any stat labs that have resulted in abnormal levels. The DON will ensure that all abnormal labs have documentation of notification to the providers and measures have been taken to provide for proper hydration as needed. The DON and Assistant DON will also review admission orders from the previous day to ensure orders for hydration have been transcribed and followed through with correctly. Any issues found with the labs or admission orders will be addressed immediately by the DON. 7. We have no agency staff currently. 8. The Ad Hoc Quality Assurance Process Improvement (QAPI) meeting was completed on [DATE] for policy review, and root cause analysis determined that staffing education was needed. No changes to the policies were needed. Attendees to the meeting were the CCO, DON, Assistant DON, and the Administrator. The Medical Director (MD) was notified by phone on [DATE]. 9. Corrective actions will be completed by [DATE] with the Alleged date of IJ removal of [DATE]. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review of progress notes revealed that R124 was discharged from the facility to the hospital on [DATE]. 2. A review of the Notification of Changes Policy dated [DATE] and revised on [DATE]. Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. A review of the Hydration Policy dated [DATE] and revised on [DATE]. Policy: The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. A review of the Physician Visits and Physician Delegation Policy dated [DATE] and revised on [DATE]. Policy: It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents. 3. A review of 85 residents' labs audited by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) for abnormal findings. All physicians were notified that hydration interventions were needed. 4. A review of the facility's Inservice Attendance Signature Sheet (dated [DATE]) revealed that the instructor of the in-service was the CCO. The staff members in attendance (as verified with their signatures) included the DON, the Administrator, and the facility's three Assistant DONs. The topics discussed during the in-service included the Notification of Change policy (revision date of [DATE]), Hydration Policy (revision date of [DATE]), and the Physician Visits and Physician Delegation policy (revision date of [DATE]). A review of the policy titled Notification of Changes Policy, (dated [DATE] and revised on [DATE]) revealed that, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. A review of the policy titled Hydration Policy (dated [DATE] and revised on [DATE]) revealed, The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. A review of the policy titled Physician Visits and Physician Delegation Policy (dated [DATE] and revised on [DATE]) revealed, It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents. During an interview on [DATE] at 1:09 pm, the DON stated that it is her responsibility to hold nursing staff and the physicians accountable for completing their job duties. The DON also stated that audits will be conducted by checking the admissions, pulling out records, and completing the audit check to make sure that nothing is missed. DON further stated that audits for labs will be performed on a weekly or daily basis, depending on what might be going on at that time in the facility. 5. Interviews were conducted on [DATE] through [DATE] with the following employees and revealed that they received education and were able to provide appropriate answers related to the in-service: [DATE] at 1:09 pm DON; [DATE] at 1:17 pm Administrator; [DATE] at 5:04 pm Physician PP; [DATE] at 11:18 am ADON HH ; [DATE] at 11:22 am Medical Director NN; [DATE] at 11:41 am ADON II; [DATE] at 12:01 pm LPN JJ; [DATE] at 1:06 am LPN AA; [DATE] at 1:40 am LPN CC; [DATE] at 1:55 am LPN BB; [DATE] at 2:10 am LPN DD; [DATE] at 11:00 am LPN EE; [DATE] 11:15 am LPN FF; and [DATE] at 12:44 pm Physician MM. 6. A review of the Inservice sheet dated [DATE] revealed the CCO provided in-services on the process of reviewing labs and adequate hydration. During an interview on [DATE] at 1:03 pm, the CCO confirmed providing several in-services to the staff regarding revision of labs and hydration to the nursing staff. During an interview on [DATE] at 1:09 pm, the DON confirmed receiving in-services from the CCO regarding the process of reviewing Labs and admission orders in their daily Morning Clinical Meetings. The DON continued that if the DON is not available to facilitate the meetings and review labs, the Assistant DONs will be responsible for reviewing those labs in the morning clinical meeting. The DON continued that since there are three Assistant DONs, they will alternate facilitating the meetings in the event the DON is out of the facility. Interviews were conducted on [DATE] through [DATE] with the following employees and revealed that they received education and were able to provide appropriate answers related to the in-service: [DATE] at 1:09 pm DON; [DATE] at 11:18 am Assistant DON HH; [DATE] at 11:41 am Assistant DON II. 7. During an interview on [DATE] at 12:43 pm, the DON stated they do not employ agency staff at the facility. A review of the facility's active employee list revealed that there was no agency staff listed. 8. A review of the Notification of Changes Policy dated [DATE] and revised on [DATE]. Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. A review of the Hydration Policy dated [DATE] and revised on [DATE]. Policy: The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. A review of the Physician Visits and Physician Delegation Policy dated [DATE] and revised on [DATE]. Policy: It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents. During an interview on [DATE] at 1:09 pm, the DON stated that it is her responsibility to hold nursing staff and the physicians accountable for completing their job duties. The DON also stated that audits will be conducted by checking the admissions, pulling out records, and completing the audit check to make sure that nothing is missed. DON further stated that audits for labs will be performed on a weekly or daily basis, depending on what might be going on at that time in the facility. 9. It was verified that the corrective actions were completed by [DATE]. The removal date of the IJ was [DATE].

Based on interviews and record review, the physician failed to assess laboratory orders for routine monitoring for two of 48 sampled residents (R) (R124 and R213).On 6/2/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the Immediate Jeopardy (IJ) for F692, F710, and F835 on 6/2/2025 at 3:00 pm. The noncompliance related to the IJ was identified to have existed on 4/2/2025. Based on observations, record reviews, interviews, and a review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on 6/4/2024.Findings included:1. Record review of the Physician Visits and Physician Delegation Policy dated 3/1/2022 and revised on 3/1/2025. Policy: It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents. Record review of an admission Record revealed R124 is an [AGE] year-old male admitted to the facility on [DATE] with medical history that included but was not limited to dementia, dysphagia, gastric tube, sepsis, urinary tract infection, hypovolemia, hyperosmolality, and hypernatremia, chronic obstructive pulmonary disease, essential hypertension, atrial fibrillation, and seizures. Record review of a Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/24/2025, revealed R124 has a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident is dependent for all activities of daily living (ADLs) and requires PEG-tube feedings, is bedfast, and non-verbal.Record review of R124's Care Plan included a focus area initiated on 2/17/2025, which indicated the resident requires tube feeding (PEG) related to dysphagia. Interventions directed staff to observe/document/report as needed (PRN) any symptoms of aspiration-fever, shortness of breath, tube dislodged, infection at tube site, self-extubation, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration date initiated 2/17/2025.On 2/17/2025, R124's facility physician (MM) ordered comprehensive metabolic panel (CMP) labs that revealed R#124 had an abnormal blood sodium level of 151 mEq/L. (Normal Sodium 136 -145 mEq/L)Record review revealed the facility's previous Director of Nursing (DON) reviewed R124's CMP labs on 2/18/2025 at 10:43 am. No record of notifying the resident's physician.Record review revealed the facility's Nurse Practitioner (NP) reviewed R124's CMP labs on 2/20/2025 at 9:31 pm. No record of notifying the resident's physician or ordering interventions.Record review of physician orders and labs revealed that physician MM provided no orders for IV fluids as an intervention to correct R124's hypernatremia, nor orders to recheck labs. Physician MM failed to monitor R124's condition to prevent serious injury, serious harm, serious impairment, or death.Record review of nurse progress notes dated 2/24/2025, a nurse observed R124 in bed using accessory muscles to breathe, and he was unresponsive. R124's oxygen saturation levels were out of range. 100% oxygen was applied with no improvement. R124's physician, MM, was notified of the resident's change in condition, and physician MM gave orders to send R124 to the hospital.Record review of hospital CMP labs dated 2/24/2025 revealed R124's abnormal blood sodium level had progressed to 161 mEq/L. R124 was hospitalized for 24 days on continuous IV fluids for severe dehydration, weakness, and acute respiratory failure.Record review of facility readmission CMP labs ordered by MM on 3/19/2025 revealed R124's sodium level was 142 mEq/L on 3/21/2025.Record review of nursing notes dated 3/25/2025 at 2:46 pm revealed, Note Text: (Nurse) Writer called physician MM concerning resident weight. Physician MM stated that she does not totally agree with fluctuating weight. Physician MM recommends that the resident (R124) be re-weighed tomorrow and that RD follow up with weights and tube feeding. Physician MM was made aware of the lab results of 3/21/2025 of hemoglobin of 8.2 compared to 9.5 on 2/17/2025. Physician MM stated no new orders at this time based on the normal value of MCV, Albumin of 2.3, and per physician MM the RD can review and recommend supplements. The Responsible Party (RP) was made aware.Record review of R124's labs revealed that physician MM did not order any new labs related to R124's change in condition noted by the RD on 3/26/2025, nor after the resident was re-weighed on 3/26/2025. Weight Results: 3/26/2025 at 10:00 am 145.4 lbs. via mechanical lift.Record review of nurse progress notes revealed on 4/1/2025, a nurse observed R124 in bed using accessory muscles to breathe, and he was unresponsive. R124's oxygen saturation levels were out of range. (No value documented) 100% oxygen was applied with no improvement. R124's physician (MM) was notified, and they gave orders to send R124 to the hospital.Record review of hospital diagnosis for R124 on 4/1/2025 includes hypoxemic respiratory failure, aspiration pneumonia, urinary tract infections (UTI), adult failure to thrive, dehydration, atrial fibrillation, and metabolic dysfunction.Record review of R124's Death Certificate lists cause of death as septic shock, hypoxic respiratory failure, and non-ST elevation myocardial infarction. R124 was pronounced dead at the hospital on 4/2/2025 at 7:04 am.In an interview with physician MM on 5/29/2025 at 12:06 pm, she admitted the abnormal CMP lab findings were not addressed in her assessment, and IV fluids should have been immediately started on 2/17/2025. Also, physician MM admitted misinterpreting new hospital discharge nutrition orders provided on 3/20/2025, requiring 8 to 10 glasses of water to be administered daily via R124's tube feedings. These orders were not implemented, nor was clarification requested. These failures resulted in two preventable hospitalizations on 2/24/2025 and 4/1/2025. During an interview on 6/3/2025 at 1:09 pm, the interim DON stated that it is her responsibility to hold nursing staff and the physicians accountable for completing their job duties. The interim DON also stated that audits will be conducted by checking the admissions, pulling out records, and completing the audit check to make sure that nothing is missed. Interim DON further stated that audits for labs will be performed on a weekly or daily basis, depending on what might be going on at that time in the facility.2. Resident 213 (R213) is a [AGE] year-old female admitted to the facility on [DATE] with a medical history of metabolic encephalopathy, Human Immunodeficiency Virus Disease (HIV), Thrombocytopenia, Dependence on renal dialysis, and chronic kidney disease.Record review revealed facility physician (MM) was notified on 4/16/2025 at 2:08 PM of R213 HgB levels being seven (7) g/dL (grams per deciliter). (Normal H Range 12.0-16.0)MM gave new orders for Complete Blood Count (CBC) with differential, iron saturation, total iron-binding capacity, ferritin level iron level on 4/17/25.Record review revealed R124's CBC lab dated 4/17/2025, reviewed by Assistant Director of Nursing (ADON) 1 documented Hgb Seven (7). g/dL (grams per deciliter) and Platelet Count 80 (Normal H Range 12.0-16.0)Record review revealed the facility physician (MM) was notified on 4/18/25 at 1:50 PM of Complete Blood Count (CBC) with differential iron saturation, total iron-binding capacity, ferritin level iron level. MM provided no orders for intervention to correct R213's low hemoglobin levels.Interview with MM on 5/29/2025 at 2:39 pm, MM stated only send residents to the hospital when their Hgb is below 7. MM stated R213 attended dialysis three times a week, where their Hgb was monitored. MM stated they would expect dialysis to notify nursing staff if there were concerns with R213's Hgb levels.Interview with Dialysis Manager (DM) on 5/30/2025 at 9:01 am, DM confirmed they do monitor dialysis residents' Hgb. DM stated they are open three days a week, so their critical lab notifications would be relayed late to nursing staff if there was a concern. Follow-up interview with MM on 5/30/2025 at 9:33 am, MM stated they planned on monitoring R213 by putting in an order to do another CBC within a week. MM stated forgot to follow up and could not remember if they told the nurses to enter an order for a follow-up CBC.Record review of Hospital Clinical Paperwork dated 4/26/2025 revealed R213 presented at the hospital today with her G tube pulled out and was found to be bradycardic and hypothermic in the hospital, as well as Hgb 5.9 and K of 2.9. R213 received a blood transfusion.The facility implemented the following actions to remove the IJ: 1. On 4/2/2025, R124 was discharged from the facility. 2. On 6/2/2025, the DON and Assistant DON began reviewing resident labs for the past two weeks to ensure that any abnormal labs from the last two weeks had physician notification and were addressed to provide adequate hydration as needed. This will be completed by 6/3/2025. 3. On 6/2/2025, the DON contacted Physician MM to provide in-service on ensuring that labs are ordered and followed up on, and proper interventions are put in place to provide for proper hydration. 4. On 6/2/2025, the DON and/or Assistant DON began contacting all of the Attending Physicians to in-service them on the importance of ensuring that labs that are ordered are followed up on and proper interventions are put in place to provide for proper hydration. This will be completed by 6/2/2025. Four of four (100%) Primary Physicians were educated.) 5. The Ad Hoc QAPI meeting was completed on 6/2/2025 for policy review, and root cause analysis determined that staffing education was needed. No changes to the policies were needed. Attendees to the meeting were the Chief Clinical Officer (CCO), DON, Assistant DON, and Administrator. The Medical Director (MD) was notified by phone on 6/2/2025. 6. Corrective actions will be completed by 6/3/2025 with the Alleged date of IJ removal of 6/4/2025. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review of the progress notes for R124 revealed that the resident was discharged from facility to the hospital via Emergency Medical Services (EMS) on 4/1/2025. 2. Record review of 85 residents' labs audited by the DON and Assistant DON for abnormal findings. All physicians were notified that hydration interventions were needed. 3. Record review of Lab Review Order dated 6/2/2025, instructed by the Regional Nurse for Physician MM via phone. 4. Record review of Lab Review Order MD/Mid-Level Providers dated 6/2/2025, instructed by the Regional Nurse. Six providers were in attendance; two in person and four via phone. Physician MM, Physician NN, Physician OO, and Physician PP were interviewed on 6/5/2025. 5. Record review of the Notification of Changes Policy dated 10/1/2022 and revised on 4/1/2024. Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Record review of the Hydration Policy dated 3/1/2022 and revised on 3/1/2025. Policy: The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. Record review of the Physician Visits and Physician Delegation Policy dated 3/1/2022 and revised on 3/1/2025. Policy: It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents. 6. It was verified that the corrective actions were completed by 6/3/2025. The removal date of the IJ was 6/4/2025.

Based on the interview and record review, the facility's previous Director of Nursing (DON) failed to administer the facility in a manner that enabled the use of resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one of 48 sampled residents (R) (R124). The facility's systemic failure to notify R124's physician of abnormal laboratory results, assess, and provide R124 with sufficient intravenous (IV) fluids, interventions/fluid intake to maintain proper hydration and health, placed the resident at risk. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the Immediate Jeopardy (IJ) for F692, F710, and F835 on [DATE] at 3:00 pm. The noncompliance related to the IJ was identified to have existed on [DATE]. Based on observations, record reviews, interviews, and a review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on [DATE]. Findings included:Record review of the Notification of Changes Policy dated [DATE] and revised on [DATE]. Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.Record review of an admission Record revealed R124 is an [AGE] year-old male admitted to the facility on [DATE] with medical history that included but was not limited to dementia, dysphagia, gastric tube, sepsis, urinary tract infection, hypovolemia, hyperosmolality, and hypernatremia, chronic obstructive pulmonary disease, essential hypertension, atrial fibrillation, and seizures. Record review of a Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of [DATE], revealed R124 has a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was dependent for all activities of daily living (ADL) care, required PEG-tube feedings, was bedfast, and was non-verbal.Record review of R124's Care Plan included a focus area initiated on [DATE], which indicated the resident requires tube feeding (PEG) related to dysphagia. Interventions directed staff to observe/document/report as needed (PRN) any symptoms of aspiration-fever, shortness of breath, tube dislodged, infection at tube site, self-extubation, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration date initiated [DATE].Record review of physician orders dated [DATE] revealed R124's facility physician (MM) ordered comprehensive metabolic panel (CMP) labs that revealed R124 had an abnormal blood sodium level of 151 mEq/L (hypernatremia - high blood sodium level). (Normal Sodium 136 - 145 mEq/L)Record review revealed the facility's previous DON reviewed/audited R124's CMP labs on [DATE] at 10:43 am. The DON failed to take immediate action after reviewing R124's abnormal CMP labs on [DATE] at 10:43 am; they did not notify/follow up with physician MM to request interventions to prevent serious injury, serious harm, serious impairment, or death.Record review of nurse progress notes dated [DATE], a nurse observed R124 in bed using accessory muscles to breathe, and he was unresponsive. R124's oxygen saturation levels were out of range. 100% oxygen was applied with no improvement. R124's physician, MM was notified of the resident's change in condition, and physician MM gave orders to send R124 to the hospital.Record review of hospital CMP labs dated [DATE] revealed R124's abnormal blood sodium level had progressed to 161 mEq/L. R124 was hospitalized for 24 days on continuous IV fluids for severe dehydration, weakness, and acute respiratory failure. This failure resulted in a preventable hospitalization on [DATE].During an interview on [DATE] at 1:09 pm, the interim DON stated that it is her responsibility to hold nursing staff and the physicians accountable for completing their job duties. The interim DON also stated that audits will be conducted by checking the admissions, pulling out records, and completing the audit check to make sure that nothing is missed. Interim DON further stated that audits for labs will be performed on a weekly or daily basis, depending on what might be going on at that time in the facility.The facility implemented the following actions to remove the IJ: 1. R124 was discharged from the facility on [DATE]. 2. On [DATE], the DON and Assistant DON began reviewing resident labs for the past two weeks to ensure that any abnormal labs from the last two weeks had physician notification and were addressed to provide adequate hydration as needed. 3. The Chief Clinical Officer (CCO) on [DATE] in-serviced the DON and Assistant DON on the Notification of Changes policy and Hydration policy to ensure that review of labs, notification to providers are done timely and correctly to provide for the hydration and health of the residents. 4. On [DATE], the CCO in-serviced the DON and the Assistant DON on the process of reviewing Labs and admission orders in Morning Clinical Meetings, Monday through Friday. In the Morning Clinical Meeting, the DON and Assistant DON will review all labs from the previous day and any stat labs that resulted in abnormal levels. The DON will ensure that all abnormal labs have documentation of notification to the providers and measures have been taken to provide for proper hydration as needed. Any issues found with the labs or admission orders will be addressed immediately by the DON. 5. On [DATE], the job descriptions of the DON and Administrator were reviewed by the CCO. The DON and Administrator were educated and voiced an understanding of responsibilities and job duties. 6. We have no agency staff currently. 7. An AD Hoc Quality Assurance Process Improvement (QAPI) meeting was completed on [DATE] for policy review, root cause analysis was determined, and staffing education was needed. No changes to the policies were needed. Attendees to the meeting were the CCO, DON, Assistant DON, and Administrator. The Medical Director (MD) was notified by phone on [DATE]. 8. Corrective actions will be completed by [DATE] with an alleged date of IJ removal of [DATE]. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Review of R124's EMR revealed R124 was transferred to the emergency room (ER) on [DATE]. Review of the Hospital Record revealed R124 was admitted on [DATE] at 10:59 pm and expired at the hospital on [DATE] at 7:04 am. 2. Record review of 85 residents' labs audited by the DON and Assistant DON for abnormal findings. All physicians were notified that hydration interventions were needed with no concerns noted. 3. Record review of the facility's Inservice Attendance Signature Sheet (dated [DATE]) revealed that the instructor of the in-service was the CCO. The staff members in attendance (as verified with their signatures) included the DON, the Administrator, and the facility's three ADONs. The topics discussed during the in-service included the Notification of Change policy (revision date of [DATE]), Hydration Policy (revision date of [DATE]), and the Physician Visits and Physician Delegation policy (revision date of [DATE]). During an interview on [DATE] at 1:09 pm, the DON stated that it is her responsibility to hold nursing staff and the physicians accountable for completing their job duties. The DON also stated that audits will be conducted by checking the admissions, pulling out records, and completing the audit check to make sure that nothing is missed. DON further stated that audits for labs will be performed on a weekly or daily basis, depending on what might be going on at that time in the facility. 4. During a record review of the in-service packet dated [DATE], revealed that the CCO provided an in-service on the topics of reviewing labs and adequate hydration. During an interview on [DATE] at 1:03 pm, the CCO confirmed providing several in-services to the staff regarding reviewing labs and hydration to the nursing staff.During an interview on [DATE] at 1:09 pm, the DON confirmed receiving in-services from the CCO regarding the process of reviewing labs and admission orders during their daily morning clinical meetings. The DON stated that if the DON is not available to facilitate the morning meetings and review labs, it is the responsibility of the ADONs to facilitate the morning meetings and review any current labs during the morning clinical meeting. The DON also stated that since there are three ADONs, the responsibility of facilitating the meetings will be alternated. During interviews conducted from [DATE] at 1:09 pm through [DATE] at 11:41 pm with the DON, ADON HH, and ADON II revealed that they received education reviewing labs and admission orders. All staff interviewed were able to provide appropriate answers related to the information provided from the in-service packet. 5. During a record review of the In-Service Attendance sheet (dated [DATE]) revealed that the in-service topic was revealed to be Job Descriptions. Review of the attendance also revealed staff in attendance to include the Administrator and DON. The in-service was provided by the CCO of the facility. During an interview on [DATE] at 1:03 pm, the CCO revealed that during the in-service (dated [DATE]), he reviewed the job descriptions of the DON and the Administrator with the DON and the Administrator. CCO stated that for the in-service, he reiterated to the administrator and the DON that their roles included being responsible for ensuring that clinical staff, direct-care staff, and individuals who are providing care to the residents are following through with orders and care according to policies and procedures. CCO also stated that the Administrator and the DON are responsible for ensuring the labs are conducted as ordered and reviewed. CCO further stated that the facility is in the process of implementing a new clinical process to ensure that labs are reviewed to catch anything that may have been missed by physicians. During an interview on [DATE] at 1:09 pm, the DON confirmed that the CCO reviewed the DON job description with her. The DON stated that part of her job duties includes the continuous oversight of the clinical department and ensuring that follow-ups are being completed. The DON also stated that it is her duty to hold the clinical staff, including physicians, accountable and to complete their job duties as assigned. The DON further stated that ensure accountability of the clinical staff by performing weekly or daily audits, which include pulling patient records and reviewing labs. During an interview on [DATE] at 1:17 pm, the Administrator confirmed that the CCO provided several in-services in the last couple of days including review of the Administrator's job description, he stated, I learned that obviously I'm over the whole facility, my role is to make sure that I'm abreast of everything that's going on, the department heads are supposed to relay information to me. 6. During an interview on [DATE] at 12:43 pm, the DON stated the facility does not employ agency staff at the facility. A review of the facility's active employee list revealed that there was no agency staff listed. 7. A review of the Quality Assurance Performance Improvement AD HOC committee meeting minutes dated [DATE] revealed that F692, F710, and F835 were reviewed. The attendees included the Administrator, the DON, the CCO, the third-floor ADON, and the second-floor ADON. The fourth-floor ADON and the Medical Director were in-service via phone. During an interview on [DATE] at 1:17 pm, the Administrator confirmed that the CCO provided several in-services in the last couple of days including review the Administrator's job description, I learned that obviously I'm over the whole facility, my role is to make sure that I'm abreast of everything that's going on, the department heads are supposed to relay information to me. In regard to tracking and trending in future QAPI meetings, the Administrator stated they meet quarterly and will discuss how to track and trend critical labs with the staff. 8. It was verified that the corrective actions were completed by [DATE]. The removal date of the IJ was [DATE].

Based on staff interviews and record reviews, the facility failed to provide adequate supervision to prevent accidents for one of nine sampled residents (R) (R122) reviewed for accident hazards. Harm was identified to have occurred on 4/23/2025 when R122 sustained an injury of unknown origin resulting in ecchymosis and swelling around the right periorbital area.Findings included:A review of the Electronic Medical Record (EMR) for R122 revealed an original admission date of 7/26/2022 with multiple diagnosis of, but not limited to, diffuse traumatic brain injury with loss of consciousness (TBI) systemic lupus erythematosus, traumatic subarachnoid hemorrhage without loss of consciousness, Parkinson's disease with dyskinesia, hypotension, type ii diabetes mellitus, restlessness and agitation, dysphagia, and personal history of transient ischemic attack (TIA).A review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed R122 had a Brief Interview for Mental Status (BIMS) score of three, indicating R122 had severe cognitive impairment.A review of R122's change of condition progress notes dated 4/20/2025 at 9:43 am revealed R122 had witnessed a fall to her knees out of the wheelchair during a smoke break.A review of R122's behavior progress notes dated 4/20/2025 at 11:01 am revealed R122 was observed with eyeglasses that did not belong to her, became aggressive when asked to give them to staff, clutching them tighter. Difficult to redirect, became very agitated, given anxiety med effective.A review of R122's Physician Progress note dated 4/20/2025 at 4:30 pm revealed According to nursing staff, patient took sunglasses that do not belong to light. She became aggressive when asked to give feedback, and she became agitated and difficult to redirect. Patient had to be given a benzodiazepine.A review of R122's late entry post-fall documentation notes dated 4/21/2025 at 8:47 am revealed R122 was not experiencing any pain. The notes also revealed no Skin Issues (Skin Intact, No Bruise/Rash or Other Issues).A review of R122's late entry post-fall documentation notes dated 4/21/2025 at 7:47 pm revealed R122 had no Skin Issues (Skin Intact, No Bruise/Rash or Other Issues).A review of R122's late entry post fall documentation notes dated 4/22/2025 at 8:22 am revealed R122 had no Skin Issues (Skin Intact, No Bruise/Rash or Other Issues.A review of R122's Change of Condition note dated 4/23/2025 at 7:18 am revealed that Nurse observed rt eye swollen, dark purple discoloration increased confusion. The note continued that Executive Director and DON notified. DON assessed the resident. NP advised. In order to transfer to the ER for evaluation. [NAME] Springs police performing an investigation. Left msg for 'R122's responsible party (RP)'A review of R122's hospital record dated 4/30/2025 revealed that R122's reason for the hospital admission was due to sustaining a blackeye from the fall. It was also noted that R122 does not take blood thinners. The hospital record continued that Patient now returns to this facility, found to have ecchymosis and swelling around the right periorbital area. Injury likely occurred between 11:00 pm to 7:00 am. Unknown method of injury. Patient was seen in the emergency room and was noted to be hallucinating, oriented to self only. This does appear to be the patient's baseline. Evaluation in the ER showed intracranial hemorrhage, and she was placed for admission.During an Interview on 5/6/2025 at 9:56 am, Assistant Director of Nursing (ADON) HH revealed that R122 had a few falls. ADON HH continued, he came into work one day and saw R122 had a black eye. They couldn't determine what happened or how to happened. ADON HH continued that R122 is confused today. Since R122's fall, they have been keeping her at the nurse's station for observation. R122 also tends to wander into other residents' rooms.During an interview on 5/21/2025 at 10:41 am, Police Officer YYY revealed that when he arrived at the facility, the resident had a blackeye and it was extremely swollen. No one seems to know what happened to R122, which is very unusual for him. Police Officer YYY continued the ADON HH claimed she fell a few days ago, and it might have happened from that. As Police Officer YYY was exiting the facility, a staff member (unidentified) stated there was another incident with a black eye earlier that week. The Police Officer YYY stated the hospital didn't think the swollen eye was caused by the fall.During an interview on 6/12/2025 at 3:15 pm, the Interim Director of Nursing (I-DON) was provided with the progress notes regarding the fall that occurred on 4/20/2025. The resident was witnessed falling to her knees from her wheelchair during a smoke break; no indication of R122 falling to her head. The I-DON confirmed that, based on the 4/20/2025 progress notes, the blackeye manifesting due to the resident falling to her knees does not make sense.

Based on observation, interview, record review, and review of the facility's infection control policies, the facility failed to: 1.) Ensure an effective Infection Prevention Control Program (IPCP) was implemented and maintained that would investigate and identify an infection outbreak to prevent or reduce the spread of COVID-19 to residents and staff. 2.) The facility was unable to provide documentation of ongoing facility-wide surveillance which included data collection, root-cause analysis, interpretation, and dissemination of surveillance information utilizing the tools identified in the facility's policy and procedure. 3.) The facility failed to properly use disinfectant per the manufacturer's guidelines while cleaning isolation rooms during three of three observations. As a result of these failures 94 residents and 47 staff have tested positive for COVID-19. In addition, 14 of 94 COVID-19 positive residents (Resident(R)#1, R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#11, R#12, R#13, and R#14) died as a result of COVID-19 as of [DATE]. Findings include: 1. According to the facility's policy titled Outbreak Investigation, revised on February 2018, An outbreak is defined as the occurrence of more cases over the usual or expected (endemic) number of cases of healthcare-associated infections in a given area or among a specific group of people over a particular period of time, usually produced by the same organism. If a condition is rare or has serious health implications, an outbreak may involve only one case. The time period will vary according to the infection .Preliminary Investigation: The Infection Preventionist (IP) (and others as assigned), is designated as the investigation coordinator. He or she will review the medical records of the involved parties and determine that an epidemic exists. The investigation coordinator, director of nursing, administrator, and medical director will confer and prepare a preliminary plan of investigation . Analysis: The data collected in the preliminary investigation are reviewed by the investigators to determine whether a common source of infection, break in technique, etc., can be implicated as the cause of the epidemic. A preliminary report will be prepared . Review of Line Listing of Resident Infections, dated [DATE], revealed R#15 complained of abdominal pain, was positive for hematuria (blood in the urine), and was diagnosed with [REDACTED]. On [DATE], R#15 was admitted to the hospital due to acute kidney injury [MEDICAL CONDITION] (a potentially life-threatening condition caused by the body's response to an infection). A hand-written note revealed, on [DATE] that R#15 was positive for COVID per hospital. Review of Ad Hoc (as necessary or needed) QAPI meeting minutes dated [DATE] and [DATE], revealed three residents (R#15, R#16, and R#17) tested positive for COVID-19. On [DATE], R#16 and R#17 tested positive for COVID-19. The facility did not identify and/or investigate the increased number of COVID-19 infections as an outbreak after two additional residents tested positive for COVID-19 on [DATE]. The Line Listing of Resident Infections dated [DATE] did not include any residents tested positive for COVID-19. However, the facility's Ad Hoc QAPI meeting minutes dated [DATE] indicated one resident (R#18) tested positive for COVID-19. The facility did not identify and/or investigate the increased number of COVID-19 infections as an outbreak after R#18 tested positive for COVID-19 on [DATE]. The Line Listing of Resident Infections dated [DATE] did not include any residents tested positive for COVID-19. However, the facility's Ad Hoc QAPI meeting minutes dated [DATE], [DATE], [DATE], and [DATE], indicated one resident (R#19) tested positive for COVID-19 on [DATE] and five facility staff tested positive for COVID-19. There was no evidence the facility completed a COVID-19 Positive Line Listing for staff. The facility did not identify and/or investigate the increased number of residents and staff COVID-19 infections as an outbreak after an additional resident and five staff members tested positive. The COVID-19 Positive Case Line Listing dated [DATE] indicated 53 residents and 21 facility staff tested positive for COVID-19. However, the Ad Hoc QAPI meeting minutes dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] indicated 75 residents and 50 facility staff tested positive for COVID-19. On [DATE], during the entrance conference, the Administrator was asked to provide a list of residents who tested positive and/or expired as a result of COVID-19. That morning, the Administrator provided an undated and untitled document that included a list of resident names, test dates, test result date (test results not included), hospitalization date, expired (yes/no), and expired date. On [DATE], the facility provided an untitled and undated document that indicated 94 residents tested positive for COVID-19 from [DATE] through [DATE]. Of the 94 residents who tested positive for COVID-19, 19 residents transferred to the hospital, and 11 residents expired, either at the hospital or in the facility. On [DATE], the District Director of Clinical Services (DDCS) provided an undated document titled, (Dunwoody) Expirations, which listed the names of three additional residents who expired because of COVID-19, for a total of 14 resident deaths. a. Review of R#1's Admission Record (commonly referred to as face sheet), indicated R#1 was admitted to the facility on [DATE]. R#1's relevant [DIAGNOSES REDACTED]. The COVID-19 Test Results dated [DATE], revealed R#1 tested negative for COVID-19. On [DATE], R#1 tested positive for COVID-19. R#1's Progress Notes dated [DATE], revealed the facility tested R#1 for COVID-19 due to potential exposure to COVID-19 (no signs and symptoms noted) and placed R#1 on droplet precautions. R#1 expired in the facility on [DATE]. b. Review of R#2's face sheet indicated R#5 admitted to the facility on [DATE]. R#2's relevant [DIAGNOSES REDACTED].#2 tested negative for COVID-19. On [DATE], R#2 tested positive for COVID-19. R#2's Progress Note dated [DATE], revealed R#2 transferred to the hospital due to acute [MEDICAL CONDITION] (ARF) and low blood pressure (BP). R#2 expired at the hospital on [DATE]. c. Review of R#3's face sheet indicated R#3 admitted to the facility on [DATE]. R#3's relevant [DIAGNOSES REDACTED]. The COVID-19 Test Results date [DATE], revealed R#3 tested negative for COVID-19. R#3's Progress Notes dated [DATE], indicated that upon returning from [MEDICAL TREATMENT], R#3 complained of chills, weakness, and unable to move legs. On [DATE], R#3 tested positive for COVID-19. On [DATE], R#3 transferred and admitted to the hospital for COVID-19. An untitled and undated documented revealed R#3 expired (at the hospital) on [DATE]. d. Review of R#4's face sheet indicated R#4 admitted to the facility on [DATE]. R#4's relevant [DIAGNOSES REDACTED]. The COVID-19 Test Results dated [DATE] and [DATE], revealed R#4 tested negative for COVID-19. On [DATE], R#4 tested positive for COVID-19. R#4's Progress Note dated [DATE], revealed R#4 discharged and admitted to the hospital on [DATE] for COVID-19. An untitled and undated facility document indicated R#4 expired (date, time, and location not noted.) e. Review of R#5's face sheet indicated R#5 admitted to the facility on [DATE]. R#5's relevant [DIAGNOSES REDACTED]. The COVID-19 Test Results dated [DATE], revealed R#5 tested negative for COVID-19. On [DATE], R#5 tested positive for COVID-19. R#5 admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Review of progress notes revealed R#5 was admitted to the hospital and expired on [DATE]. f. Review of R#6's face sheet indicated R#6 admitted to the facility on [DATE]. R#6's relevant [DIAGNOSES REDACTED].#6 tested negative for COVID-19 on [DATE]. On [DATE], R#6 tested positive for COVID-19. R#6's Progress Notes, dated [DATE], revealed staff found R#6 unresponsive and without a pulse. On [DATE], the staff initiated CPR, applied an AED (automated external defibrillator), called 911, and transferred R#6 to the hospital where she expired. g. Review of R#7's face Sheet indicated R#7 admitted to the facility on [DATE]. R#7's relevant [DIAGNOSES REDACTED]. The COVID-19 Test Results; dated [DATE] and [DATE], revealed R#7 tested negative for COVID-19. On [DATE], R#7 tested positive for COVID-19. On [DATE], R#7 transferred and admitted to the hospital [MEDICAL CONDITION] and GI bleed, placed on comfort care, and expired at the hospital on [DATE]. h. Review of R#8's face sheet indicated R#8 admitted to the facility on [DATE]. The COVID-Test Results, dated [DATE], revealed R#8 tested negative for COVID-19. On [DATE], R#8 tested positive for COVID-19. R#8's Progress Notes dated [DATE] revealed the staff noted R#8 in respiratory distress, unresponsive, and transferred R#8 to the hospital on [DATE]. On [DATE], R#8 expired at the hospital. i. Review of R# 9's face sheet indicated R#9 admitted to the facility on [DATE]. R#9's relevant [DIAGNOSES REDACTED].#9 tested positive for COVID-19. R#9's Progress Notes, dated [DATE], revealed the staff found R#9 unresponsive, with no BP, and no pulse. The staff initiated CPR, applied an AED, and called 911 (emergency services). When emergency services arrived, the paramedics continued CPR, however, R#9 expired at the facility. j. Review of R#10's face sheet indicated R#10 admitted to the facility on [DATE]. R#10's relevant [DIAGNOSES REDACTED]. According to the COVID-19 Test Results, dated [DATE], revealed R#10 tested negative for COVID-19. On [DATE], R#10 tested positive for COVID-19. On [DATE], R#10 expired at the facility. k. Review of R#11's face sheet indicated R#11 admitted to the facility on [DATE]. R#11's relevant [DIAGNOSES REDACTED].#11 tested negative for COVID-19. The Discharge Tracking Record dated [DATE], showed R#11 expired at the facility on [DATE]. R#11 had a sample taken COVID-19 test on [DATE] and the COVID-19 Test Results, dated as completed on [DATE], revealed R#11 tested positive for COVID-19. l. Review of R#12's face sheet indicated R#12 admitted to the facility on [DATE]. COVID-19 Test Results dated [DATE], [DATE], and [DATE], revealed R#12 tested negative for COVID-19. R#12's Progress Note dated [DATE], revealed R#12 stated, I don't feel good. R#12 complained of weakness, fatigue, and a headache. R#12's temperature - 99.9, pulse -77 bpm, SpO2 (oxygen saturation level) 90% on RA, BP - ,[DATE]. COVID-19 test results completed [DATE] were positive for COVID-19. On [DATE], R#12 expired at the facility. m. Review of R#13's face sheet indicated R#13 admitted to the facility on [DATE]. R#13's relevant [DIAGNOSES REDACTED]. The COVID-19 Test Results dated [DATE] and [DATE] revealed R#13 tested negative for COVID-19. On [DATE] a COVID-19 test results came back positive. On [DATE], R#13 expired. n. Review of R#14's face sheet indicated R#14 admitted to the facility on [DATE]. R#14's relevant [DIAGNOSES REDACTED].#14 tested negative for COVID-19. R#14's Progress Notes dated [DATE], revealed R#14 was lethargic, BP - ,[DATE], pulse 119 bpm, respirations 24, temperature 100.7, oxygen saturation level 84% on RA. On [DATE], R#14 tested positive for COVID-19. R#14 sent to the hospital via emergency medical services on [DATE] where the resident expired. 2. The facility's Infection Control Surveillance policy, revised [DATE], revealed .The Infection Preventionist (IP) conducts surveillance of communicable disease and infections among residents and employees . the IP conducts surveillance of healthcare-associated infections . on the Surveillance Line Listing, and Antibiotic Tracking Tool, Log of Employee Infections, and Infection Surveillance Summary Report. Review of the facility's Tool Kit B - Section II - Managing COVID-19 in your Center, dated [DATE] and effective [DATE], revealed, .Healthcare Facility COVID-19 Contact Tracking Log .These spreadsheets are designed to be used by the center as a tool for organizing information related to exposure to COVID-19 positive persons in healthcare setting. If your state has state specific form required, please use those forms .Step 1: For any resident or employee who is confirmed with COVID-19 place their name on the Positive Case Line Listing and compile the information needed. Suspected cases may be included on this tool if directed by your DDCS or local Health Department .Step 2: When a person is added to the Positive Case Line Listing, complete the Location Tracking Form. One form is used for each confirmed person .When residents or employees are identified as having been exposed to the confirmed COVID-19 person, add them to the Exposed Resident or Exposed Employee Spreadsheet. This spreadsheet includes variables that may be important to understand the risk to healthcare workers and other residents .Step 4A: For each person exposed to a resident who is confirmed with COVID-19, investigate the interaction between the case-resident and the exposed contact. Step 4B: For each person exposed to an employee who is confirmed with COVID-19, investigate the interaction between the case-resident and the exposed contact . Review of the facility's [DATE] Line Listing of Resident Infections, which the IP completes, indicated two respiratory facility acquired infections (FAIs) related to pneumonia (unrelated to COVID-19), one respiratory illness (not considered an infection); and two respiratory community-acquired infections (CAIs) related to pneumonia (unrelated to COVID-19). Also, the hospital notified the facility that one resident (Resident (R) #15), who transferred to the hospital related to acute kidney injury (AKI) [MEDICAL CONDITION] (a potentially life-threatening condition caused by the body's response to an infection) tested positive for COVID-19 on [DATE]. Review of the facility's [DATE] Line Listing of Resident Infections indicated one respiratory FAI related to pneumonia (unrelated to COVID-19). Review of the facility's [DATE] Line Listing of Resident Infections indicated one respiratory FAI and one respiratory CAI related to pneumonia (unrelated to COVID-19). The facility could not locate a COVID-19 Positive Cases Line Listing for the tracking and surveillance of staff. Review of the facility's Infection Control Logbook revealed the IP did not complete a Line Listing of Resident Infections outlining any FAIs and/or CAIs identified in [DATE]. On [DATE], the facility provided a copy of the [DATE] COVID-19 Positive Case Line Listing. Review of the COVID-19 Positive Cases Line Listing revealed 53 residents and 20 facility staff tested positive for COVID-19 in [DATE]. The list did not include the four residents with pending test results. The COVID-19 Positive Case Line Listing included the date the residents were placed on droplet precautions but did not include the resident room number/unit, signs/symptoms, rationale why residents or staff were test, disposition (e.g., discharged , expired, transferred, etc.) or additional follow-up. The information listed under the section titled, Date Symptoms First Started is incomplete and includes dates (for some residents) after the date the resident tested positive for COVID-19. On [DATE] at 5:09 p.m., two attempts to contact and interview the previous IP by telephone were unsuccessful. During an interview on [DATE] at 11:13 a.m., MDS Coordinator TT stated that the facility completed surveillance through frequent Ad Hoc (as needed) QAPI (Quality Assurance Performance Improvement) meetings. MDS Coordinator TT further stated that the Interdisciplinary Team (IDT) discussed all residents and staff that tested positive for COVID-19. During the interview, review of the Ad Hoc QAPI meeting minutes with the MDS Coordinator TT, DDCS, and Administrator revealed the Ad Hoc QAPI meeting minutes included a list of residents and or staff-tested and, at times, those residents who came into contact with a staff member who tested positive for COVID-19. Review of the Ad Hoc QAPI meeting minutes revealed some minutes included names of residents or staff who tested positive that month but not the date, some included the identification and testing of residents who may have been exposed or in-service training. There was no evidence the IP and IDT team reviewed surveillance activities of resident and staff infections, audits of facility practices to determine the potential cause of the increase in COVID-19 infections throughout the facility. The information noted in the Ad Hoc QAPI meeting minutes was not included in the surveillance activities as outlined in the facility policy. There was no tracking, trending, or root cause analysis present. On [DATE] at 11:09, and [DATE] at 8:16 a.m. and 11:28 a.m., a copy of the facility's Infection Control Surveillance Plan, based on the facility's assessment, was requested from the Administrator and DDCS; however, the facility did not provide a copy of their completed Infection Control Surveillance Plan during the survey and/or before the survey exit on [DATE]. During an interview on [DATE] at 8:16 a.m., the DDCS indicated the facility is looking for the surveillance records in the IP office. She acknowledged that the current infection control documentation did not give a full picture of what actions the facility took regarding the increase in COVID-19 infections. She indicated that this was because the facility staff knew what they did and that everything happened so quickly that there was a lack of documentation. During an interview with the Medical Director (MD) on [DATE] at 1:30 p.m., the MD said the facility did a great job at the beginning identifying COVID positive residents and that the facility sent those that tested positive to one of their sister facilities. The MD said the facility conducted several Ad Hoc QAPI meetings to discuss the status of infections within the facility. She did review the QAPI meeting minutes, attended the AD Hoc committee meetings when she was in the facility and through conference calls. She felt the facility did identify/investigate the outbreak and conduct surveillance but did not do a great job documenting what actions they took so that it read like a story and showed what steps the facility took. The MD also stated the facility should follow CDC guidelines when conducting surveillance; unfortunately, this virus follows no guidelines. 3. A review of a facility contractors undated policy titled, Interim Recommendations for Routine and Terminal COVID-19 Isolation Room/Unit Cleaning, identified .to protect the facility from the patient, every effort is made to keep the bacteria in the room and isolated by using the double bag procedure for soiled lines, cleaning rags, and trash along with using an EPA (Environmental Protection Agency) approved solution according to manufacturer specifications. Be sure to follow the manufacturer's recommended dwell time. Review of List N: Disinfectants for Use Against [DIAGNOSES REDACTED]-CoV-2 (COVID-19) last updated on [DATE], . (VirexTM II/256) is an EPA-registered disinfectant for use against [DIAGNOSES REDACTED]-CoV2 (COVID-19). This product kills a harder to kill pathogen than [DIAGNOSES REDACTED]-CoV2 (COVID-19); Emerging [MEDICAL CONDITION] pathogen claim. When using an EPA-Registered disinfectant, follow the labeled direction for safe, effective use. Make sure to follow the contact (dwell) time, when the surface should be visibly wet. The contact time for (VirexTM II/256) is 10 minutes. Observation on the third floor COVID unit [DATE] at 9:20 a.m., revealed Environmental Services (ES) QQ cleaned room [ROOM NUMBER], a semiprivate room in which two residents (R#21 and R#22) resided. ES QQ arrived at the room in an isolation gown, mask, and face shield. ES QQ sanitized her hands, gathered her supplies, and entered the room. There was a droplet precaution sign posted on the door to the room. At 9:30 a.m., ES QQ sprayed an approved disinfectant (VirexTM)on the hard surfaces throughout the bathroom and resident's room. At 9:31 a.m., ES QQ started wiping down the hard surfaces and did not allow the disinfectant to remain on the hard surfaces for the appropriate dwell time (10 minutes) to ensure the proper disinfection of the hard surfaces. ES QQ completed cleaning the room at 9:26 a.m. Observation on the fourth floor COVID unit on [DATE] starting at 9:40 a.m., revealed ES RR cleaned a 443A (a private room) for R#23. There was a droplet precaution sign posted on the door to the room. ES RR arrived on the floor dressed in a gown, gloves, mask, and a face shield. ES RR entered the room and began spraying the hard surfaces in the room with a disinfectant solution (VirexTM) and wiping high touch surfaces. ES RR obtained another cloth from the housekeeping cart, sprayed down the bathroom with the disinfectant, and immediately began wiping down the hard surfaces. ES RR did not leave the disinfectant on the hard surfaces for the proper dwell time. ES RR then swept the floor in the room by mopping with a sanitized mopping cloth. ES RR left the room, removed the mopping cloth from the mop, and placed it in a plastic bag hanging on the cart. At 9:50 a.m., ES RR then went back into the resident's room, removed her gloves, and washed her hands with soap and water. Observation on the fourth floor COVID unit on [DATE] at 9:50 a.m., revealed ES RR cleaned room [ROOM NUMBER]A (a private room) for R#24. There was a droplet precaution sign posted on the door to the room. ES RR entered the room in a gown, gloves, mask, and a face shield. ES RR began spraying the hard surfaces in the room with a disinfectant solution (VirexTM) and wiping high touch surfaces. ES RR obtained another cloth from the housekeeping cart, sprayed down the bathroom with the disinfectant, and immediately began wiping down the hard surfaces. ES RR did not leave the disinfectant on the hard surfaces for the proper dwell time. ES RR then swept the room, by mopping with a sanitized mopping cloth. ES RR left the room, removed the mopping cloth from the mop, and placed it in a plastic bag hanging on the cart. At 10:00 a.m., ES RR then went back into the resident's room, removed her gloves, and washed her hands with soap and water. During an interview on [DATE] at 9:36 a.m., ES QQ said the facility uses (VirexTM) to disinfect hard surfaces in the isolation rooms. ES QQ said the disinfectant is supposed to remain on the hard surface for 10 minutes to kill germs effectively. When asked why she did not leave the disinfect on the hard surface for the correct dwell time, she indicated that she thought she did. She said she counts in her mind as she is cleaning the room. She was surprised to learn that she only left the disinfectant in place for one minute before wiping down the hard surface and that cleaning the room only took six minutes. She said that the supervisor provided training on the correct dwell time of the chemicals they use, and depending on the chemical, they staff should allow the disinfectant to sit on the hard surface for five to 10 minutes. During an interview with ES RR on [DATE] at 10:05 a.m., ES RR said the disinfectant should remain on hard surfaces for 10 minutes. When asked why she did not leave the disinfectant on the hard surfaces for the required 10 minutes, the ES RR did not state a reason but acknowledged she received training regarding the ten-minute dwell time. During an interview with the Account Manager for Environmental Services (AMES) on [DATE] at 9:48 a.m., the AMES said that he instructed staff to spray down the bathroom, let the disinfectant air dry while completing other cleaning tasks, and then come back and wipe down the bathroom with a cloth to allow for the required dwell time. Review of the facility's Quality Control Inspection - Housekeeping checklists dated [DATE] through [DATE], the Account Manager for Environmental Services (AEMS) or designee conducted supervised and unsupervised audits. However, there are no indication concerns related to staff not following manufacturer's instructions for the dwell time of chemicals identified. During a second interview [DATE] at 12:45 p.m., the AMES indicated that he had additional Quality Control Inspection - Housekeeping checklists; however, they got wet and were unable to provide copies for review. The AMES also said the environmental services staff uses a five-step cleaning process when cleaning resident rooms. Staff uses (VirexTM) to disinfect all hard surfaces. Staff is required to follow the manufacturer's guidelines for use to disinfect hard surfaces properly. The dwell time for this disinfectant is ten minutes. Dwell time is most important to ensure adequate sanitation to kill [MEDICAL CONDITION]. Staff finds it challenging to wait for the disinfectant to dry. He said that he had advised the staff to spray areas and then go into another area of the room to clean and allow the disinfectant to sit for the proper dwell time so that the chemical is effective. The AMES said that he conducts morning huddles and in-services with staff and that staff complete additional training via online courses. Also, he conducts Quality Control Inspections, some supervised and some unsupervised (look-behind). When he identified concerns, he corrected the staff on the spot. He said the housekeepers are trying to be efficient but know there are more rooms to clean and try to get through the process to get the rooms cleaned.

Based on record review, staff interview and review of facility policies titled Comprehensive Care Plan revised (MONTH) (YEAR) and Elopement Management revised (MONTH) (YEAR) the facility failed to develop a comprehensive care plan with interventions that specify the frequency of service(s) provided and failed to implement the care plan related to provision of monitoring of one resident (R) (R#1) sufficiently to prevent elopement. Seven residents were reviewed for risk of elopement. These failures to provide a care plan that specifically identified how often R#1 should be monitored, and provide sufficient monitoring to prevent elopement resulted in the elopement of R#1. who was found by a bystander at a busy intersection on 4/8/19 at 6:20 p.m. This failure resulted in Immediate Jeopardy. On 4/23/19, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. On 4/23/19 at 4:00 p.m. the facility's Administrator was informed of the Immediate Jeopardy (IJ). The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/8/19 when R#1 eloped from the facility undetected through an exit door on the first floor. The Immediate Jeopardy is outlined as follows: On 4/8/19 resident (R) #1 exited the facility undetected through an exit door on the first floor. The resident was found by a bystander near a busy road after falling to the ground. The bystander called 911 and the Police and Emergency Medical Service (EMS) arrived at the scene. The resident was assessed by EMS to be unharmed. The facility was unaware of the resident's elopement until they were notified by EMS. R#1 has a history of wandering and was wearing a Wander Guard bracelet on his ankle when he left the facility. It was determined that the mechanical function of the handicap assessable/smoker exit door on the first floor allowed the resident to elope from the facility undetected. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements as follows: CFR 483.21(b)(1) Comprehensive Care Plans (F656 Scope and Severity: J) CFR 483.25(d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J) CFR 483.70 Administration (F835 Scope and Severity: J) Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25 (d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J) On 4/25/19 the facility provided an Immediate Jeopardy Removal Plan alleging that interventions had been put into place to remove the immediacy on 4/24/19. Based on interviews, record reviews, and review of facility policies as outlined in the Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 4/25/19. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight as well as develops and implements a Plan of Correction (P[NAME]). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. Findings include: Review of the clinical record for R#1 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the progress notes for R#1 revealed on 3/23/19 at 10:05 a.m. LPN VVVV had observed R#1 wandering in the hallways, walking to stairwells, and to elevators waiting for the door to open. LPN VVVV documented that this behavior was noted several times during the shift and that she placed a Wander Guard and had reported this information to the oncoming shift. An Elopement Risk assessment dated [DATE] was completed by LPN VVVV at 2:30 p.m. with a score of twelve (12) indicating R#1 was at risk for elopement. A review of the care plan for R#1 revealed a focus for elopement risk dated 3/26/19 related to an elopement risk score of 12, new admission to the facility and exit seeking behaviors. Interventions included in part as follows: Monitor resident for wandering and offer pleasant diversions, structured activities, food, conversation, television, book . he enjoys large puzzles, playing basketball and yardwork/gardening. Date initiated 3/27/19. An interview was conducted on 4/16/19 at 3:15 p.m. with LPN VVVV second floor wound care nurse, charge nurse and unit coordinator, related to the assessment of R#1 as an elopement risk. LPN VVVV revealed she had worked 7-3 on 3/23/19 and had observed R#1 attempting to open doors and standing in front of the elevator doors several times and each time she redirected him to his room, to an activity, or gave him a snack. She stated she had told the Certified Nursing Assistant's (CNA's) and others on the second floor such as housekeeping and activities. She stated she had also alerted the Minimum Data Set (MDS) nurse that she knew was developing the comprehensive care plan. She revealed she had applied a Wander Guard to his right ankle after notifying the Physician and obtaining an order and called the family, and updated the elopement books on the first floor in the reception area and the second, third and fourth floor nurses stations. An interview was conducted on 4/17/19 at 1:05 p.m. with the Director of Nurses (DON) related to elopement and care planning for R#1. The DON revealed she expects the nurses and the CNA's to alternate rounds on all residents every hour, with the CNA's ensuring the residents are accounted for and have not become ill or injured every two hours and the nurses visualizing the residents every two hours. The DON acknowledged the residents who are at risk for elopement should be checked more often than this but did not give any length of time between rounds. The DON stated she expected the care planning to reflect the residents elopement risk and guidance related to how often the resident needs to be checked and visualize residents frequently enough to prevent elopement. On 4/17/19 at 4:10 p.m. CNA II was interviewed she revealed she checked the care tracker for each of her residents at the start of every shift and was aware from being assigned to the care of R#1 occasionally that he was at risk from elopement. CNA II revealed the Care Tracker did not mention any specific time frame to monitor R#1 but she had checked his location every time she walked down the hall, sometimes every twenty (20) to thirty (30) minutes to ensure he was able to be located and had not fallen or become ill. CNA II revealed she had worked 4/8/19 3-11 and had taken R#1 to the first floor Bistro to get a snack at about 3:50 p.m. An interview was conducted on 4/18/19 at 8:20 a.m. with CNA EEE related to the elopement of R#1. CNA EEE revealed he checked Care Tracker for all his residents after report from the nurses and the CNA's. He also was familiar with R#1 and was aware of prior exit seeking and wandering. CNA EEE revealed he had been assigned to the care of R#1 the day he eloped and R#1 had been escorted down to the first floor dining area known as the Bistro, by 2 of his coworkers, for a snack at approximately 4:00 p.m. CNA EEE revealed the 2 coworkers brought R#1 back to the second floor a short time later and he went to his room, then when dinner trays came he brought R#1 his dinner in his room. After getting R#1 settled and setting up the tray he left him sometime from 5:30 p.m. to 5:45 p.m. and did not see him again until the paramedics brought him back to the facility. CNA EEE was not sure of the time the Paramedic called and asked if they had a missing resident or what time R#1 returned. An interview on 4/18/19 at 9:29 a.m. with LPN DDD was conducted related to the last time she observed R#1 on 4/8/19. LPN DDD revealed she was told in report that R#1 wandered, and had looked for exits in the past. LPN DDD revealed she also checked care plans for the residents on her assignment. LPN DDD stated she had seen R#1 before his elopement a little before 5:00 p.m. and returned with him to his room to administer two oral medications and a fingerstick blood sugar (FSBS). She stated she had checked to see that R#1 had his Wander Guard in place and it was on his left ankle. LPN DDD revealed she was not aware R#1 was missing until the Unit Manager asked her if she knew where R#1 was and she does not have any recollection of what time that was or what time the Paramedics returned him to the second floor. LPN DDD revealed she does not have any specific amount of time she thinks is adequate to check on residents with a risk of elopement, but thinks they should be in view of the staff or monitored as much as possible. Review of the Facility Incident Report Form revealed R#1 was noted outside of the facility without supervision on 4/8/19 at approximately 6:50 p.m. Review of the 911 Communications Event Report revealed on 4/8/19 at 6:12 p.m. 911 received two calls related to an elderly male at the intersection of two high traffic city streets. The first call revealed he had fallen into the road. The second call revealed he was lying in the road. A third call was received at 6:13 p.m. and revealed he kept falling down. The call was answered with local police on the scene at 6:20 p.m. An observation on 4/23/19 at 5:20 p.m. was made by the surveyor related to the time dinner trays arrive on the second floor and the time dinner tray is delivered to the room that R#1 resided in. The first cart arrived at 4:26 p.m. and the tray for R#1's former room. The second cart arrived at 5:35 p.m. and the tray was delivered to the resident currently residing in room at 5:44 p.m. A review of the facility policy titled Comprehensive Care Plan revised (MONTH) (YEAR) revealed on page 3 of 4 , #9 That care plans must be developed within 7 days after completing the comprehensive assessment and must include interventions that specify the frequency of service(s) provided. A review of the facility policy titled Elopement Management revised (MONTH) (YEAR) revealed the following: While alarms can help to monitor a resident's activities, staff must be vigilant in order to respond to them in a timely manner. Alarms do not replace necessary supervision. Refer to F689 The facility implemented the following actions to remove the Immediate Jeopardy: SS=IJ F656 Develop/Implement Comprehensive Care Plan Immediate Corrective Measures: On (MONTH) 8th, 2019, Resident #1 exited the facility without notification or supervision via the side entrance door. The resident wears a Wander Guard alert bracelet secondary to his risk of elopement. The side entrance door is equipped with a Wander Guard Alert system. The Unit Manager validated that the resident's alarm was in place and functioning appropriately upon the resident's return to the facility on [DATE] and Resident #1 was immediately placed on 1:1 continuous supervision. A review of the plan of care revealed the facility failed to implement a comprehensive care plan to address Resident #1's elopement risk and subsequently led to the resident exiting the facility without staff knowledge or supervision. A review of Resident #1's plan of care revealed that Resident #1's care plan was revised by MDS Nurse on 04/10/19 post-elopement to include 1:1 supervision and resident's triggers for wandering/eloping and how staff can assist in de-escalating wandering and exit seeking behaviors by being offered a snack and or calling his daughter so he can talk to her. Resident #1 was discharged to another facilty with a secure until on 4/11/2019. Identification of Others At Risk Residents who utilize a Wander Guard have the potential to be affected. There is one resident who utilizes a Wander Guard currently in the facility. This resident's Wander Guard is reviewed for placement and functionality daily 7 days per week and door monitors remain at elevators 24/7 on the floor which this resident resides. No other residents were affected. The Licensed Nurse reviewed this resident's plan of care on 04/10/2019. On 04/23/2019 a revision was made to include redirection when the resident states she has to go pick up her children. Resident #1 and Resident #5 were discharged to another facility with a secure unit on 04/11/2019. Resident #4 was discharged to another facilitiy with a secure unit on 04/12/2019. Resident # 6 remains in the facility and utilizes a Wander Guard. Residents #11, #2,and #3 were reviewed by nursing leadership on 04/17/2019 and were determined to not be at risk for elopement and care plans revised. Systemic Changes The Nurse Managers (Director of Nursing, Assistant Director of Nursing, Unit Managers, Unit Coordinators and Staff Development Nurse) initiated education on 4/08/19 to the staff regarding the facility's policies governing Elopement Prevention & Management and Development of the Comprehensive Care Plan to include identification of residents with behaviors and development and accessing the resident's plan of care. This education includes a review of the process for how the Certified Nursing Assistants access the resident plan of care via the electronic medical record. Staff accesses the residents' plan of care via the electronic medical record in Point of Care. Kiosks are located throughout the unit as well as at the nurse's station for staff access to the electronic medical record. Resident centered interventions, including the use of a Wander Guard device, are communicated to the Certified Nursing Assistant via the plan of care contained in the resident's electronic medical record. A list of residents who wear a Wander Guard device is also maintained in a Red Binder at the 2 nd Floor nursing station. An Elopement Risk binder is maintained at each nurses station and at the Receptionist Desk. This education also included maintaining the integrity of the door and Wander Guard codes. Education has been provided to 93% of the facility's staff members including the 2 receptionist (1 classed under CNA, 1 classed under Administration). Current facility staffing consists of: 49 LPNs (1 on LOA), 72 CNA's (1 on LOA), 16 RN's, Dietary Services 18, Environmental Services 16, Social Services 2, Administration 14, Activities 5, Maintenance 3, and Rehabilitation Services 27. Of the facility's current employee roster the following have received education: LPN's 48, CNA's 71, RN's 16, Dietary Srvcs 15, Environmental Services 11, Social Services 2, Administration 13, Maintenance 3, and Rehabilitation Services 26. The Nurse Managers will continue to provide education to current staff prior to the start of their next scheduled shift and to new staff members during the orientation process. No staff shall work in the resident care area prior to receiving education. The IDT team (Administrator, Director of Nursing, Medical Director, Nurse Managers, Social Services, Activities, Dietician, Therapy, and Maintenance Director) will continue to adhere to the established process for Elopement Prevention & Management in accordance with organizational policy and regulatory guidelines. A letter was mailed to resident representatives providing education regarding elopement prevention on 04/17/2019 and added to the admission packet on 04/23/2019. This is documented in the Ad-Hoc QA/PI Plan held on 04/08/2019. Education to alert, oriented, and ambulatory residents was provided on 04/24/2019 to 27 of 46 residents. Education will continue until all of the identified residents are educated. This is documented via in-service education sheets. Through an Ad-Hoc Quality Assurance meeting held on 04/08/2019 the ID team which consisted of Administrator, Director of Nursing, Medical Director, and clinical managers conducted a review of the established facility policy governing Resident Elopement and Development of the Comprehensive Care Plan with no revisions indicated. The Administrator is responsible for the implementation of and adherence to this removal plan. The State Survey Agency (SSA) validated the implementation of the facility's Plan of Immediate Jeopardy Removal as follows: A review of an incident report dated 4/9/19 revealed on 4/8/19 R#1 was noted outside the building without supervision. A review of the care plan dated 3/26/19 for R#1 revealed he was at risk for elopement related to exit seeking behaviors and on 3/23/19 began to wear a Wander Guard device. Review of the Nurses Progress Notes for R#1 revealed that after he was returned to the facility on [DATE], with no time documented, he was placed on one to one monitoring. This was verified by an interview with the second floor Unit Manager during an interview on 4/ 16/19 at 9:45 a.m. The Unit Manager revealed she had checked the Wander Guard as soon as R#1 was back in the building and the device was on and functioning and she had immediately kept him at the desk with her or with a CNA to stay with him one to one until all the door and elevator monitors were in place. An interview with MDS Nurse CCCC on 4/26/19 at 11:10 a.m. revealed she had revised the care plan for R#1 on 4/10/19 to include useful and individualized information for the staff on how to help R#1 to remain safe by offering food and calling his daughter if needed to redirect his attention in another direction. During interviews with CNA EEE on 4/18/19 at 8:20 am, CNA II on 4/17/19 at 4:10 p.m., CNA KK on 4/17/19 at 4:15 p.m., LPN DDD on 4/18/19 at 9:29 a.m. revealed they had worked on the second floor on the 3-11 shift the evening of 4/8/19 when R#1 eloped and they had not seen him from 5:30 p.m. - 5:45 p.m. until the EMS paramedics returned him to the floor after 7:00 p.m. The CNA's and LPN revealed they were all aware of the residents need for monitoring due to the Care Plan and Care Tracker that revealed he was at risk for elopement and were also aware of interventions for diverting him from exit seeking behaviors. A review of the elopement books on the second, third and fourth floors and in the reception area of the first floor, each with listings of residents who are provided with Wander Guards, face sheets, their elopement risk care plans, and daily Wander Guard Checks listing the location of the device, the state of the device, the date of the check, the name of the nurse performing the check and the signature of the nurse, revealed on 4/19/19 there was one resident in the facility with a Wander Guard, R#6. The Wander Guard checks were reviewed from for R#6 and were completed daily. A review of the three residents care plans was completed and they had been revised to reflect the risk of elopement had been resolved. A review of residents utilizing Wander Guard devices on 4/8/19 revealed there were seven residents listed. Three residents, R#2, R#3, and R#11 were reviewed by the survey team and had documented elopement risk assessments that were negative for risk on 4/17/19, and when observed were not wearing Wander Guard devices. A review of the clinical record for R#1 revealed he was discharged to a nearby sister facility with a Life Engagement Program on 4/11/19. An interview with the legal guardian of R#1 on 4/17/19 at 10:15 a.m. revealed she had approved of the transfer of R#1 to a facility with a dedicated program for residents who were at risk of elopement and had not felt any pressure to transfer her father. On 4/17/19 at 2:23 p.m. R#5's brother was interviewed on the telephone. He stated he was the Power of Attorney for R#5 and his RP, though his daughter handled many of his day-to-day affairs. He stated his daughter texted him to advise him of the transfer and he understood the new facility offered care for dementia and was a better placement for him. He stated the facility did not pressure him in any way to accept the transfer. He stated if R#5's daughter was against it she certainly would have told him. On 4/19/19 at 9:00 a.m. R#4's family member was interviewed over the telephone. She stated she was R#4's daughter, RP, and POA. She stated she did not feel pressured to agree to the transfer because the Administrator explained everything about the new facility to her and she agreed it was a better place. She stated she was satisfied with the facility's response to her mother's elopement and she thought it was too bad her mother had to leave the facility, but she did agree to the transfer. Interviews were conducted with the following staff on the fourth floor on 4/25/19. RN GG 10:40 p.m., 3-11 shift, length of service (LOS) two years, LPN DDD 10:45 p.m., 11-7 shift, LOS 30 days, CNA JJJ 10:55 p.m. 11-7 shift, LOS three years, the ADON 11:05 p.m. LOS three weeks, CNA KKK, 11:15 p.m. LOS 10 months, LPN LLL 11:25 p.m., 11 - 7 shift, LOS three weeks - agency nurse, CNA EEE 11:35 p.m., 11-7 shift, LOS one year, CNA MMM 11:45 p.m., 11-7 shift, LOS eight months, LPN NNN 11:55 p.m., 11-7 shift, LOS four years, and LPN OOO 4/25/19 12:00 a.m., 11-7 shift, LOS [AGE] years. Interviews were also conducted with LPN AAAA on 4/26/19 at 10:55 a.m., fourth floor, 7-3 shift, LOS [AGE] years, and LPN BBBB on 4/26/19 at 10:55 a.m. in the conference room, third floor staff, 7-3 shift, LOS one year. On 4/26/19 at 11:30 a.m. CNA HHHH, 2nd floor, 3-11 shift, LOS two years, and CNA JJJJ, third floor, 7-3 shift, LOS three months were interviewed in the conference room. On 4/26/19 at 11:45 CNA KKKK, Staffing Coordinator, LOS one year and CNA LLLL, fourth floor, day shift, LOS [AGE] years, were interviewed in the conference room. Interviews were conducted confirming education received related to Elopement Prevention and Management, Development of the Comprehensive Care Plan, identification of residents with behaviors and development and accessing the resident's plan of care, maintaining the integrity of the door and Wander Guard codes, and monitors for doors and elevators are never to leave their posts unless a relief staff person is present from 4/8/19 through 4/24/19 with the following staff: Night Receptionist PPP at the front door on 4/25/19 at 10:30 p.m. LOS 3.5 years hours 7:00 p.m. to 8:30 a.m., CNA KK who works all shifts at 10:35 p.m. monitoring at the first floor side entrance LOS one year, LPN QQQ second floor at 10:40 p.m. 3-11 shift , CNA RRR at 10:45 p.m. on the second floor monitoring the main elevators, works 3-11 shift, Maintenance Assistant AA at 10:50 p.m. monitoring the second floor ambulance elevator and was called in to monitor the first floor side entrance on 4/8/19 at 7:00 p.m., LPN SSS second floor 11-7 shift at 10:52 p.m., LPN TTT at 10:53 p.m. second floor 3-11 shift, CNA UUU at 11:00 p.m. second floor main elevator monitor for 11-7 shift, LOS 5 years, CNA VVV at 11:25 p.m. third floor CNA 11-7, LOS [AGE] years, CNA VV at 11:20 p.m. 11-7, LOS 8 years, CNA WWW at 11:35 p.m. float 11-7, CNA KKK at 11:27 p.m. second floor, CNA XXX at 11:28 p.m. fourth floor 11-7. On the fourth floor the following staff were interviewed and confirmed knowledge of the above education provided to them between 4/8/19 and 4/24/19: CNA YYY 11-7 shift at 11:40 p.m. , LPN ZZZ at 11:55 p.m. 11-7 shift LOS [AGE] years All of the above employees affirmed they had attended multiple in-services, online trainings, and education by telephone from 4/8/19 and as recently as 4/24/19, with informal discussions of elopement during shift report. All affirmed they participated in one or two elopement drills in the past week. These employees confirmed if there was a Code Yellow (resident elopement) called over the paging system, the would do an eyes-on head count of their assigned residents even if they had to go to another area such as the dining room to lay eyes on them. The affirmed they would then report their head count to the charge nurse who would then declare all clear or continue the search for the missing resident. The employees affirmed if they were in the lobby on the first floor and heard a Wander Guard alarm they would find out the reason the alarm went off and would look outside for the missing resident if the resident was not in the lobby. All employees affirmed that facility staff were the only ones authorized to possess the keypad access codes and would report any visitor or resident possession so the codes could be changed. All affirmed they could access the residents' care plans in shift report, communication with the resident's nurse, or by accessing it in the electronic health record (EHR). All CNAs interviewed demonstrated on the CNA kiosks how they accessed care plans the electronic Kardex. Nurse interviews in this group revealed the nurses had access to the Point, Click, Care (PCC) EHR software suite and they demonstrated proficiency. Nurse interviews further revealed they could make changes to the care plans when there was a change of condition, such as exit-seeking behaviors, and the policy was to bring these changes up at morning report and it would be discussed at the daily interdisciplinary team meeting. All employees agreed the training offered on elopement was mandatory and they were not allowed to work without it. On 4/26/19 at 11:00 a.m. the Director of Maintenance was interviewed in the conference room. He stated he had three mandatory in-services in the last three weeks, with the last one being on 4/24/19. He stated his role during a Code Yellow was to be sure the equipment on the doors was working properly. He stated he would go to the affected area to check the door alarm. He stated if a resident was not found quickly inside the building an outside search would be started fast. He further stated multiple jobs had been done to upgrade the door locks, panic bar alarms, daily checks of all outside doors to ensure they were locked, and to improve the Wander Guard system. On 4/26/19 at 11:10 a.m. the following staff were interviewed in the conference room: RN CCCC, MDS nurse, day shift, LOS [AGE] years, RN DDDD, Wound Care Nurse, day shift, LOS two years, and RN EEEE, MDS nurse, LOS four years. These nurses all agreed recent elopement in-service training was essentially an on-going daily project, consisting of daily in-service briefing and formal classes. They affirmed if a Code Yellow was called they would be assigned a role by the unit affected charge nurse. Their roles would involve a head count or assisting with the search. The affirmed if they heard a door alarm they would not leave that door until the cause of the alarm was ascertained. They agreed any nurse in the facility could easily access and change any residents' care plan and the CNAs were kept in the know by their kiosks and verbal communication. RN EEEE stated they often got calls from the floor nurses to advise MDS of the changes; the MDS nurses would give assistance with care plan format and of course to update the MDS. On 4/26/19 at 12:00 p.m. the Assistant Administrator, Medical Records Tech XX, and the Human Resources Director were interviewed in the conference room. They affirmed they had had three in-services on elopement in the past two weeks with the last in-service being on 4/24/19. MRT XX stated if she heard a Code Yellow she was to stop what she was doing, leave her office on the first floor and to search for the resident or at least find out why the alarm was going off and to keep at it until the Code Yellow was cleared. The Assistant Administrator stated they would continue to have a person guarding the elevators and doors until they believed the building to be safe. He stated further they had discharged the residents with exit-seeking behaviors because the facility could not meet their needs. The Human Resources Director stated her job during a Code Yellow was to man the door where the alarm was going off and to call for help. She stated an outside search would be conducted if they did not find the resident quickly. On 4/26/18 at 12:30 a.m. Physical Therapy Assistant (PTA) MMMM, LOS one year, PTA NNNN, LOS 18 months, and Physical Therapist (PT) OOOO, LOS [AGE] years, were interviewed in the conference room. They all affirmed they had three recent trainings on elopement, with the latest one being on or about 4/21/19. The stated their role in elopement prevention consisted of assisting with the search, redirecting residents, guarding doors, and to report their observations to the facility staff running the code yellow. On 4/26/18 at 1:15 p.m. Social Worker (SW) PPPP, LOS seven years, SW QQQQ, LOS six years, the Activity Manager, Activities Assistant SSSS, and Activities Assistant TTTT were interviewed in the conference room. Each of these employees affirmed there had been three elopement-based inservices in the last two weeks, with the last one being several days ago. The Activities Manager stated these inservices were mandatory and no worker could clock in without having completed the training by the deadline. All further agreed their roles during a Code Yellow elopement alarm were situational, but involved first ensuring resident safety, searching for the missing resident, responding to the particular door alarm and not leaving the door unattended. On 4/26/18 at 1:40 p.m. R#13 was interviewed in the lobby near the side smoking doors. He was sitting in an electric wheelchair and wearing clean clothes and shoes. He was noted to have left-sided [MEDICAL CONDITION]. No odors were noted. He stated he lived in the facility for three years and was a retired Navy man. He stated after the elopement UM OO came to his room and explained the elopement and how she was keeping the building and the residents safe. He stated he had no problem with this. On 4/26/18 1:55 p.m. R#12 was interviewed with a family member near the Administrator's office. She was in an electric wheelchair and wearing clean clothes and shoes with no odors noted. She was clean and well-groomed. She stated she had lived at the facility for a while. She stated she heard about the elopement and the facility was safe from someone on the staff. The family member stated there was a letter from the facility, but she had not opened it yet. On 4/26/18 at 2:00 p.m. Cook UUUU, LOS [AGE] years, Dietary Aide BB, LOS two years, and Dietary Aide CC were interviewed in the dining room near the kitchen. They affirmed three recent in services on elopement, with the last one being two or three days ago. Cook UUUU stated the first thing she would do during a Code Yellow would be to secure her work station and shut down her oven. She would then go to the front of the house, find out who was missing, and search inside and outside the building until the resident was found or there was a Code Yellow Clear on the overhead speaker. All affirmed this and that the trainings were mandatory. Dietary Aide BB stated he would first shut down his dishwasher and search for the resident after he found out who was missing up front. He stated he could not clock in without taking the elopement classes. On 4/26/19 at 2:10 p.m. R#14 was interviewed on the fourth floor. He was seated in a wheelchair wearing clean clothes and shoes with no odors noted. He was accompanied by a gentleman who identified himself as R#14's son and his Responsible Party. He stated the facility sent him a letter about the elopement and he was satisfied with the response of the facility. Education sign in rosters were compared with the list of all current employees in all departments provided by the Administrator. The listing of all current employees included two hundred and twenty four names and was divided by the number of employees signing the rosters, which included two hundred and ten names and resulted in confirmation of 93.75% of all employees educated as alleged in the Plan of Removal from 4/8/19 through 4/24/19. A letter with no date was submitted to the survey team by the Administrator that explained important tips to ensure the safety of the residents. The Administrator was interviewed on 4/19/19 at 8:20 a.m. and revealed he had mailed this letter to the families, responsible parties, and first contacts listed for each resident on 4/17/19, and the letter would also be included in each admission packet. A review of the Ad Hoc Quality Assurance Performance Improvement Committee Plan Meeting minutes dated 4/8/19 revealed the Interdisciplinary t

Based on observations, clinical record review, staff and Emergency Medical Services (EMS) interview and review of facility policy and practice guidelines titled Elopement Management dated (MONTH) (YEAR), the facility failed to provide supervision and monitoring to prevent the elopement of one resident (R), (R#1) from a sample of seven (7) residents identified by the facility to be at high risk for elopement. The facility failed to ensure the first floor side entrance/exit door Wander Guard system functioned adequately to prevent the elopement of one resident (R) (R#1) who exited the building undetected on 4/8/19. In addition, the facility failed to provide a safe and secure environment related to a first-floor side entrance door that was not in view of staff on 4/8/19, the day R#1 eloped and was found by a bystander. On 4/23/19, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. On 4/23/19 at 4:00 p.m. the facility's Administrator was informed of the Immediate Jeopardy (IJ). The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/8/19 when R#1 eloped from the facility undetected through an exit door on the first floor. The Immediate Jeopardy is outlined as follows: On 4/8/19 resident (R) #1 exited the facility undetected through an exit door on the first floor. The resident was found by a bystander near a busy road after falling to the ground. The bystander called 911 and the Police and Emergency Medical Service (EMS) arrived at the scene. The resident was assessed by EMS to be unharmed. The facility was unaware of the resident's elopement until they were notified by EMS. R#1 has a history of wandering and was wearing a Wander Guard bracelet on his ankle when he left the facility. It was determined that the mechanical function of the handicap assessable/smoker exit door on the first floor allowed the resident to elope from the facility undetected. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements as follows: CFR 483.21(b)(1) Comprehensive Care Plans (F656 Scope and Severity: J) CFR 483.25(d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J) CFR 483.70 Administration (F835 Scope and Severity: J) Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25 (d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J) On 4/25/19 the facility provided an Immediate Jeopardy Removal Plan alleging that interventions had been put into place to remove the immediacy on 4/24/19. Based on interviews, record reviews, and review of facility policies as outlined in the Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 4/25/19. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight as well as develops and implements a Plan of Correction (P[NAME]). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures Findings include: Review of facility policy titled Elopement Management revision date (MONTH) (YEAR) page 1 of 2 revealed in part: Fundamental Information Unsafe Wandering or Elopement According to the Center for Medicare and Medicaid Services, wandering is random or repetitive locomotion. This movement may be goal-directed (e.g., the person appears to be searching for something such as an exit) or may be non-goal directed or aimless. Non-goal directed wandering requires a response in a manner that addresses both safety issues and an evaluation to identify root causes to the degree possible . while alarms can help to monitor a resident's activities, staff must be vigilant in order to respond to them in a timely manner. Alarms do not replace necessary supervision. Review of the clinical record for R#1 revealed an original admission date of [DATE]. [DIAGNOSES REDACTED]. An elopement risk assessment completed by Licensed Practical Nurse (LPN) VVVV on 3/23/19 revealed R#1 was at high risk for elopement. LPN VVVV was interviewed on 4/16/19 at 3:15 p.m. and revealed she was working on 3/23/19 and mid-morning R#1 started to try to open doors and seemed to be looking for a way off the second floor. She had redirected him with food and the activities staff were there and helped to involve him in the activities room, but he was observed several more times trying doors. She then notified the Physician and was given an order for [REDACTED].#1's face sheet and Wander Guard checklist to the elopement books on the three resident care floors and the front lobby. LPN VVVV revealed she had also given the next shift nurses and CNA's the information in report and discussed the behavior with the Minimum Data Set (MDS) Nurse CCCC who was developing a comprehensive care plan. LPN VVVV revealed she had documented this information in Nurse's Progress Notes. LPN VVVV confirmed she had not added this information to the baseline care plan or documented the behavior on the 24 Hour Report. LPN VVVV acknowledged she should have documented this behavior on the 24 Hour Report and on the Baseline Care Plan. Further review of Nurse's Progress Notes revealed on 3/29/19 at 2:17 p.m., 4/1/19 at 11:50 a.m., 4/1/19 at 7:39 a.m., and 4/1/19 at 5:40 a.m.,4/3/19 at 4:06 p.m., 4/3/19 at 10:44 a.m., 4/4/19 at 11:14 a.m., there was documentation of R#1 wandering in the hallways. On 4/4/19 at 11:05 p.m. LPN QQQ documented that R#1 was noted wandering from his room attempting to go on elevator and was angrily aggressive to staff, and had removed the furniture from his room and attempting to hit staff and threw water on them. His daughter was notified and spoke with him but he remained angrily aggressive. A therapist came and spoke and he remained in his room that night. Review of the Progress Notes for R#1 dated 4/8/19 at 9:35 p.m. revealed LPN DDD documented that R#1 was wandering in the halls of the second floor at dinner time and was redirected back to his room and meal tray. The staff was later notified that R#1 had been found by Emergency Medical Service (EMS) with no noted injuries and returned to the facility. No time was documented for the notification from EMS or the return of R#1 back to the facility. An interview was conducted with the Administrator on 4/16/19 at 9:15 a.m. The Administrator revealed he was called by staff at approximately 7:00 p.m. on 4/8/19 and was informed that R#1 had eloped and been found at the intersection of two streets with heavy traffic. The Administrator revealed he immediately gave orders to have staff posted at the side entrance/exit door, and at the main and ambulance elevator doors on the second floor. The Administrator revealed there is no way to determine how R#1 entered the elevator on the second floor or exited through the side entrance/exit door. He revealed there is always a receptionist at the front lobby desk 24 hours a day 7 days a week and they do not leave that desk until someone comes to relieve them. The Administrator revealed there are two alarm sensors that the resident would have to go through on the second floor and one on the first floor to travel to the front lobby by way of the ambulance elevator, then when exiting that elevator a resident with a Wander Guard would activate the front door locks and the alarm system, and they would be directly in front of the reception desk, so an exit through that door is very unlikely. The Administrator revealed that on 4/8/19 at 10:35 p.m. he and the door technician and the Maintenance Director had determined that the Wander Guard system on the side entrance/exit could be disabled by a person without a Wander Guard opening the door and standing or sitting in the doorway. The Wander Guard system was over ridden by a door sensor so there was no alarm, door closure or locking when a resident with a Wander Guard approached if someone was in the doorway. The Administrator revealed he and the Maintenance Director, and the door technician had no knowledge of the over ride on the Wander Guard system and he and the Maintenance Director had not been employed here when the system was installed. He revealed the door had not been tested with someone standing or sitting in the doorway without a Wander Guard device before 4/8/19 at 10:35 p.m. The Administrator revealed this is a very high traffic door with independent residents and families with their residents gathering outside this door. He did not know there was a way for a resident with a Wander Guard to exit through this door without activation of the alarm, door closure, and the recently installed magnetic locks. The Administrator revealed he had this override removed from the door sensor on 4/16/19 prior to the surveyor's entrance and could not demonstrate on this door how the override had deactivated the Wander Guard system. The Administrator revealed he had investigated the elopement of R#1 and determined that he had last been observed on 4/8/19 between 5:30 p.m. and 5:45 p.m. He was unable to determine what time the EMS paramedic called to ask if there was a missing resident with the name of R#1 because no one documented the time. A review of door and elevator maintenance statements revealed on 4/8/19 at 10:35 p.m. the Administrator signed an invoice from a door company acknowledging satisfactory work and that the Wander Guard system was not detecting devices correctly and the customer was to call Information Technology (IT) to correct the issue. On 4/16/19 another invoice was reviewed from a door and lock company to replace a function lever on a first floor side door. Review of door and elevator monitoring (staff)schedules for the first floor side entrance, the main entrance which was the receptionist, the second floor main elevator and the second floor ambulance elevator were reviewed from 4/8/19 at 7:00 p.m. through 4/25/19 at 7:00 a.m. On 4/16/19 at 9:32 a.m. the main elevators on the second floor were observed by the surveyor. The surveyor stood outside the elevator doors for four (4) minutes and one elevator door opened and the surveyor was able to get on the elevator without entering a 4 digit code on the keypad outside the elevator. On 4/18/19 at 8:40 a.m. the surveyor again waited outside the second-floor main elevators for the door to open and in eight (8) minutes the door opened and the surveyor was able to use the elevator with no numeric code. On 4/19/19 at 8:50 a.m. the surveyor was again able to exit the second floor by the main elevator by waiting for ten (10) minutes for someone to come to the second floor and boarding the elevator when they exited. On 4/23/19 at 10:33 a.m. the surveyor observed the second-floor main elevators and the door remained open for seventeen (17) seconds before closing. The surveyor was again able to travel to the first floor without entering any numeric code into the key pad. This would allow an independent mobile resident enough time, if there was no staff at the desk or if the staff were not observing the elevator, to enter the elevator door and travel to the first floor. Interview on 4/16/19 at 9:45 a.m. with the second floor Unit Manager LPN WWWW revealed she had been on the second floor when R#1 eloped on 4/8/19. She is often in the building throughout the dinner meal. Unit Manager LPN WWWW revealed there could have been times when no one was at the desk because they all have to attend to passing trays, feeding, supervising the residents in the dining area and call lights. Unit Manager LPN WWWW revealed she also assists with the dinner service, works at the desk or in her office. Unit Manager LPN WWWW confirmed there could have been brief periods from 5:30 p.m. through 7:00 p.m. when the main elevator area was not observed, and it is possible for a resident to board the elevator without using the key pad and travel to the first floor if the elevator stopped and the doors opened on the second floor. Unit Manager LPN WWWW revealed she had not documented the time EMS called to ask if the facility was missing a resident, thinks the time was approximately 7:00 p.m. Unit Manager LPN WWWW was present when R#1 was returned and he was assessed with [REDACTED]. Unit Manager LPN WWWW had observed his Wander Guard in place on his left ankle and had verified the function with the scanner that is used daily to verify function of all the Wander Guards in use. On 4/16/19 at 5:10 p.m. the Administrator was interviewed and revealed that on 4/8/19 at 10:35 p.m. he and the Maintenance Director and the Wander Guard consultant had discovered that if someone without a Wander Guard activated the door button to open the automatic door at the side entrance and stood or sat in a wheelchair in the doorway the Wander Guard system would be disabled and no alarm would sound and the door would not close or lock if someone with a Wander Guard approached the door. The Administrator revealed he had this corrected on 4/16/19 prior to the surveyor's arrival and could not be observed for this door now. An interview was conducted with the Director of Nurses (DON) on 4/17/19 at 1:05 p.m. The DON revealed she expects the Charge Nurse's to coordinate rounds with the CNA's every 2 hours so that someone sees the residents every hour to determine if they are present, clean, not ill and have not fallen. If a resident cannot be found there should be a Code Yellow called. An interview was conducted on 4/18/19 at 8:20 a.m. with CNA EEE who was assigned to the care of R#1 on 4/8/19 on the 3-11 shift. CNA EEE revealed he was aware from the CNA Care Tracker, from report and from working with R#1 previously that he was at risk for elopement. CNA EEE revealed he had not observed R#1 to be exit seeking that afternoon. He was just walking in the halls like he always did. He was aware of ways to divert R#1 from exit seeking like helping him to find something to watch on TV, take him to activities, or with a snack. CNA EEE revealed R#1 had been in the bathroom when he brought him his dinner tray between 5:30 p.m. and 6:00 p.m. CNA EEE revealed he had assisted R#1 out of the bathroom and to wash his hands and then to sit beside the bed, set up the tray and left the room. He had then continued to pass trays with the other staff and to assist residents to eat and had not seen R#1 again until the EMS paramedics were returning him to the second floor after 7:00 p.m. CNA EEE revealed there is a lot of coming and going at that time of the evening with families visiting for dinner, residents returning from appointments, and the independent residents going to the first floor to socialize and go to the dining room on the first floor, then returning to the second floor. CNA EEE revealed he tried to see R#1 at least every hour to make sure he was not ill and had not fallen, to check his foot wear and to make sure he was on the second floor, and had not disappeared. CNA EEE revealed there is usually someone at the desk that could observe the elevators but not always and he was aware that anyone could travel in the elevators by waiting for the door to open, without having the code for the key pad. An interview was conducted with LPN DDD on the phone, 3-11 Charge Nurse on the second floor, on 4/18/19 at 9:29 a.m. LPN DDD revealed she was assigned to the care of R#1 the night he eloped 4/8/19. LPN DDD revealed he had not seemed unusually restless or exit seeking that afternoon, just his normal wandering behavior, ambulating in the halls. He had not been trying doors or standing near the elevators. LPN DDD revealed she had been told in report and knew from checking the care plan that R#1 was at risk for elopement and she coordinated her rounds with the CNA's to observe him at least every hour. She revealed she was assisting with feeding residents and picking up trays and the Unit Manager had found her and asked if she knew where R#1 was and she did not. The last time she had observed him was just before 5:00 p.m. when she had performed a finger stick blood sugar (FSBS) and checked to see if his Wander Guard was present and functioning and administered two oral (PO) medications scheduled for 5:00 p.m. An interview was conducted with Occupational Therapist (OT) WW on 4/18/19 at 12:10 p.m. She revealed R#1 had been discharge from Physical Therapy and Occupational Therapy that day. R#1 was physically able to do everything but his cognition was at about 10%. During a meeting with the family of R#1, OT WW had told them he required a one to one caregiver because he would not be safe if left alone for more than a few minutes. He received therapy for about two weeks and was not able to make any progress with safety awareness and he was at maximum potential physically. He did not fatigue easily, his balance was not the best, but his strength was fine. Interview on 4/19/19 at 3:42 p.m. with the Maintenance Director revealed the first floor side entrance use to have an over ride on the Wander Guard system, that would prevent the door from closing and the alarm from sounding if the door was approached by someone with a Wander Guard and there was someone without a Wander Guard in the doorway. He revealed this was not known by anyone in the building until 4/8/19 after R#1 eloped and he, the Administrator and the Wander Guard consultant had tested this door in several different ways. The Maintenance Director revealed this over ride had been removed from the door earlier this week. He stated he checks every door for closing, locking and alarming when approached with a Wander Guard every day and provided his daily logs which were reviewed with no concerns. An interview was conducted on 4/19/19 at 4:20 p.m. with Receptionist QQ. Receptionist QQ revealed she had been on duty on 4/8/19 from 8:00 a.m. to 7:00 p.m. Receptionist QQ revealed she had received a phone call from an EMS paramedic asking if there was a missing resident and they gave the resident's name. She thinks this call occurred sometime around 6:30 p.m. because she looked at her watch because she was supposed to go home at 7:00 p.m. She transferred the call to the second floor after checking the elopement book to determine the resident's room number and did not document the time. Receptionist QQ revealed R#1 was returned to the facility by EMS a few minutes later but did not document the time. Interview on 4/19/19 at 11:00 a.m. with one of the two Emergency Medical Service (EMS) Paramedics who had accompanied R#1 back into the facility on [DATE]. The Paramedic revealed when he first observed R#1 he was in the back of a police patrol car. EMS had been called by the police officer after responding to three 911 calls related to an male who had appeared lost on the sidewalk of a busy intersection. One called had revealed he had fallen and hit his head. The Paramedics assisted him out of the patrol care and into their ambulance and had checked him for injuries and there were no signs of any injuries. The Paramedics had noted the residents name when looking inside his clothing and had also noted the Wander Guard device on his ankle and they knew he was from a local nursing home. They brought him to another nursing home first because it was closet and then when they were told he did not belong there the Paramedic had called the facility and brought him back. The Paramedic revealed he had tried to communicate with him using a translator, but R#1 did not make any response. The Paramedic revealed R#1 did not seem to be upset or traumatized in any way. The Paramedic revealed he had no idea of any of the times because he did not have access to past Patient Care Reports, but the whole call took about 20 to 25 minutes. He stated that the location where R#1 was found was about a half mile from the facility. One of the two Paramedics remembers responding to the call from the police at 6:21 p.m. The Paramedic was unable to remember the time he had called the facility to ask if they were missing a resident with the last name of R#1. Review of the 911 Communications Event Report revealed the first call to 911 related to R#1: alone and looking lost at a busy intersection was received at 6:12 p.m. and the police officer arrived at 6:20 p.m. Multiple attempts were made to obtain the patient care reports from EMS without a response, therefore no time is available for the EMS call to the facility to verify the length of time R#1 left the facility undetected and the time that EMS returned R#1 to the facility. Review of the 911 tapes of calls related to the elopement of R#1 revealed the first caller at 6:12 p.m. requested assistance for an elderly male who had fallen into to road. The second call was also received at 6:12 p.m. and the called stated there was a man lying in the road and he had gotten up and fell again. The third caller at 6:13 p.m. revealed an elderly male was alone and at a busy intersection and kept falling down. An interview was conducted with the Corporate Vice President of Operations on 4/26/19 at 2:40 p.m. regarding the function of the side entrance/exit door. He stated he had been notified of the elopement of R#1 on 4/8/19. The Corporate Vice President revealed he had been notified of the malfunctioning Wander Guard system on this door and had observed the malfunction when visiting the facility. He revealed the system was disabled by anyone exiting the side door without a Wander Guard standing in the doorway and was not aware the system had been installed with an override. He stated he had never seen a Wander Guard system that was disabled by anything other than entering the correct numeric code on the key pad. Cross refer to F656 The facility implemented the following Removal Plan to remove the Immediate Jeopardy: SS=IJ F 689 Free of Accident Hazards/Supervision/Devices Immediate Corrective Measures: On (MONTH) 8th, 2019, Resident #1 exited the facility without notification or supervision via the side entrance door. The resident wears a Wander Guard alert bracelet secondary to his risk of elopement. The side entrance door is equipped with a Wander Guard Alert system. The Unit Manager validated that the resident's alarm was in place and functioning appropriately upon the resident's return to the facility on [DATE] and Resident #1 was immediately placed on 1:1 continuous supervision. The Physician was notified at 8:00pm and Responsible Party at 7:00pm on 4/08/19 by the Licensed Nurse. Orders were obtained for an X-Ray of the skull and pelvic/bilateral hips per the Physician at the facility. The X-Ray results revealed no fracture. Staff was placed at the second floor elevators for continual visual monitoring on 4/8/2019 at 7pm. Service elevator located on all floors and 1st floor service corridor function was disabled on 4/08/2019 at 7:00 p.m Staff was also placed at the front and side entrance/smoking door 1st floor for continual visual monitoring on 4/8/2019 at 7pm. Visual monitoring of both the second floor elevators and the front and side entrance is being maintained 24/7 and assignments for door coverage are managed by the Director of Nursing via the Door Monitoring Assignment Tool. Door monitoring of the above mentioned doors will be maintained indefinitely 24/7 until appropriate modifications of the current safety features of the facility are completed and functionality validated by the Vice President of Operations and District Director of Facility Engineering. The ID team which consists of the Administrator, Director of Nursing, Medical Director, Assistant Director of Nursing, and Nurse Managers completed an AD-Hoc QAPI meeting on 4/08/2019 at 7:00 p.m. with an immediate corrective action of placing door monitors at the main entrance door, side entrance door, 2nd floor main elevator, and 2nd floor center elevators. The service elevator was suspended on 4/08/2019 at 7:00 p.m. and remains suspended. Resident #1 was discharged to another facilty with a secure until on 4/11/2019. Identification of Others At Risk Residents who utilize a Wander Guard have the potential to be affected. There is one resident who utilizes a Wander Guard currently in the facility. This resident's Wander Guard is reviewed for placement and functionality daily 7 days per week and door monitors remain at elevators 24/7 on the floor which this resident resides. No other residents were affected. The Licensed Nurse validated the placement and functionality of this resident's device on 4/8/2019. Resident #1 and Resident #5 were discharged to another facility with a secure unit on 4/11/2019. Resident #4 was discharged to another facility with a secure unitl on 4/12/2019. Resident # 6 remains in the facility and utilizes a Wander Guard. Residents #11, #2, and #3 were reviewed by nursing leadership on 4/17/2019 and were determined to not be at risk for elopement and care plans revised. Systemic Changes The Nurse Managers (Director of Nursing, Assistant Director of Nursing, Unit Managers, Unit Coordinators and Staff Development Nurse) initiated education on 4/08/19 to the staff regarding the facility's policies governing Elopement Prevention & Management and Development of the Comprehensive Care Plan to include identification of residents with behaviors and development and accessing the resident's plan of care. This education also included maintaining the integrity of the door and Wander Guard codes. Education has been provided to 93% of the facility's staff members including the 2 receptionist (1 classed under CNA, 1 classed under Administration). Current facility staffing consists of: 49 LPNs (1 on LOA), 72 CNA's (1 on LOA), 16 RN's, Dietary Services 18, Environmental Services 16, Social Services 2, Administration 14, Activities 5, Maintenance 3, and Rehabilitation Services 27. Of the facility's current employee roster the following have received education: LPN's 48, CNA's 71, RN's 16, Dietary Services 15, Environmental Services 11, Social Services 2, Administration 13, Maintenance 3, and Rehabilitation Services 26. The Nurse Managers will continue to provide education to current staff prior to the start of their next scheduled shift and to new staff members during the orientation process. No staff shall work in the resident care area prior to receiving education. The IDT team (Administrator, Director of Nursing, Medical Director, Nurse Managers, Social Services, Activities, Dietician, Therapy, and Maintenance Director) will continue to adhere to the established process for Elopement Prevention & Management in accordance with organizational policy and regulatory guidelines. A letter was mailed to resident representatives providing education regarding elopement prevention on 4/17/2019 and added to the facility admission packet on 4/23/2019. This is documented in the Ad-Hoc QA/PI Plan held on 4/08/2019. Education regarding elopement prevention was provided through an ad-hoc resident council meeting held on 04/09/2019. This is documented via Resident Council Minutes. Education to alert, oriented, and ambulatory residents was provided on 4/24/2019 to 27 of 46 residents. Education will continue until all of the identified residents are educated. Through an Ad-Hoc Quality Assurance meeting held on 4/08/2019 the ID team which consisted of Administrator, Director of Nursing, Medical Director, and clinical managers conducted a review of the established facility policy governing Resident Elopement and Development of the Comprehensive Care Plan with no revisions indicated. The Administrator is responsible for the implementation of and adherence to this removal plan. The State Survey Agency (SSA) validated the implementation of the facility's Plan of Immediate Jeopardy Removal as follows: A review of an incident report dated 4/9/19 revealed on 4/8/19 R#1 was noted outside the building without supervision. A review of the care plan dated 3/26/19 for R#1 revealed he was at risk for elopement related to exit seeking behaviors and on 3/23/19 began to wear a Wander Guard device. Review of the Nurses Progress Notes for R#1 revealed that after he was returned to the facility on [DATE], with no time documented, he was placed on one to one monitoring. This was verified by an interview with the second floor Unit Manager on 4/16/19 at 9:45 a.m. The Unit Manager revealed she had checked the Wander Guard as soon as R#1 was back in the building and the device was on and functioning and she had immediately kept him at the desk with her or with a CNA to stay with him one to one until all the door and elevator monitors were in place. A review of the Situation, Background, Assessment, Recommendation (SBAR) communication tool related to the elopement of R#1 dated 4/8/19 confirmed the time of family notification of the elopement was documented at 7:00 p.m. on 4/8/29, and the Physician was notified on 4/8/19 at 8:00 p.m. and X rays of bilateral hips, skull and lumbar spine were ordered. Review of the X ray reports dated 4/9/19 revealed there were no acute findings. The Administrator revealed in an interview on 4/25/19 at 8:45 a.m. that he had instructed the Maintenance Director to disable the utility elevator on 4/8/19 and it will remain disabled because it is not really needed, and it will remain disabled. This was verified by observation of the utility elevator during tours on 4/16/19 at 9:25 a.m., 4/17/19 at 8:45 a.m., 4/18/19 at 8:10 a.m., 4/19/19 at 8:30 a.m., 4/23/19 at 8:45 a.m., 4/24/19 at 12:20 p.m. and 4/25/19 at 12:30 p.m. The Maintenance Director was interviewed on 4/26/19 at 11:07 a.m. and revealed he had been instructed to shut down the utility elevator on 4/8/29 at 7:00 p.m. and also instructed to leave it shut down. During tours of the reception area, the first floor side entrance, the second floor main visitor elevators and area surrounding the second floor ambulance elevator on 4/16/19 at 9:25 a.m., 4/17/19 at 8:45 a.m., 4/18/19 at 8:10 a.m., 4/19/19 at 8:30 a.m., 4/23/19 at 8:45 a.m., 4/24/19 at 12:20 a.m. and 4/25/19 at 12:30 a.m. the above areas were being observed by a staff person assigned to monitoring. Record review of the door and elevator monitoring schedules and assignments revealed from 4/8/19 through 4/25/19 at 7:00 a.m. the four areas were monitored twenty four hours a day. An interview on 4/24/19 at 10:20 a.m. with the Director of Nurses (DON) revealed the schedule was still in progress and twenty-four hour monitoring would continue indefinitely, she was currently calling to fill the monitoring needs for 4/25/19 at 7:00 a.m. through the next week. Observations conducted 4/25/19 from 10:30 p.m. through 4/26/19 at 12:15 a.m. revealed Receptionist PPP seated at front desk in lobby at 10:30 p.m. with Elopement Book in view. CNA KK at 10:35 p.m. was seated across the foyer in full view of the first floor side entrance doors. At 10:45 p.m. CNA RRR was observed seated in front of the second-floor main visitor elevators and at 10:50 p.m. Maintenance Assistant AA was seated beside the second-floor ambulance elevator. The service elevator was not functioning on the second, third and fourth floors and was not accessible from the first floor because there was a key pad lock system installed and the door was locked. An interview on 4/26/19 at 2:40 p.m. with the Corporate Vice President of Operations revealed he fully supports the Administrator continuing providing door and elevator monitoring by staff until he is satisfied the building is as secure as possible and will continue to over see the process of monitoring the doors and elevators and will also over see the modifications needed to secure the doors and elevators. A review of the elopement books on the second, third and fourth floors and in the reception area of the first floor, each with listings of residents who are provided with

Based on record review, staff interview and review of the Administrator Job Description revised 1/29/03, the facility failed to be administered in a manner to ensure there was an effective elopement prevention program that consistently monitored residents at risk for elopement and determine the root cause of resident elopements, and failed to ensure that all staff were knowledgeable regarding how the first floor side entrance /exit door functioned with a Wander Guard system which had an override function allowing residents identified at risk for elopement to exit the facility undetected. From a sample of seven residents assessed as elopement risk (R) (R#1 left the facility undetected on 4/8/19. This failure resulted in Immediate Jeopardy. On 4/23/19, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. On 4/23/19 at 4:00 p.m. the facility's Administrator was informed of the Immediate Jeopardy (IJ). The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/8/19 when R#1 eloped from the facility undetected through an exit door on the first floor. The Immediate Jeopardy is outlined as follows: On 4/8/19 resident (R) #1 exited the facility undetected through an exit door on the first floor. The resident was found by a bystander near a busy road after falling to the ground. The bystander called 911 and the Police and Emergency Medical Service (EMS) arrived at the scene. The resident was assessed by EMS to be unharmed. The facility was unaware of the resident's elopement until they were notified by EMS. R#1 has a history of wandering and was wearing a Wander Guard bracelet on his ankle when he left the facility. It was determined that the mechanical function of the handicap assessable/smoker exit door on the first floor allowed the resident to elope from the facility undetected. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements as follows: CFR 483.21(b)(1) Comprehensive Care Plans (F656 Scope and Severity: J) CFR 483.25(d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J) CFR 483.70 Administration (F835 Scope and Severity: J) Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25 (d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J) On 4/25/19 the facility provided an Immediate Jeopardy Removal Plan alleging that interventions had been put into place to remove the immediacy on 4/24/19. Based on interviews, record reviews, and review of facility policies as outlined in the Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 4/25/19. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight as well as develops and implements a Plan of Correction (P[NAME]). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. Findings include: Review of the facility Administrator Job Description revised 1/29/03, revealed a Summary as follows: Responsible for the overall management of a facility. Plans, develops, directs, monitors and supports all operational, administrative, clinical, human resources, customer service and fiscal activities for the facility's programs and services. Essential Duties and Responsibilities include the following: Other duties may be assigned .Makes sure facility is a safe, clean, comfortable and appealing environment for residents, patients, visitors and staff in accordance with company guidelines. An interview was conducted with the Administrator on 4/16/19 at 5:10 p.m. related to the Wander Guard system on the first-floor side entrance/exit. The Administrator revealed on 4/8/19, after he had learned of the elopement of R#1, he had contacted the vendor for maintenance of the facility doors. The Administrator arrived at the facility and with the vendor and the Maintenance Director had determined at approximately 10:35 p.m. that the Wander Guard alarm and lock on this side door did not function if someone without a Wander Guard was in the door opening. He stated this was the first time this door had been tested by someone without a Wander Guard standing in the doorway and someone with a Wander Guard approaching from a distance. The Administrator revealed he and the Maintenance Director had no knowledge that the Wander Guard system had been installed with an override. He revealed the front door was also installed this way, but there was a receptionist at that door twenty-four (24) hours a day seven (7) days a week. The Administrator revealed he had staff stationed at the side door for two days after the last elopement but had stopped the monitoring on 3/28/19 at 7:00 p.m. after magnetic locks were installed. The Administrator revealed he could not demonstrate the override on the side door now because it had been corrected this morning (4/16/19). A review of invoices for work by door and lock companies revealed an invoice dated 4/8/19. The invoice description of work revealed the following: Arrived to find the mag (magnetic) locks holding properly. However, found that Wander Guard System not detecting fobs correctly. Customer to call IT company to resolve issue. The time out on the invoice was 10:35 p.m. An invoice from a door and lock company dated 4/16/19 revealed the following: Replaced function lever on first floor. A interview was conducted with the Maintenance Director on 4/19/19 at 3:40 p.m. related to the first floor side entrance/ exit door. The Maintenance Director revealed he tested the Wander Guard systems and door locks at every door each day by approaching the doors and alarms with a Wander Guard. He stated he had never tested the doors with someone without a Wander Guard standing in the doorway and was unaware the system had been installed this way. The door vendor that came the night R#1 eloped had said the door sensor that kept the door from closing on someone in the doorway was overriding the system, and it disabled the whole Wander Guard system including the alarm. He revealed the two recent elopements must have been through this door because the other door always has a receptionist there day and night. Refer to F 656 and F689 The facility implemented the following actions to remove the Immediate Jeopardy: SS=IJ F 835 Administration Immediate Corrective Measures On (MONTH) 8th, 2019, Resident #1 exited the facility without notification or supervision via the side entrance door. The resident wears a Wander Guard alert bracelet secondary to his risk of elopement. The side entrance door is equipped with a Wander Guard Alert system. The Unit Manager validated that the resident's alarm was in place and functioning appropriately upon the resident's return to the facility on [DATE] and Resident #1 was immediately placed on 1:1 continuous supervision. The ID team which consists of the Administrator, Director of Nursing, Medical Director, Assistant Director of Nursing, and Nurse Managers completed an AD-Hoc QAPI meeting on 04/08/2019 at 7pm with an immediate corrective action of placing door monitors at the main entrance door, side entrance door, 2 nd floor main elevator, and 2 nd floor center elevators. The service elevator was suspended on 04/08/2019 at 7:00pm and remains suspended. Staff was placed at the second floor elevators for continual visual monitoring on 4/8/2019. Staff was also placed at the front and side entrance/exit door for continual visual monitoring on 4/8/2019. Visual monitoring of both the second floor elevators and the front and side entrance is being maintained. The vendor for maintenance of the entrance door was immediately contacted and did arrive at the facility on 4/8/2019 to perform a quality check of the door. At this time it was validated that the Wander Guard system on the first floor side exit was over ridden by the automatic door closure sensor making it possible for a person without a Wander Guard to open the door with the wheel chair button, stand in the doorway on the sensor pad and the Wander Guard alarm would not sound, the door would not close or lock thus allowing a resident at risk for elopement to exit the door undetected. Staff visual monitoring of the door is continuous. Visual monitoring of both the second floor elevators and the front and side entrance is being maintained 24/7 and assignments for door coverage are managed by the Director of Nursing via the Door Monitoring Assignment Tool. The Director of Nursing met with the Resident Council on 4/9/2019 to provide education on safety in the living environment; to include not assisting unfamiliar residents on/off the elevators and the exit doors. The members verbalized understanding. The Maintenance Director updated the codes to the entrance doors, elevators and stairwells on 4/9/2019. Resident #1 was discharged to another facility with a secure unit on 4/1/19. Identification of Others at Risk Residents who utilize a Wander Guard have the potential to be affected. There is one resident who utilizes a Wander Guard currently in the facility. This resident's Wander Guard is reviewed for placement and functionality daily and door monitors remain at elevators 24/7 on the floor which this resident resides. No other residents were affected. Resident #1 and Resident #5 were discharged to another facility with a secure unit on 4/12/19 Resident #4 was discharged to another facility with a secure unit on 4/12/19 Resident # 6 remains in the facility and utilizes a Wander Guard. Residents #11, #2, and #3 were reviewed by nursing leadership on 04/17/2019 and were determined to not be at risk for elopement and care plans revised. Systemic Changes Education was provided to the facility administrator on 04/23/2019 by the District Director of Clinical Services regarding the regulatory and interpretative guidelines for F 835. On 04/24/2019 the Vice President of Operations reviewed the Licensed Nursing Home Administrator job description to include ensuring the facility is safe and in accordance with company policy and regulatory guidelines. The Licensed Nursing Home Administrator job description was reviewed on 04/24/2019 with the Vice President of Operations and Administrator with no revisions. The District Director of Clinical Services or Vice President of Operations will attend the QA/PI meeting monthly for additional recommendation to the Administrator related to elopement management and facility administration. The Administrator is responsible for the implementation of and adherence to this removal plan. The State Survey Agency (SSA) validated the facilities Plan of Immediate Jeopardy Removal as follows: A review of an incident report dated 4/9/19 revealed on 4/8/19 R#1 was noted outside the building without supervision. A review of the care plan, dated 3/26/19 for R#1 revealed he was at risk for elopement related to exit seeking behaviors and on 3/23/19 began to wear a Wander Guard device. Review of the Nurses Progress Notes for R#1 revealed that after he was returned to the facility on [DATE], with no time documented, he was placed on one to one monitoring. This was verified by an interview with the second floor Unit Manager during an interview on 4/ 16/19 at 9:45 a.m. The Unit Manager revealed she had checked the Wander Guard as soon as R#1 was back in the building and the device was on and functioning and she had immediately kept him at the desk with her or with a CNA to stay with him one to one until all the door and elevator monitors were in place. A review of the Ad Hoc Quality Assurance Performance Improvement Committee Plan Meeting minutes dated 4/8/19 revealed the Interdisciplinary team had identified an opportunity for improvement in regards to promoting enhanced safety and freedom from risk of accidents. The root cause analysis related to R#1, with a Wander Guard in place and functioning, identified the likelihood of R#1 entering the main elevator with another independent resident or a visitor, traveling to the first floor and exiting the building through the side entrance/exit door. The root cause analysis also identified that post event testing had identified that exiting the side entrance/exit was possible when a staff member walked through this door while a staff member with a Wander Guard was also going through the door, and the alarm failed to be activated. The Administrator revealed in an interview on 4/25/19 at 8:45 a.m. that he had instructed the Maintenance Director to disable the utility elevator on 4/8/19 and it will remain disabled because it is not really needed, and it will remain disabled. This was verified by observation of the utility elevator during tours on 4/16/19 at 9:25 a.m., 4/17/19 at 8:45 a.m., 4/18/19 at 8:10 a.m., 4/19/19 at 8:30 a.m., 4/23/19 at 8:45 a.m., 4/24/19 at 12:20 p.m. and 4/25/19 at 12:30 p.m The Maintenance Director was interviewed on 4/26/19 at 11:07 a.m. and revealed he had been instructed to shut down the utility elevator on 4/8/29 at 7:00 p.m. and also instructed to leave it shut down. During tours of the reception area, the first floor side entrance, the second floor main visitor elevators and area surrounding the second floor ambulance elevator on 4/16/19 at 9:25 a.m., 4/17/19 at 8:45 a.m., 4/18/19 at 8:10 a.m., 4/19/19 at 8:30 a.m., 4/23/19 at 8:45 a.m., 4/24/19 at 12:20 a.m. and 4/25/19 at 12:30 a.m. the above areas were being observed by a staff person assigned to monitoring. Record review of the door and elevator monitoring schedules and assignments revealed from 4/8/19 through 4/25/19 at 7:00 a.m. the four areas were monitored twenty four hours a day. An interview on 4/24/19 at 10:20 a.m. with the Director of Nurses (DON) revealed the schedule was still in progress and twenty-four hour monitoring would continue indefinitely, she was currently calling to fill the monitoring needs for 4/25/19 at 7:00 a.m. through the next week. Observations conducted 4/25/19 from 10:30 p.m. through 4/26/19 at 12:15 a.m. revealed Receptionist PPP seated at front desk in lobby at 10:30 p.m. with Elopement Book in view. CNA KK at 10:35 p.m. was seated across the foyer in full view of the first floor side entrance doors. At 10:45 p.m. CNA RRR was observed seated in front of the second-floor main visitor elevators and at 10:50 p.m. Maintenance Assistant AA was seated beside the second-floor ambulance elevator. The service elevator was not functioning on the second, third and fourth floors and was not accessible from the first floor because there was a key pad lock system installed and the door was locked. On 4/18/19 at 1:30 p.m. a door technician from the local automatic door company was interviewed while he was working on the main entrance door. He stated he was working on the front door to make it better integrated with the Wander Guard system. He stated you could not put a magnetic lock on a sliding door, such as the main entrance door because if another person approached from the other side and triggered the motion sensor the lock would activate and burn out the electric motors of the door as it tried to open. He stated instead the doors were functionally locked because for fire code reasons they would automatically close if they were open but could then be opened by applying great force to the doors and they would go from sliding to opening. He stated he did not think a frail senior could get through the doors on his own if his Wander Guard shut the door. He stated a further concern was if a person coming in had activated the doors to open the Wander Guard would override the safety system in the door and it might close when a person was in the doorway. He stated the door could keep a Wanderguard resident in the facility by sounding an alarm and by closing the door or it could keep from closing on a visitor or other person if they were in the doorway, possibly causing an accident, but it could not do both at the same time. He stated he was pretty sure he could come up with something. During an observation on 4/19/19 at 3:40 p.m. the Maintenance director and the surveyor observed the first floor side door, where R#1 was suspected of exiting the building on 4/8/19 at approximately 6:00 pm. The surveyor stood in the open doorway of the exit door. The Maintenance Director approached with the Wander Guard and the door closed and the alarm sounded. The Maintenance Director revealed the safety over ride that prevented the door from closing on someone in the open doorway had been removed after R#1 eloped. He revealed no one at the facility had been aware of the override and the system had been installed before he and the administrator had worked here. The Maintenance Director was interview on 4/26/19 at 11:07 a.m. and revealed he had changed the key pad codes for every door in the facility approximately five times, possibly more, since 4/8/19 to keep the code from residents and visitors. Resident Council meeting minutes dated 4/9/19 were reviewed and the former Director of Nurses, Activities Director and Resident Council President attended the meeting, related to only facility staff having the door codes, and observation of who is near, and notification of staff if another resident attempts to get on the elevator. The Director of Nurses, Resident Council President and Activities Director all confirmed this meeting and also confirmed no one had kept any attendance record and no one could remember who was there. Additional resident education, related to the elopement prevention was provided on 4/24/19 to twenty-seven of forty-six residents identified as alert, oriented and ambulatory. An interview with the Administrator on 4/25/19 at 12:35 p.m. revealed the interdisciplinary team had met and identified residents who were alert, oriented, independently mobile and left their rooms and their units to socialize and attend activities in other parts of the building. The team identified forty six residents. The Administrator provided the list, which was compared with the resident education roster and education was confirmed by interview with R#7, R#12, R#13, and R#14 as above. An interview with the Administrator on 4/26/19 at 12:01 p.m. revealed he had been provided with education regarding his responsibilities to implement and maintain safety of the residents and a review of his job description on 4/24/19 by the Vice President of Operations. The Administrator revealed he was responsible for the implementation and adherence to the Plan of correction and would be provided with over sight from the Vice President of Operations as well as the District Director of Clinical Services to ensure compliance with company policy and regulatory guidelines. An interview with the Corporate Regional Vice President of Operations on 4/26/19 at 2:40 p.m. revealed the Administrator would be responsible for the implementation and adherence to the Plan of Immediate Jeopardy Removal. The Corporate Regional Vice President revealed he would be responsible for the oversight and support of the implementation and adherence to the Plan of Immediate Jeopardy Removal. The Vice President confirmed he or the District Director of Clinical Services will attend monthly QA/PI meetings to provide additional guidance and recommendations related to elopement management and facility administration. A review of the elopement books on the second, third and fourth floors and in the reception area of the first floor, each with listings of residents who are provided with Wander Guards, face sheets, their elopement risk care plans, and daily Wander Guard Checks listing the location of the device, the state of the device, the date of the check, the name of the nurse performing the check and the signature of the nurse, revealed on 4/19/19 there was one resident in the facility with a Wander Guard, R#6. The Wander Guard checks were reviewed from for R#6 and were completed daily. A review of the three residents care plans was completed, and they had been revised to reflect the risk of elopement had been resolved. A review of residents utilizing Wander Guard devices on 4/8/19 revealed there were seven residents listed. Three residents, R#2, R#3, and R#11 were reviewed by the survey team and had documented elopement risk assessments that were negative for risk on 4/17/19, and when observed were not wearing Wander Guard devices. A review of the clinical record for R#1 revealed he was discharged to a nearby sister facility with a Life Engagement Program on 4/11/19. An interview with the legal guardian of R#1 on 4/17/19 at 10:15 a.m. revealed she had approved of the transfer of R#1 to a facility with a dedicated program for residents who were at risk of elopement and had not felt any pressure to transfer her father. On 4/17/19 at 2:23 p.m. R#5 ' s brother was interviewed on the telephone. He stated he was the Power of Attorney for R#5 and his RP, though his daughter handled many of his day-to-day affairs. He stated his daughter texted him to advise him of the transfer and he understood the new facility offered care for dementia and was a better placement for him. He stated the facility did not pressure him in any way to accept the transfer. He stated if R#5 ' s daughter was against it she certainly would have told him. On 4/19/19 at 9:00 a.m. R#4 ' s family member was interviewed over the telephone. She stated she was R#4 ' s daughter, RP, and POA. She stated she did not feel pressured to agree to the transfer because the Administrator explained everything about the new facility to her and she agreed it was a better place. She stated she was satisfied with the facility ' s response to her mother ' s elopement and she thought it was too bad her mother had to leave the facility, but she did agree to the transfer. An interview with the Administrator on 4/26/19 at 12:01 p.m. revealed he had been provided with education regarding his responsibilities to implement and maintain safety of the residents and a review of his job description on 4/24/19 by the Vice President of Operations. The Administrator revealed he was responsible for the implementation and adherence to the Plan of correction and would be provided with over sight from the Vice President of Operations as well as the District Director of Clinical Services to ensure compliance with company policy and regulatory guidelines. During interview the Corporate Regional Vice President of Operations on 4/26/19 at 2:40 p.m. revealed the Administrator would be responsible for the implementation and adherence to the Plan of Immediate Jeopardy Removal. The Corporate Regional Vice President revealed he would be responsible for the oversight and support of the implementation and adherence to the Plan of Immediate Jeopardy Removal. The Vice President confirmed he or the District Director of Clinical Services will attend monthly QA/PI meetings to provide additional guidance and recommendations related to elopement management and facility administration

Based on observation, clinical record review, staff interviews, and review of the facility policies titled Elopement Management dated (MONTH) (YEAR) and Comprehensive Care Plan with a Revision date of (MONTH) (YEAR) the facility failed to revise the care plan related to exit seeking behaviors for one Resident (R#8) out of six residents reviewed with wandering behaviors. This failure to revise R#8's care plan contributed to the resident exiting the facility undetected. On 4/2/19, a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator was informed of the Immediate Jeopardy on 4/2/19 at 4:30 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed as of 3/26/19. The Immediate Jeopardy continued through 4/3/19 and was removed on 4/4/19. The Immediate Jeopardy is outlined as follows: On 3/26/19 resident (R) #8 exited the facility undetected through an exit door on the first floor that was not functioning properly. The resident was found on the ground by a bystander near a busy road. The bystander called 911 and Emergency Medical System (EMS) arrived at the scene. The resident was taken to the local hospital and treated for [REDACTED]. The facility was unaware of the resident's elopement until they were notified by the emergency roiagnom on [DATE]. R#8 has a history of wandering and was wearing a Wander Guard bracelet on her ankle when she left the facility. It was determined that a handicap assessable door on the first floor which has an alarm system was not working properly and therefore, the resident was able to elope from the facility undetected. The Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR 483.21(b)(2) Comprehensive Person-Centered Care Plans (F657 Scope and Severity: J). CFR 483.25(d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J). CFR 483.90 (d)(2) Essential Equipment, Safe Operation Condition (F908 Scope and Severity: J). Additionally, Substandard Quality of Care was identified with the requirements at CFR:483:25(d))1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J). A Removal Plan was received on 4/4/19. Based on interviews, record reviews, and review of facility policies as outlined in the Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 4/4/19. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight as well as develops and implements a Plan of Correction (P[NAME]). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. Findings include: Review of the undated face sheet revealed R#8 was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. Review of R#8's Quarterly Minimum Data Set (MDS) assessment dated [DATE], Section C revealed a Brief Interview for Mental Status (BIMS) score to be 8 out of 15, signifying impaired cognition. Review of Section G revealed she required supervision for nearly all Activities of Daily Living (ADLs). Further review revealed she could only walk with supervision. Review of the policy titled Elopement Management dated (MONTH) (YEAR) revealed impart; The goal of the Elopement Management System is to identify residents with potential exit-seeking behavior, to assure the Care Plan and Kardex reflect effective and consistent interventions and safety measures and to assure staff are educated regarding the Elopement Management system and resident specific interventions. Review of a progress note dated 1/31/19 revealed the Physician wrote the patient was confused at baseline and wanders the floor. (sic) Review of another progress note dated 2/12/19 revealed R#8 wanders on the floor and a Wander Guard in place. A progress note dated 2/27/19 notes; resident continues to pack her belongings walking towards the EXIT doors. Resident asking every person on the unit to take her home. Sometimes is difficult to redirect and sometimes easily redirected. Review of the policy titled Comprehensive Care Plan dated (MONTH) (YEAR) inpart states; Purpose: To provide effective and person-centered care plan for each resident. and #5 The care plan is reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes, or a change in condition. Review of R#8's Comprehensive care plan dated 1/31/19 revealed the resident was at risk for elopement related to adjustment to nursing home, disorientation to place, and she wandered aimlessly. Interventions in part included, observe location at regular and frequent intervals, check placement and function of wander/elopement alarm every shift and resident picture was to be placed in elopement book. Despite a notation in the clinical record on 2/27/19 regarding R#8 packing her belonging and going to the exit door and asking every person to take her home, the facility did not revise the residents care plan to address exit seeking behavior. On 3/28/19 at 11:30 a.m. interview with the Director of Nursing (DON) revealed on 3/26/19 at about 2:50 p.m., per staff interviews during subsequent investigation, R#8 was observed near the elevator and was redirected by the staff. She stated R#8 was demented but could ambulate independently and was a brisk walker. She stated on 3/26/19 at about 3:00 p.m. Licensed Practical Nurse (LPN) BB told her in an interview that she directly saw R#8 in the bathroom. She stated around 3:15 p.m. the receptionist received a call from the acute hospital across the street from the facility. The DON stated at that point two facility staff, the second-floor Unit Manager (UM) and the Assistant Director of Nursing (ADON) went to the hospital in a facility vehicle and picked R#8 up in the ED. She stated she wasn't sure how R#8 was able to leave the second floor and out of the building without supervision. She stated she thought the system for preventing elopement before R#8 eloped was adequate because her elopement could not have been foreseen. On 3/28/19 at 3:05 p.m. interview with Licensed Practical Nurse (LPN) BB revealed on 3/26/19 at around 2:30 p.m. or 2:45 p.m. she was helping another resident when she saw R#8 heading for the elevator. She stated R#8 was pleasant and easily re-directed and she took R#8 to the bathroom. She stated then around 3:00 p.m. (she recalled the time because the next shift was coming on), she was told R#8 was missing and they started looking for her. Review of the 3/26/19 police department Communications Event Report revealed a 911 call was received at 2:32 p.m. on 3/26/19 to report an elderly person was observed by passers-by to be walking in the road and the officer arrived on-scene at 2:37 p.m. Further review revealed the officer identified the subject as R#8 and noted a bracelet on her left ankle and R#8 was on the ground. Review of the Facility Incident Report Form dated 3/27/19 revealed R#8's elopement occurred on 3/26/19 at 3:15 p.m. On 4/1/19 at 2:50 p.m. the DON was further interviewed and stated her investigation of the R#8 elopement on 3/26/19 was complete and she was satisfied with its conclusions. She stated all she had to go on was that her staff told her R#8 was in the building at 2:50 p.m. on 3/26/19. She stated she could not answer for the discrepancy between what her staff told her and the police report and the ED notes. She stated she agreed R#8's care plan called for frequent observation, as she expected for every resident. She stated she agreed, obviously, R#8 eloped unobserved even though she had a functional Wander guard (elopement bracelet) on at the time. Cross Refer to F 689 Based on further review by DCH it was determined the F657 was cited in lieu of F656. The facility implemented the following actions to remove the Immediate Jeopardy: SS= IJ F 656 Development/Implement Comprehensive Care Plan Immediate Corrective Measures: The Unit Manager re-evaluated Resident #8's elopement risk factors on 3/26/19. Per her Elopement Risk assessment, she is deemed to be at risk. Resident #8's was also evaluated per the psychiatric Nurse Practitioner to identify any further psychosocial needs on 3/28/19. The ID team reviewed Resident #8's current plan of care on 3/26/19 with applicable revisions to include her daughter increasing opportunities to take the resident on desired outings for shopping, recreational walks and eating at desired restaurants. Staff will also offer the resident additional opportunities to participate in supervised outdoor recreational activities at the facility. The resident's falls risk assessment was also reviewed with revisions as indicated. Resident #8's is currently receiving rehab services and her plan of care has been revised to include modalities to address enhancing safety with outdoor ambulation; to include maneuvering sidewalks, inclines and curbs. Identification of Others Residents identified as being at risk for elopement have the potential to be affected. There are six residents identified. These six residents wear a Wander guard device. Residents who utilize a Wander guard will be supervised per a staff member when off the unit. No other residents were affected. The ID Team reviewed 100% of the care plans of the six residents identified as being at risk for an elopement on 3/26 & 3/27/19. The Licensed nurses conducted a current elopement risk evaluation of the six identified residents. Systemic Changes Nurse Managers initiated education on 3/26/2019. All ID team members received education on 4/3/19 regarding the policy for Comprehensive Care Plan. The Nurse Managers provided education to the direct care staff regarding the facility's policy governing the development and implementation of comprehensive care plans. This education includes a review of the process for how the Certified Nursing Assistants access the resident plan of care via the electronic medical record. Staff accesses the residents' plan of care via the electronic medical record in Point Click Care. Kiosks are located throughout the unit as well as at the nurse's station for staff access to the electronic medical record. Resident centered interventions, including the use of a Wander guard device, are communicated to the Certified Nursing Assistant via the plan of care contained in the resident's electronic medical record. A list of residents who wear a Wander guard device is also maintained in a Red Binder at the 2 ND Floor nursing station. This information is communicated to new employees during the General Orientation process. The Nurse Managers utilized educational content as outlined in the following Policy & Procedure Practice Guidelines: * OP 4 0208.00 Development of the Comprehensive Care Plan Education has been provided to 91% of the staff. Current facility staffing consists of: 45 LPNs (1 on LOA), 68 CAN's (2 on LOA), 16 RN's, Dietary Services 13, Environmental Services 13, Social Services 2, Administration 12, Activities 4, Maintenance 3, and Rehabilitation Services 25. Of the facility's current employee roster the following have received education: LPN's 44, CAN's 66, RN's 15, Dietary Services 12, Environmental Services 8, Social Services 2, Administration 12, Maintenance 3, and Rehabilitation Services 21. The Nurse Managers will continue to provide education to current staff prior to the start of their next scheduled shift and to new staff members during the orientation process. No staff shall work in the resident care area prior to receiving this required education. The ID team which consisted of Administrator, Director of Nursing, Medical Director, Assistant Administrator, Clinical Managers, Social Services, Activities, and MDS has conducted a review of the established facility policy governing Comprehensive Care plans with no revisions indicated. Through an Ad-Hoc Quality Assurance meeting held on 03/27/2019 the ID team which consisted of Administrator, Director of Nursing, Medical Director, Assistant Administrator, Clinical Managers, Social Services, Activities, Maintenance, and MDS has conducted a review of the established facility policy governing Resident Elopement with no revisions indicated. The State Survey Agency (SSA) validated the facility's Removal Plan as follows: Review of R#8's care plan revealed revision on 3/26/19 with changes including outings as noted above, frequent and regular supervision, and redirection. Fall risk assessments on the six at-risk residents effective 3/26/19 were reviewed and found to be revised Checklists for six residents with Wander Guard's titled sensory stimulation participation response records were reviewed from 2/27/19 through 3/29/19 with varying degrees of participation recorded. Review of a progress note dated 3/28/19 at 4:20 p.m. revealed a psychiatric assessment for R#8 including memory stimulation plan of care. No medications were recommended. Review of the care plan for R#8 revealed falls risk and was updated 3/28/19. Interventions included walking on sidewalks and curbs. Identification of Others On 3/29/19 at 5:00 p.m. observation and interview with CAN DD revealed she was sitting in a chair observing the dining area and R#8's room. She stated R#8 had gone to the bathroom and she was keeping an eye on her and the dining room. Review of the six residents' care plans in the Electronic Medical Record (EMR) revealed their care plans had been reviewed and updated for elopement risk between 3/26/19 and 4/3/19. Further review revealed elopement risk assessments (evaluations) were completed for these residents on 3/26/19 or 3/27/19. CAN DD stated that she did attend the in-services. Systemic Changes Review of the Comprehensive Care Plan policy revealed policy for ensuring comprehensive person-centered care plans for the residents. Review of the care plan in-services were conducted with all disciplines as stated in the removal plan. On 4/4/19 at 7:15 p.m. interview with the DON revealed the Resident Care Specialists (CNAs) could access the resident care plan in their EMR kiosks and were expected to do so every shift. She stated the nursing staff could make changes to the care plan which would show up immediately in the CAN kiosks. She stated further the CNAs get report from the off-going CNAs every shift as well as from the nurse. On 4/4/19 at 6:50 p.m. interview with CAN QQ revealed she made a daily check on the Kardex on the EMR kiosk to see if there were any changes with their residents. She then demonstrated the use of the kiosk and showed safety information related to wandering behaviors and Wander Guard devices. CAN QQ stated she did attend the in-services. On 4/4/19 6:55 p.m. interview with CAN RR revealed she made a daily check on the Kardex on the EMR kiosk to see if there were any changes with their residents. She then demonstrated the use of the kiosk and showed safety information related to wandering behaviors and Wander Guard devices. CAN RR stated that she did attend the in-services. On 4/4/19 at 7:05 p.m. interview with CAN SS revealed she made a daily check on the Kardex on the EMR kiosk to see if there were any changes with their residents. She then demonstrated the use of the kiosk and showed safety information related to wandering behaviors and Wander Guard devices. CAN SS stated that she did attend the in-services. On 4/4/19 at 7:10 p.m. interview with CAN TT revealed she made a daily check on the Kardex on the EMR kiosk to see if there were any changes with their residents. She then demonstrated the use of the kiosk and showed safety information related to wandering behaviors and Wander Guard devices. CAN TT stated she did attend the in-services. On 4/4/19 at 7:12 p.m. interview with CAN UU revealed she made a daily check on the Kardex on the EMR kiosk to see if there were any changes with their residents. She then demonstrated the use of the kiosk and showed safety information related to wandering behaviors and Wander Guard devices. CAN UU stated that she did attend the in-services. Observation revealed binders entitled Elopement Book were found at each nursing station and at the reception desk at the main entrance. On 4/1/19 at 11:45 a.m. interview with Receptionist GG revealed the Elopement book had been at her desk for a long time, over a year. The Receptionist stated she did attend the in-services. Review of the Comprehensive Care Plan policy revealed policy for ensuring comprehensive person-centered care plans for the residents. Review of the care plan in-services were held as stated in the facility's Removal Plan. Review of the Comprehensive Care Plan document revised 11/2017 revealed policy that each resident should have a comprehensive and person-centered care plan. Further review revealed care plans were to include the resident or responsible party's participation, goals interventions, and rehab services. The ID team was responsible for care plan development. Review of the attendance sheet for the Ad-hoc meeting regarding Resident Elopement was held on 3/27/19 all committee members in attendance. Review of the Elopement Management document dated 7/2017, revealed elopement policy. Further review revealed the resident and RP would be notified of the Wander Guard placement. Further review revealed if the resident at risk for elopement exhibits exit-seeking behavior it must be documented in the 24-hour report and additional interventions must be considered. Further review revealed the facility must develop a consistent method for tracking the expiration of devices and ensure the devices were replaced prior to expiration. Further review revealed residents were to be assessed for elopement quarterly. Further review revealed exit doors were to be monitored daily for function.

Based on observation, clinical record review, resident and staff interviews, and review of the facility policy titled Resident Elopement dated (MONTH) 2012 the facility failed to prevent one Resident (R), #8 out of six residents reviewed who wear Wander Guards from eloping from the facility. The facility failed to comply with established policies and procedures regarding resident elopement. R#8 exited the facility undetected and was found by passers-on a busy urban street near an interstate ramp. The facility also failed to identify potential hazardous areas residents could access due to unsecured doors. On 4/2/19, a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator was informed of the Immediate Jeopardy on 4/2/19 at 4:30 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed as of 3/26/19. The Immediate Jeopardy continued through 4/3/19 and was removed on 4/4/19. The Immediate Jeopardy is outlined as follows: On 3/26/19 resident (R) #8 exited the facility undetected through an exit door on the first floor that was not functioning properly. The resident was found on the ground by a bystander near a busy road. The bystander called 911 and Emergency Medical System (EMS) arrived at the scene. The resident was taken to the local hospital and treated for [REDACTED]. The facility was unaware of the resident's elopement until they were notified by the emergency roiagnom on [DATE]. R#8 has a history of wandering and was wearing a Wander Guard bracelet on her ankle when she left the facility. It was determined that a handicap assessable door on the first floor which has an alarm system was not working properly and therefore, the resident was able to elope from the facility undetected. The Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR 483.21(b)(2) Comprehensive Person-Centered Care Plans (F657 Scope and Severity: J). CFR 483.25(d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J). CFR 483.90 (d)(2) Essential Equipment, Safe Operation Condition (F908 Scope and Severity: J). Additionally, Substandard Quality of Care was identified with the requirements at CFR:483:25(d))1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J). A Removal Plan was received on 4/4/19. Based on interviews, record reviews, and review of facility policies as outlined in the Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 4/4/19. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight as well as develops and implements a Plan of Correction (P[NAME]). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. Findings include: Review of the undated face sheet revealed R#8 was admitted to the facility on [DATE] her [DIAGNOSES REDACTED]. Review of R#8's Quarterly Minimum Data Set ((MDS) dated [DATE], Section C revealed her Brief Interview for Mental Status (BIMS) score to be 8 out of 15, signifying impaired cognition. Review of Section G revealed she could walk with supervision. Review of R#8's progress notes dated 1/31/19 the Physician wrote patient is confused at baseline and wanders all over the floor (sic). Review of a nursing progress dated 2/12/19 revealed R#8 had a Wander Guard on the left ankle because she wandered within the unit. A progress note dated 2/27/19 notes; resident continues to pack her belongings walking towards the EXIT doors. Resident asking every person on the unit to take her home. Sometimes is difficult to redirect and sometimes easily redirected. On 3/28/19 at 11:10 a.m., Case Manager AA was interviewed over the telephone. She stated she was a case manager at a local acute care hospital. She stated on 3/26/19 and Emergency Department (ED) nurse called her and asked her to file a complaint with the State Agency because of an elopement from the facility. She stated the nurse told her R#8 eloped from the facility on 3/26/19 in the afternoon and made it almost all the way to the Interstate when she fell . She stated Emergency Medical Services (EMS) then picked her up and took her to the ED. She stated she did not know who called EMS. She stated she was told R#8 was demented so the ED nurse started calling the nursing homes in the area, including the facility R#8 lives at. She stated the ED nurse told her when she called the facility she was told R#8 did not reside there. She stated the ED nurse told her sometime after that staff from the facility showed up at the ED and took R#8 back to the facility. Review of the 3/26/19 police department Communications Event Report revealed the police were notified of a person (R#8) revealed a 911 call was received at 2:32 p.m. on 3/26/19 and the officer arrived on-scene at 2:37 p.m. Further review revealed the officer identified the subject as R#8 and noted a bracelet on her left ankle and R#8 was on the ground. Further review revealed witnesses reported she was walking in the bike lane with a walker before she fell and she was transported to the hospital. On 3/28/19 at 11:27 a.m. interview with Registered Nurse (RN) DD revealed she was one of two Assistant Directors of Nursing (ADONs) for the facility. She stated on 3/26/19 at around 3:15 p.m. she saw the second-floor UM (unit manager) getting on the elevator and the UM told her R#8 was at the acute hospital ED and she and Licensed Practical Nurse (LPN) BB were going to pick her up. She stated they got into a car and she was dropped off at the building, part of the acute hospital campus, next door to the facility to see if R#8 was there. She stated R#8 was not in that building and while she was walking around in that building she was called on the phone and was told R#8 was at the ED in a building farther away. She stated she walked back to the facility from where she was and was not involved in picking R#8 up from the ED. She stated this all happened in a very short period of time, maybe 15 minutes. On 3/28/19 at 11:30 a.m. interview with the Director of Nursing (DON) revealed on 3/26/19 at about 2:50 p.m. per staff interviews during subsequent investigation, R#8 was observed near the elevator and was redirected by the staff. She stated R#8 was demented but could ambulate independently. She stated R#8 had a Wander Guard elopement alarm on. She stated the Wander Guard would not trigger an alarm if a resident on the second floor tried to get on the elevator, only for the front and side exit doors on the first floor. She stated she did not know why the second-floor elevators could only be accessed by a keypad since the second floor was not a locked unit. She stated on 3/26/19 at about 3:00 p.m. Licensed Practical Nurse (LPN) BB told her in an interview that she directly saw R#8 in the bathroom, then around 3:15 p.m. the receptionist received a call from the acute hospital across the street from the facility. She stated at that point two facility staff, the second-floor Unit Manager (UM) and the Assistant Director of Nursing (ADON) went to the hospital in a facility vehicle and picked R#8 up in the ED. She stated R#8 walked the short distance from the facility to the ED on her own. She stated shortly after this R#8 arrived back at the facility with the staff members and she stopped in her (DON's) office. She stated R#8 told her she had fallen on the sidewalk and a man helped her up. She stated she noted R#8 had a small abrasion on each knee and on her left lateral eye. She stated she assessed the resident thoroughly, even though the ED assessed her and ordered x-rays, which came back negative. She stated after that she checked the Wander Guard system on the front door and the side doors and found the front door to be good but when she checked the side door she found the alarm did not go off until after the resident was out the door. She stated she informed the Administrator and the Maintenance Director about it on the same day. She stated a human monitor had been watching the side door 24/7 since the elopement until the mechanical improvements were made. She stated she thought it was most likely R#8 had gone out the side door. She stated the alarm would be heard all over the large lobby area of the side door. She stated the only way to silence the side door alarm would be to enter in a code on a keypad near the door (the key pad is inside of the building to the right of the door). She stated some unknown person would have had to silence the alarm after R#8 left the facility. The DON revealed the Interdisciplinary Team (IDT) met on the evening of 3/26/19 and the morning of 3/27/19 and determined the plan included human monitoring and placing or strengthening the magnets on the side door. She stated she thought the system for preventing elopement before R#8 eloped was adequate because her elopement could not have been foreseen. Observation on 3/27/19 at 10:00 a.m. revealed no staff member was monitoring the side exit door (also known as the side smoking door) located on the first floor. The door was identified by facility staff as the door that R#8 eloped out of on 3/26/19. According to the DON during the previous interview on 3/28/19 at 11:30 a.m. the door was monitored 24/7 since the incident occurred on 3/26/19. Review of the Pre-hospital (ambulance trip sheet) dated 3/26/19 revealed the ambulance was on the scene at R#8's side on 3/26/19 at 2:55 p.m. Further review revealed they left the pick-up location at 3:08 p.m. and they arrived at the acute care hospital at 3:14 p.m. on 3/26/19. Further review revealed R#8's chief complaint to be a fall from standing to ground. Further review revealed R#8 had a facial abrasion and altered mentation. Further review revealed R#8 was observed by a witness to fall into the dirt on the road; this witness called 911. The report revealed the resident was lying in the roadway when the ambulance arrived. Further review revealed R#8 stated she was in Florida and had just left work at the nursing home; the ambulance crew noted the presence of a Wander Guard bracelet which led them to conclude R#8 had eloped from a nursing home. Review of the acute care hospital face sheet dated 3/26/19 at 3:20 p.m. revealed R#8 arrived at the ED at that time. The ED notes revealed the Physician wrote that caregivers from the facility arrived to pick R#8 up and no further care was needed - the Physician electronically signed this note on 3/26/19 at 4:33 p.m. Review of an audio recording of a 911 call dated 3/26/19 at 2:32 p.m. revealed the first report of a black elderly female walking in the road with a walker wearing glasses and a green cardigan. Review of an additional audio recording of a 911 call dated 3/26/19 at 2:42 p.m. revealed the caller reported a black female in a green cardigan to have fallen in the road. Review of the Interdisciplinary Post Fall Review dated 3/26/19 at 6:06 p.m. revealed R#8 eloped from the facility and sustained an unwitnessed fall on 3/26/19 at 4:00 p.m. Further review revealed R#8 sustained two small superficial abrasions on the left knee and left eye which were cleansed, and no further treatment was required. Further review revealed no changes to baseline range of motion (ROM) were noted on all extremities and R#8 was also assessed at the acute ED. On 3/28/19 at 1:30 p.m. interview with Door Service Technician CC revealed he worked for an outside contractor specializing in commercial doors. He stated he was installing a magnetic lock on the side door designed to lock the door if a Wander Guard elopement bracelet should activate the lock. He stated the door would automatically lock to prevent a resident from going through the door if they had a Wander Guard device on their person. He stated prior to the installation of this lock the door would alarm but not lock and would not prevent a resident with a Wander Guard from leaving the facility. On 3/28/19 at 3:05 p.m. interview with LPN BB revealed that the second floor where R#8 lived, of the facility had mostly demented residents. She stated on 3/26/19 at around 2:30 p.m. or 2:45 p.m. she was assisting another resident when she saw R#8 heading for the elevator. LPN BB stated that she approached R#8 and asked her what she was doing. She stated R#8 told her she was going to the bathroom. She stated R#8 was pleasant and easily re-directed and she took R#8 to the bathroom herself. She stated then around 3:00 p.m. (she recalled the time because the next shift was coming on), she was told R#8 was missing and they started looking in every room of the entire building. She stated she went up to the fourth floor because she thought she might be there and the staff there would not know her. She stated she then heard the receptionist got a call from an acute care hospital about a block or a little more up the street. She also stated she heard the receptionist did not know the resident and told the hospital R#8 did not live at the facility. She stated when they got to the ED they found the doctor was just finishing with R#8 and R#8 had bandages on both knees and her left eye. She stated R#8 told her she fell , and she was glad to see her nurse. She stated the ED nurse told her she had been calling the other nursing homes in the vicinity since she had been told R#8 did not live at the original facility. She stated they then took R#8 back to the facility. On 3/28/19 at 3:25 p.m. a tour was made of the second-floor accompanied by LPN BB. There was a main elevator with a keypad that was in front of the nurse's station and easily visible. LPN BB then showed the surveyor an elevator in an alcove out of sight of the nursing station. She stated it would be easy for a demented resident to wait by this elevator unobserved then get on the elevator when a visitor or some person who did not know not to let these residents on. She stated some of the visitors had the access codes to the elevator. She stated there were no alarms for the Wander Guard on the second-floor, so no one would notice if a resident got on the elevator unobserved. She stated she did not think this was a good situation and she thought they should lock the unit down. On 3/29/19 at 12:45 p.m. interview with the Director of Maintenance revealed he checked the Wander Guard system every day and kept records of that, which he would provide. He stated he checked it by taking a Wander Guard bracelet and walking near the sensors with it to be sure the alarm went off. He stated there were Wander Guard sensors on the front door on the first floor, on the side (smoking) door on the first floor, and on the second floor at the ends of the hall near the elevator where the nurses could not see. He stated before 3/28/19 the front door and the second-floor sensors would give an audible alarm but not lock any door. He stated that before 3/28/19 the sensor on the side smoking door would give an audible alarm and swing the double doors closed but would not lock them. He stated a resident could push through the smoking doors even if they were closed because the doors did not lock. He stated the only way to mute the alarm was to enter in a code on the keypad next to the door. He stated R#8 either went through the door with a non-functioning Wander Guard and the alarm did not go off or somebody silenced the alarm without checking outside. He stated as the Facility Safety Officer he would expect anyone hearing an alarm to check and see what set the alarm off. He stated to not check would be unacceptable. He stated the second-floor audible alarm was not audible at the nurse's station for about the past week. He stated you could not consider an inaudible alarm to be a functioning system. He stated you could not consider the old system to be perfect since, obviously, R#8 got out of the building. He stated he thought the new system was pretty good, since it had keypads on the second floor backed up by the Wander Guard system. Review of the policy titled Resident Elopement document revised (MONTH) 2012 page 2 of 4 revealed in part; 1. If an employee hears a door alarm he or she should: a. immediately go to the site of the alarm c. If no resident is found to be exiting the facility, the employee should; i. Exit the facility, walk around the building, and ensure that a resident has not already exited the facility; IMPORTANT: Be sure to search locked rooms and in stairwells. ii. Notify the Director of Nursing and the Administrator immediately; and iii. Complete a head count to ensure that all residents are accounted for. On 3/29/18 at 3:15 p.m. R#8 was interviewed as she was walking with a rolling walker accompanied by a staff member. She stated she went for a walk a couple of days ago and she fell . She stated the traffic was whooshing by. She stated she was mighty embarrassed, and a nice man came and picked her up. She stated she did not go to the hospital. It was readily apparent during the interview that R #8 was cognitively impaired. On 3/29/19 at 5:00 p.m. observation and interview with CNA DD revealed she was sitting in a chair observing the dining area and R#8's room. She stated R#8 had gone to the bathroom and she was keeping an eye on her. She stated she knew R#8 well. She stated R#8 would often go up to the elevator and try to get on it when the door opened. She stated R#8 would say she had to go out or to catch a bus or to see someone. She stated when that happened she would redirect her which was easy to do. She stated the Wander Guard would not alarm on the second-floor, only on the first-floor doors. On 3/29/19 at 5:15 p.m. observation of the front entrance of the facility, the side entrance (smoking door) on the first floor of the facility, and the elevator at the end of a second-floor hall, accompanied by the Director of Nursing (DON). The DON provided the surveyor with a Wander Guard bracelet. There was an elevator on the second-floor, out of sight of the nursing station. As the surveyor approached this elevator a dim alarm sound was heard. The DON stated she agreed this alarm could only be heard in the vicinity of the elevator but not at the nursing station. The elevator could only be accessed by a keypad. The access code was entered in by the DON and the elevator door opened. No second-floor personnel responded to the nearly inaudible alarm. On 4/1/19 at 11:45 a.m. interview with Receptionist GG revealed the Elopement book had been at her desk for a long time, over a year. She stated she was on duty on 3/26/19 when R#8 eloped. She stated she thought around 1:00 p.m. the acute care hospital called and asked if R#8's name sounded familiar, (but she did not check the elopement book). She stated she knew R#8 by face but not by name up until that day. She stated she told the nurse from the hospital it didn't sound familiar and the nurse hung up before she could get another word in. She stated she thought to herself let me check on that and found R#8 in the computer. She stated she then called the second-floor, where R#8 lived, and asked if they had R#8 up there. She stated she was told yes but she told the person on the phone she needed someone to directly see R#8 right now. She stated she hung up and the next thing she knew several staff members went flying past her desk out the front door to look for R#8. She stated she said y'all, if you'll just stop, I'll tell you where she is. She stated she then told them she was at the acute care hospital nearby and then staff left to go pick R#8 up. She stated she had seen and spoken to R#8 in the lobby on two other occasions. On 4/1/19 at 2:50 p.m. interview with the DON was conducted and she stated her investigation of the R#8 elopement on 3/26/19 was complete and she was satisfied with its conclusions. She stated she had no knowledge until now about the ambulance being called for R#8 or her being found on the road. She stated all she had to go on was that her staff told her R#8 was in the building at 2:50 p.m. on 3/26/19. She stated she could not answer for the discrepancy between what her staff told her and the ambulance trip sheet and the ED notes. She stated the second-floor Unit Manager (UM) told her the hospital told her R#8 walked in and had not come by ambulance. She stated the hospital staff gave the UM ED records but the records they got were incomplete. She stated she never sought hospital or ambulance records because she had no reason to. She stated she agreed the alarm on the second-floor was very hard to hear but a large alarm sounded on the second-floor nurses station when a Wander Guard resident got on the elevator. She stated she was not sure why the second-floor nurses did not respond to this loud alarm when R#8 got on this elevator. She stated it was unlikely R#8 left through the main entrance because the Wander Guard would have set off the automatic lock on the front door. She stated the receptionist was also monitoring that door. She stated it was more likely R#8 left through the side (smoking) door on the first-floor. She stated she was certain R#8's Wander Guard worked that day (3/26/19) because when she returned from the ED she set off the alarms at the front and side doors. She stated she agreed the only other way out for R#8 was through the side door. DON interview revealed the elopement alarm on the side door of the facility did not sound until the resident was several feet outside the door. She stated, since she knew R#8 had a functioning Wander Guard, the alarm would have sounded when she went through the door. She stated some staff member or even a resident could have silenced the alarm. She stated they changed the door codes recently, per policy, because of the possibility of code compromise, but she was not sure when the codes were changed. She stated the policy was if an employee heard an alarm they were to find out who set off the alarm even if it meant going outside and looking for the resident. She stated to silence the alarm without finding who set it off was against policy and her expectations. On 4/3/19 at 3:55 p.m. interview with the Administrator revealed he had been the Administrator since 3/1/19. He stated he was aware of R#8's elopement and arrival at the hospital on [DATE]. He stated he did not become aware the resident had made her way to the intersection of an interstate and a busy road until the surveyor shared his investigation with the DON on 4/1/19. He stated the DON's investigation could have been better, being that it did not reveal the ambulance involvement, the fall, and how R#8 got to the hospital. He stated the DON's assertion R#8 had walked across the street to the ED was incorrect. He stated the QAPI (Quality Assurance Process Improvement) committee had an ad hoc (when necessary or needed) meeting on 3/26/19 the day R#8 eloped. He stated he did not know R#8 had experienced exit-seeking behaviors for several weeks because he did not always attend the daily meeting in which these matters were discussed. He stated he expected the DON to have this knowledge and he considered her his delegate. He stated there was no formal process to ensure he knows of resident behaviors, but he heard about many of them and he expected the DON to know. He stated he did not know R#8's care plan had been updated on 1/31/19 to reflect exit-seeking behavior. He stated there was a process to ensure the committee was made aware of resident behaviors or incidents. Additional Hazardous areas and means of Egress were identified during tour of the facility: On 4/3/19 from 12:15 p.m. until 12:30 p.m. DON and Administrator interviews revealed the access codes were changed on or about 4/1/19. At 1:10 p.m. the elevators, stairwell doors, and the door to the rehab part of the facility were all checked by direct observation. The access code on all devices was found to be 1810#. This was the same code as was used by the surveyor on 3/26/19 and subsequent days. Further direct observation revealed the stairwell door at the end of the east hall of the second floor also had a code of 1810#. This door was opened to access the stairwell. On the other side of this door was a door to the outside of the facility with a panic bar. On the metal panic bar were the words alarm will sound. The door was slightly larger than the door frame and was stuck open. The surveyor pushed the door open using the panic bar and no alarm sounded. A tour of the outside of the building on 4/3/19 from 4:20 p.m. - 4:55 p.m. revealed a fenced courtyard on the east side of the building. The gate was open to this courtyard and a door leading inside the building was unlocked. The door was opened, and no alarm sounded. Inside the door was a maintenance room. A door from the maintenance room lead to the hallway and the door to the hallway was unlocked and no alarm sounded when the door was opened. In the hallway to the left were 2 doors, one where cleaning supplies were kept, not locked and electrical equipment, with a sign on the door indicating Danger High Voltage. Double doors lead to the common area outside the dining room and were marked Employees Only. The common area adjacent to the doors marked Employees Only was easily accessible by residents and provided access to high voltage, cleaning chemicals and an unlocked exit from the facility to the above-mentioned courtyard which was open to the parking lot and then to the public sidewalk and street. These double doors did not lock and had no alarm and were located immediately to the left of the two elevators leading to the resident care areas. On 4/3/19 at 5:15 p.m. the Administrator was interviewed in the conference room after touring the unlocked double doors marked Employees Only adjacent to the lobby, the unlocked room marked Danger High Voltage and the unlocked outside door leading to the courtyard from the electrical room. He stated he agreed a resident could exit the facility using this route. He stated he agreed the route included electrical and other hazards. He stated this route had not been considered during the QAPI evaluation of R#8's elopement. On 4/4/19 at 9:15 a.m. - 9:25 a.m. the double doors in the lobby common area adjacent to the dining area were directly observed. These two wooden doors had a sign on them on which was written Employees Only. No staff member was guarding or observing the doors. Two residents were in the lobby sitting in wheelchairs. The surveyor found the doors to be unlocked and he passed through them easily. These doors led to a hallway with multiple doors observed. One door had a sign on which was written Danger High Voltage. This door was unlocked and easily entered. This led to a small room filled with industrial-type circuit boards and circuit breakers. Just past this room was an unlocked louvered door that easily opened to an outside courtyard. The surveyor then retraced his steps to the hall adjacent to the double wooden doors marked Employees Only. Another unlocked door was found on this hall which led to a room with a large machine. The machine suddenly came on with a loud noise. Just past this machine was a partly open door that led to the maintenance shop which led to the courtyard described above. The door could not be opened completely because it was blocked with a wheeled cart that had a portable hot dog air compressor on top of it. The shop was observed to have multiple tools and other maintenance objects in it. The surveyor retraced his steps and made his way back to the lobby through the double wooden doors marked Employees Only. These doors were not observed to be monitored by any staff member, nor was any staff member visible on 4/4/19 at 9:25 a.m. On 4/4/19 at 9:30 a.m. the east end of the second-floor was directly observed. The exit had a keypad on the wall. To the left of this door was an outside door partially open. The building was observed to be on a hill making the second-floor level with the ground at this point. The egress door was metal with a panic-bar on which was written Warning Alarm Will Sound. The panic-bar was pushed by the surveyor and the alarm did not sound. The stairwell was further observed and found to be accessible from the first floor. On 4/4/19 at 12:00 p.m. interview with the DON revealed the lock on the wrought iron gate of the courtyard was always in place and the gate was always locked. She stated she personally laid eyes on this lock on several occasions. She stated the Interdisciplinary Team met on 3/26/19 and again on 3/27/19 to discuss performance improvement regarding R#8's elopement on 3/26/19. She stated she personally inspected the inside of the building on or about 3/27/19 and did not find any concerns about other egress routes. She stated she instructed the Maintenance Director to make a thorough inspection for egress routes of the entire building and he did so. She stated every door in the facility was checked. She reviewed the door check documentation with the surveyor and agreed the door check log only showed checks for the main entrance door and the side smoking door. She stated those checks included checking the other doors also. She stated the side smoking entrance was not the only focus of the QAPI process as an egress route. She stated further she could not explain why the double wooden doors marked Employees Only were not under observation this morning and she could not explain why the courtyard gate was not locked when the surveyors observed it. She stated she did agree this was a possible egress route for a resident. A tour of the facility and interview with the Director of Maintenance was conducted on 4/4/19 at 1:10 p.m. The tour began with the Employees Only section on the first floor. The Director of Maintenance went through the double wooden doors marked Employees Only and stated the room marked Danger High Voltage was unlocked. He stated he agreed the door past the electrical panel led to the courtyard. He stated the courtyard had a lock on the gate every day, but if the gate was not locked a resident could get to the street. He stated the room marked Equipment was dangerous for a resident to be in and it would be possible for a resident to be in a hazardous environment or to leave the facility if they got past the wooden double doors to the lobby common area marked Employees Only. He stated the doors to the courtyard were not checked every day because they were not considered exit doors. He stated he agreed the residents could get out that way. Cross Refer to F908 The facility implemented the following actions to remove the Immediate Jeopardy: SS=IJ F689 Free of Accident Hazards (Supervision/Devices Immediate Corrective Action Resident #8 is an [AGE] year old female resident who was admitted to the facility on [DATE] with a DX of Altered Mental Status, [MEDICAL CONDITION], and Hypertension. She is alert and verbal with confusion noted. She is alert to self without prompting. She ambulates independently with the use of her walker. Resident #8 is oriented to place, day and time with prompting. She presents with short term memory deficits. On 3/26/19, she was observed per the staff around the change of shift near the elevator between 2:45-2:50 p.m. She was easily redirected per the staff and stated that she was going to her room to use the bathroom. She was observed by both a certified nursing assistant and licensed nurse going into her room at approximately 2:50 p.m. Resident #8 stated to the nurse, as she entered her room, that she was going to the bathroom. Resident #8 is independent in toileting. The staff was notified at approximately 3:11p.m-3:20 p.m. that Resident #8 was at the ho

Based on observation, interview, and record review, the facility failed to ensure the first floor side exit door was working properly to alert staff when a resident was exiting the building unattended. This failure resulted in one Resident (R#8) out of six residents eloping from the facility undetected. On 4/2/19, a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator was informed of the Immediate Jeopardy on 4/2/19 at 4:30 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed as of 3/26/19. The Immediate Jeopardy continued through 4/3/19 and was removed on 4/4/19. The Immediate Jeopardy is outlined as follows: On 3/26/19 resident (R) #8 exited the facility undetected through an exit door on the first floor that was not functioning properly. The resident was found on the ground by a bystander near a busy road. The bystander called 911 and Emergency Medical System (EMS) arrived at the scene. The resident was taken to the local hospital and treated for [REDACTED]. The facility was unaware of the resident's elopement until they were notified by the emergency roiagnom on [DATE]. R#8 has a history of wandering and was wearing a Wander Guard bracelet on her ankle when she left the facility. It was determined that a handicap assessable door on the first floor which has an alarm system was not working properly and therefore, the resident was able to elope from the facility undetected. The Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR 483.21(b)(2) Comprehensive Person-Centered Care Plans (F657 Scope and Severity: J). CFR 483.25(d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J). CFR 483.90 (d)(2) Essential Equipment, Safe Operation Condition (F908 Scope and Severity: J). Additionally, Substandard Quality of Care was identified with the requirements at CFR:483:25(d))1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J). A Removal Plan was received on 4/4/19. Based on interviews, record reviews, and review of facility policies as outlined in the Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 4/4/19. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight as well as develops and implements a Plan of Correction (P[NAME]). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. Findings include: Review of the undated face sheet revealed Resident (R) #8 was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. Review of her Quarterly Minimum Data Set (MDS) assessment dated [DATE], section C, revealed her Brief Interview for Mental Status (BIMS) score to be 8 out of 15, signifying impaired cognition. Review of section G revealed she required supervision for all Activities of Daily Living (ADLs). Further review revealed she could walk with supervision. Review of R#8's progress notes dated 1/31/19 revealed the Physician wrote the resident was confused at baseline and wandered the floor. Review of another progress note dated 2/12/19 revealed R#8 wandered on the floor and a Wander Guard (safety bracelet) was in place. On 3/28/19 at 11:30 a.m. interview with the Director of Nursing (DON) revealed on 3/26/19 R#8 eloped from the facility undetected. She stated R#8 was demented but could ambulate independently. The DON revealed that R#8 had a Wander Guard elopement alarm on. She stated the Wander Guard would not trigger an alarm if a resident on the second floor tried to get on the elevator, only for the front and side exit doors on the first floor. She stated after the elopement she checked the Wander Guard system on the front door and the side doors and found the front door to be good. Continued interview with the DON revealed she checked the side door to the smoking area she found the alarm did not go off until after the resident was out the door. On 3/28/19 at 1:30 p.m. Door Service Technician CC was interviewed and stated he worked for an outside contractor specializing in commercial doors. He stated he was installing a magnetic lock on door designed to lock the door if a Wander Guard should activate the lock by proximity. He stated the door would automatically lock to prevent a resident from going through the door if they had a Wander Guard device on their person. He stated prior to the installation of this lock the door would alarm but not lock and would not prevent a resident with a Wander Guard from leaving the facility. He stated you could say the door prior to the addition of the lock the door was not effective in keeping residents with a Wander Guard bracelet in the facility. He stated the alarm would be going off, but all the resident had to do was push on the unlocked door. On 3/29/19 at 12:45 p.m. interview with the Director of Maintenance revealed he checked the Wander Guard system every day and kept records of that, which he would provide. Review of the Wander Guard records revealed no concerns. He stated he checked it by taking a Wander Guard bracelet and walking near the sensors with it to be sure the alarm went off. He stated there were Wander Guard sensors on the front door on the first floor, on the side (smoking) door on the first floor, and on the second floor at the ends of the hall near the stairwells where the nurses could not see. He stated before 3/28/19 the front door and the second-floor sensors would give an audible alarm but not lock any door. He stated that before 3/28/19 the sensor on the side smoking door would give an audible alarm and swing the double doors closed but would not lock them. He stated a resident could push through the smoking doors even if they were closed because the doors did not lock. He stated the only way to mute the alarm was to punch in a code on the keypad next to the door. He stated R#8 either went through the door with a non-functioning Wander Guard and the alarm did not go off or somebody silenced the alarm without checking outside. He stated the second-floor audible alarm was not audible at the nurse's station for about the past week. He stated you could not consider an inaudible alarm to be a functioning system. He stated on 3/28/19 the side smoking door was modified to have an automatic lock and the door would lock down anytime anyone with a Wander Guard came near it. He stated you could not consider the old system to be perfect since, obviously, R#8 got out of the building. On 4/4/19 at 11:50 a.m. interview with the Administrator revealed he had never personally made an inspection of possible exit routes from the facility until after 3/26/19, the date of R#8's elopement. He stated he inspected inside the building only and had never inspected the outside of the facility because he had no concern up until recently about who could get in the building only how to get out. On 4/4/19 at 1:00 p.m. interview with Maintenance Tech KK revealed he checked every door of the facility every morning. He stated the computer documentation system was not set up for documenting these checks except for the main entrance and the side smoking door. Cross Refer to F689 The facility implemented the following actions to remove the Immediate Jeopardy: IJ F908 Essential Equipment Safe Operating Condition Immediate Corrective Measures: On (MONTH) 26, 2019, Resident #8 exited the facility without notification or supervision via the side entrance door. The resident wears a wander guard alert bracelet secondary to her risk of elopement. The side entrance door is equipped with a Wander Guard Alert system. The Wander Guard Alert System was functioning per Maintenance Director's routine 7 day per week operational check pre-event on 3/26/19 at 8:30am. The door was also noted to be functioning per Maintenance Director checks post event on 3/26/19. The Licensed Nurse validated that the resident's alarm was in place and functioning at approximately 10:00 am prior to the resident exiting the facility on 3/26/19. The Director of Nursing validated that the resident's alarm was in place and functioning appropriately upon the resident's return to the facility on [DATE]. The ID team which consists of the Administrator, Director of Nursing, Medical Director, Assistant Director of Nursing, Nurse Managers, Activities, Social Services, and Maintenance has identified an opportunity to enhance safety in the resident care environment by the addition of a Maglock to the existing Wander Guard door alert system. The NHA contacted the vendor for immediate installation on 3/26/19. Installation of the Mag-Locks was initiated 3/27/19 with completion of installation on 3/28/19. Staff assignment was initiated for continual visual observation on 03/27/2019 at 3pm and monitoring of the door. Proper functioning of the Mag-Locks post installation was validated via a Certified Inspector on 3/28/19. See above for validation. Certification review dated 3/28/19 revealed DH Pace validated all inspection points on the Maglocks were functional. The Maintenance Director updated the code for the silencing of the Wander Guard Alert System door alarm on 04/01/2019. The Nurse Managers (Director of Nursing, Assistant Director of Nursing, Unit Managers, Unit Coordinators and Staff Development Nurse) initiated education on 3/26/19. Education has been provided to 91% of the staff regarding the facility's policy governing Elopement Prevention and Management. This included education regarding the updated code for proper silencing of the door alarm. Staff also received education on the expectation of maintaining the confidentiality of the door alarm codes. Current facility staffing consists of: 45 LPNs (1 on LOA), 68 CNA's (2 LOA), 16 RN's, Dietary Services 13, Environmental Services 13, Social Services 2, Administration 12, Activities 4, Maintenance 3, and Rehabilitation Services 25. Of the facility's current employee roster the following have received education: LPN's 44, CNA's 66, RN's 15, Dietary Services 12, Environmental Services 8, Social Services 2, Administration 12, Maintenance 3, and Rehabilitation Services 21. Identification of Others At Risk The Nurse Managers reviewed 100% of the medical records of six residents identified as being at risk for an elopement on 3/26/19. These six residents wear a wander guard device. The Licensed Nurses conducted a current elopement risk evaluation of the six identified residents on 3/26/19 and 3/27 /19. The ID Team (Director of Nursing, Nurse Managers, Social Services, Activities, Dietician, Therapy) has reviewed the plan of care for these residents with revisions as indicated on 04/02/2019. The Licensed Nurses also validated the placement and functionality of the wander guard devices placed on current residents on 3/26/19. Residents who utilize a wander guard will be supervised per a staff member when off the unit. Systemic Changes The Nurse Managers initiated education on 3/26/2019. The Nurse Managers provided education to the staff regarding the facility's policy governing Elopement Prevention & Management. Education also included managing residents with exit-seeking behaviors. The Nurse Managers utilized educational content as outlined in the following Policy & Procedure Practice Guidelines: * Resident Elopement Policy (OP2 0401.04) Education has been provided to 91% of the facility's staff members. Current facility staffing consists of: 45 LPNs (1 on LOA), 68 CNA's (2 on LOA), 16 RN's, Dietary Services 13, Environmental Services 13, Social Services 2, Administration 12, Activities 4, Maintenance 3, and Rehabilitation Services 25. Of the facility's current employee roster the following have received education: LPN's 44, CNA's 66, RN's 15, Dietary Services 12, Environmental Services 8, Social Services 2, Administration 12, Maintenance 3, and Rehabilitation Services 21. The Nurse Managers will continue to provide education to current staff prior to the start of their next scheduled shift and to new staff members during the orientation process. No staff shall work in the resident care area prior to receiving education on facility elopement policy. The Maintenance Director will continue to perform operational quality checks 7 days per week on the entry doors in conjunction with the established routine Maintenance Inspection of the doors and alarms systems. The IDT team (Administrator, Nurse Managers, Social Services, Activities, Dietician, Therapy) will continue to adhere to the established process for Elopement Prevention & Management in accordance with organizational policy and regulatory guidelines. The Licensed Nurse will conduct an Elopement Risk assessment upon admission, quarterly and with a Significant Change in Condition. The IDT team will develop and implement an individualized resident centered plan of care to address the residents identified risk factors. The Licensed Nurse will obtain and implement utilization of wander guard alert devices as indicated when the residents exhibit exit seeking behaviors. The devices will be monitored 7 days per week for placement and functionality per the Licensed Nurse. How will you monitor and sustain compliance The IDT team has identified an OFI (Opportunity For Improvement) on 03/26/2019 in the delivery of resident-centered care in regards to promoting an environment of care that enhances safety and is free of risk of accidents. This is in accordance with regulatory guidelines as outlined in F908, F689 & F656. This OFI is evidenced as a result of a resident exiting the facility without staff supervision or notification. Through an Ad-Hoc Quality Assurance meeting held on 03/27/2019 the ID team which consisted of Administrator, Director of Nursing, Medical Director, Assistant Administrator, Clinical Managers, Social Services, Activities, Maintenance, and MDS has conducted a review of the established facility policy governing Resident Elopement with no revisions indicated. The State Survey Agency (SSA) validated the facility's Removal Plan as follows: These six residents wear a Wander Guard device. The Licensed Nurses conducted a current elopement risk evaluation of the six identified residents on 3/26/19 and 3/27/19. Review of the undated Wanderguard Resident document revealed a list of six residents on wander guard anti-elopement bracelets. Review of the Elopement Book confirmed this. Review of the six residents' care plans in the EMR revealed their care plans had been reviewed and updated for elopement risk between 3/26/19 and 4/3/19. Further review revealed elopement risk assessments (evaluations) were completed for these residents on 3/26/19 or 3/27/19. The ID Team (Director of Nursing, Nurse Managers, Social Services, Activities, Dietician, Therapy) has reviewed the plan of care for these residents with revisions as indicated on 4/2/19. Review of the six residents' care plans in the EMR revealed their care plans had been reviewed and updated for elopement risk between 3/26/19 and 4/3/19. The Licensed Nurses also validated the placement and functionality of the wander guard devices placed on current residents on 3/26/19. Residents who utilize a Wander Guard will be supervised per a staff member when off the unit. Review of the second-floor Elopement Book revealed daily check sheets for wander guard placement and function on all six Wander Guard residents. On 3/27/19 these residents' Medication Administration Records (MARs) began documenting Wander Guard placement and function for these residents. On 4/1/19 at 10:15 p.m. observation and interview with LPN BB revealed she demonstrated the electronic device used to check the functionality of the Wander Guard on R#8. The device beeped when brought near R#8's device on her shoe and the nurse explained she did this every day. Systemic Changes Review of the 3/26/19 - 4/4/19 in-service sign-in sheet revealed 153 signatures on an in-service entitled Wandering and Elopement. On 4/4/19 at 1:00 p.m. the Maintenance Technician stated in interview a resident asked him for the access code yesterday and he told him that only staff were allowed to have the codes. On 4/4/19 at 10:10 a.m. CNA HH was interviewed, she stated they had class on not giving the residents or visitors the access codes. Managers also conducted additional Wandering and Elopement Drills on all three shifts for validation of education provided from 3/26/19-4/1/19. On 4/3/19 the side smoking door on the first floor was approached with a Wander Guard. Upon approaching the door a click could be heard in the door lock and the doors did not open. The door would not open when pushed hard. An alarm was heard. Shortly after the words Code Yellow could be heard from the speakers overhead. Two staff members came and stated they were looking for a resident. One of them entered the code on the key pad and opened the doors. Both staff members went outside and looked for a resident. Record review of education attendance revealed on 3/26/19 an elopement drill was conducted and on 3/29/19, 4/1/19 and 4/3/19. Both staff members verified that they attended the in-service training. On 3/29/19 at 12:45 p.m. interview with the Director of Maintenance revealed he stated he checked the Wander Guard system every day and kept records of that, which he would provide. He stated he checked it by taking a Wander Guard bracelet and walking near the sensors with it to be sure the alarm went off. He stated there were Wander Guard sensors on the front door on the first floor, on the side (smoking) door on the first floor, and on the second floor at the ends of the hall near the stairwells where the nurses could not see. He stated that he attended the in-services. Review of the door check logs revealed the main entrance doors and the side smoking door were checked for functionality every day from 1/1/19 until 4/4/19 with no concern. On 4/4/19 at 1:00 p.m. interview with Maintenance Tech KK revealed he worked for the company a long time and at this facility for five months. He stated he checked every door of the facility every morning. He stated that he attended the in-services. Multiple Elopement Risk Assessments were reviewed during the survey and found to be done upon admission, quarterly, and with a significant change. On 4/4/19 at 5:04 p.m. interview with LPN LL revealed he received education recently in wandering/elopement management and completion of elopement risk assessments. He stated he completed these assessments on admission, re-admission, quarterly, and with any change. On 4/4/19 at 5:08 p.m. interview with LPN MM revealed he received education recently in wandering/elopement management and completion of elopement risk assessments. He stated he completed these assessments on admission, re-admission, quarterly, and with any change. Review of the Elopement Management document dated 7/2017, revealed elopement policy. Further review revealed the resident and RP would be notified of the Wander Guard placement. Further review revealed if the resident at risk for elopement exhibits exit-seeking behavior it must be documented in the 24-hour report and additional interventions must be considered. Further review revealed the facility must develop a consistent method for tracking the expiration of devices and ensure the devices were replaced prior to expiration. Further review revealed residents were to be assessed for elopement quarterly. Further review of the second-floor elopement book revealed each resident with a Wander Guard had the serial number and the expiration date of the devices. Review of manufacturer's documentation of Wander Guard usage revealed the devices would alert the tester as the expiration date approached or if the batteries became low.14 resident care plans were reviewed and found to be reasonable person-centered and identified risk factors such as falls, elopement, or isolation. Review of the six residents' who used the Wander Guard system revealed their care plans had been reviewed and updated for elopement risk between 3/26/19 and 4/3/19. Review of the second-floor Elopement Book revealed daily check sheets for Wander Guard placement and function on all six Wander Guard residents. On 3/27/19 these residents' Medication Administration Records (MARs) began documenting Wander Guard placement and function for these residents. On 4/1/19 at 10:15 p.m. observation and interview with LPN BB revealed. She demonstrated the electronic device used to check the functionality of the Wander Guard on R#8. The device beeped when brought near R#8's device on her shoe and the nurse explained she did this every day. She stated that she attended the in-services. Certification review dated 3/28/19 revealed DH Pace technician validated all inspection points on the Maglocks were functional. How will you monitor and sustain compliance Review of the Ad Hoc QAPI Meeting /Four Point Plan of Correction Agenda and Summary dated 3/27/19 revealed a meeting of the ad-hoc meeting to consider R#8's elopement of 3/26/19. The meeting consisted of root-cause analysis, a corrective action plan, identification of other residents who might be at risk, changes to be communicated to staff, continued monitoring and sustaining compliance. The Survey Pathway document dated 4/1/19 revealed the six residents in the facility using the Wander Guard devices to be at risk. .