Every finding on record at Pine Forest Health and Rehabilitation

Based on observation, facility policy review, record review and interviews, the facility failed to update the resident's care plan after a fall to prevent recurrence for one (1) of four (4) sampled residents. Resident #3.Findings Included: Record review of the facility policy, Falls Standard with a revision date of May 2026, revealed, POST FALL STANDARD.Revise/update intervention on the Plan of Care and included FALLS: DECISION TREE.Step 3 Has the resident just fallen? ->Step 4 Evaluate the factors associated with the fall. ->Step 5 Identify the resident's actual and potential complications of falls. -> Step 6 Develop a plan for managing falls and fall risks.Record review of the facility policy, COMPREHENSIVE CARE PLAN with a revision date of July 2026 revealed, . 3. The comprehensive care plan shall describe.f. Resident specific interventions that reflect the resident's needs. Record review of the Care Plan Report for Resident #3 revealed, Focus. At risk for Falls.06/21/2026 Fall with no injuries.Interventions/Tasks.Send to RE related to a fall. Date Initiated 06/21/2026. There were no updated interventions or revisions that addressed the cause of the 6/21/26 fall or prevention of future falls based on the incident report root cause analysis conducted by the facility dated 6/21/26. Record review of the Progress Notes *NEW* dated 6/21/26, Type: Post Fall Evaluation, revealed she experienced a fall from her bed with the reason for the fall: Resident's bed was sitting up in high fowlers.On 8/18/26 at 1:30 PM, observation, record review and interview with Certified Nursing Assistant (CNA) #1 revealed that she and Licensed Practical Nurse (LPN) #1 transferred Resident #3 into bed from her wheelchair following lunch. The side rails were in place and up and head of bed elevated to high fowler's position (head of bed elevated in an upright position). She then demonstrated the use of the facility laptop to review care instructions for Resident #3. CNA #1 confirmed there were no instructions regarding partial side rails or positioning Resident #3 to prevent a fall. On 8/19/26 at 12:35 PM, during an interview the Director of Nurses (DON) revealed Resident #3 had a fall from bed on 6/21/26, after which the facility had completed an incident report, conducted a root cause analysis and determined the cause of the fall, and that the resident's fall care plan had not been updated with an intervention directed at prevention of further falls. She explained that the root cause of the fall was determined to be that the resident was left with her bed in high fowler's position (head of bed elevated in an upright position). She confirmed that the only intervention added stated, Send to RE related to a fall. Date Initiated:6/21/26 which did not address the cause of the resident's fall or interventions to prevent further falls. The DON confirmed that the care plan should be updated following any incident/fall and should include/update interventions to address the cause and prevent further falls. She confirmed that the facility procedure included review of and notification of the MDS Nurse of all incidents/falls during the daily clinical meetings and that the MDS Nurse was responsible for updating the care plan but confirmed that any nurse could update the care plan. She explained that the Individual Care Service Plan (ICSP) was pulled directly from the care plan to provide care instructions for each resident to all CNAs and was available to them on laptops or tablets, therefore if interventions to prevent falls were not added to a care plan, they were also not listed in the resident's ICSP. She confirmed that the resident was transferred to local ER (emergency room) for evaluation and treatment as needed and returned without hospital admission and no new diagnoses or physician orders and that Resident #3 had not experienced any falls since 6/21/26.On 8/19/26 at 12:50 PM, interview with the Minimum Data Set (MDS) Nurse revealed that the only revision or update to the care plan of Resident #3 following 6/21/26 fall was Send to RE related to a fall. Date Initiated:6/21/26 and that intervention did not address the cause of the resident's fall or interventions to prevent further falls. On 8/19/26 at 3:20 PM, interview with the Administrator revealed she expected nursing staff to complete a review of all incidents including falls during daily clinical meetings and update resident care plans as needed in response and include interventions that addressed the cause of the fall and prevention of future falls. She confirmed that updating and revising care plans as needed according to facility policies on falls and care plans provided necessary care instructions for nursing staff and protection for residents. Record review of the admission Record for Resident #3 revealed the resident was admitted to the facility on [DATE] with an original admission date of 7/15/16 with diagnoses that included intracerebral hemorrhage onset 8/25/21 and dementia onset 9/27/18.Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/17/26 revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment.

Based on facility policy review, record review and interviews, the facility failed to ensure the residents' right to access the medical records for one (1) of four (4) sampled residents. Resident #1. Findings Included:Record review of the facility document titled, NURSING HOME RESIDENTS' RIGHTS undated revealed Residents of nursing homes have rights that are guaranteed to them under Federal and State laws.Right to Self Determination.Participate in developing and implementing a person-centered plan of care.Right to be Fully Informed of the type of care to be provided.Changes to the plan of care.Record review of the facility policy, MEDICAL RECORD REQUESTS, undated, revealed, Medical records will be released with a valid request and in accordance with state and federal laws.6. Upon receipt of a request for medical record copies, the facility should notify the requesting party, in writing, of the cost for obtaining records and that records are available 5 business days after receipt of payment for the copies.Access Rights to Medical Information are as follows: The resident (current) resident - the resident's record is accessible to him/her within 24 hours (excluding weekends and holidays) notice, following written request .On 8/18/26 at 9:33 AM, during a telephone interview the Complainant for CI # 3152582 the Resident Representative (RR) for Resident #1 reported the facility had actively obstructed the resident rights of Resident #1. She said she had been designated as the conservator for Resident #1 in January 2026 and presented the documentation to the facility and was therefore designated as the RR for Resident #1. She said she had completed and submitted a written request on 7/02/26 to inspect and obtain the clinical records of Resident #1. She reported that after the facility ignored written requests for 35 days, she went to the facility in person 8/06/26 and was granted access to electronic records. She said the Assistant Director of Nursing (ADON) claimed that electronic access to clinical logs was not available on-site after 30 days and required a corporate request. She said the administration refused to produce her brother's treatment records/therapy records and shower schedules documentation and claimed they do not have access to those on the computer.Record review of the Request to Inspect Medical Records dated 7/02/26 revealed the RR for Resident #1 requested medical records 6/30/26-7/02/26.nursing notes, respiratory notes for dates 6/30-7/2/26. and 07/2/2025.shower schedule for the month of June 2026 and July 2026.schedule that (Resident #1) is gotten out of the bed for activities or therapy for June and July.Record review of the email response from the Shareholder and .Arbitrator to the RR for Resident #1dated 8/6/26 revealed, . I am providing to you a copy of (Resident #1's) Progress Notes for 6/30/2026-7/2026, which includes Respiratory.On 8/19/26 at 12:35 PM, during an interview the Director of Nurses (DON) confirmed that she received a request for records for Resident #1 by his RR on 7/02/26. She said she provided Resident #1's RR with the facility policy on record requests and asked her to complete a records request form, which was completed and that the RR had included a typed list of her requests to be included or attached. She said that the RR was allowed to view Resident #1's electronic records accompanied by facility staff for an extended period of at least an hour and a half on 8/06/26. She said that according to facility policy and confirmed that some of the records the RR had requested for review were not available at the facility.On 8/19/26 at 2:20 PM, during an interview with the RR for Resident #1, she confirmed she had spoken with the DON on 7/02/26 and requested access to inspect Resident #1's medical records and that on 8/06/26 she was allowed to view his records with nursing staff for thirty minutes. She stated that she received only nursing progress notes from the corporate office for 6/30/26 through 7/02/26 and nothing more than 8/19/26.On 8/19/26 at 3:20 PM, during an interview the Administrator revealed that she was aware that the RR for Resident #1 had changed in January or February 2026. She confirmed that on 7/02/26 she had received a verbal and written request for records from the RR for Resident #1 and on 8/10/26 received a certified letter that some of the requested records still had not been provided as of 8/19/26, including care records for 6/30/25 through 7/02/25. The Administrator confirmed that the Resident's RR had not received copies of all requested medical records for Resident #1 as of 8/19/26. She confirmed that the resident and/or their representative had the right to access the residents' medical records within (24) business hours of verbal or written request and copies of the resident's medical records within two business (2) days, assuming cooperation with the allowable fees.Record review of the admission Record for Resident #1 revealed the facility admitted him on 12/11/24 with an original admission date of 8/07/23 with diagnoses that included and he had diagnoses of hemiplegia and hemiparesis and aphasia following cerebral infarction (stroke).

Based on facility policy review, record review and interviews, the facility failed to ensure the Resident Representative (RR) was included in the development of the care plan for one (1) of four (4) sampled residents. Resident #1.Findings Included:Record review of the facility document titled, NURSING HOME RESIDENTS' RIGHTS undated revealed Residents of nursing homes have rights that are guaranteed to them under Federal and State laws.Right to Self Determination.Participate in developing and implementing a person-centered plan of care.Right to be Fully Informed of the type of care to be provided.Changes to the plan of care.Record review of the facility policy COMPREHENSIVE CARE PLAN with a revision date of July 2026 revealed, The comprehensive care plan shall describe.Resident specific interventions that reflect the resident's needs.The comprehensive care plan shall be prepared by an interdisciplinary team, that includes.The resident and the resident's representative.The comprehensive care plan shall be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment.The physician, other practitioner, or professional shall inform the resident and/or representative of the risks and benefits of proposed care, of treatment, and treatment alternatives/options.On 8/18/26 at 9:33 AM, during a telephone interview the Complainant for CI MS # 3152582, the RR for Resident #1 said she had not been notified of a care plan meeting since she was designated as Resident #1's RR and was unaware of any care plan meeting in 2026, although she had requested a care plan meeting multiple times, verbally and in writing. On 8/19/26 at 12:35 PM, during an interview the Director of Nurses (DON) confirmed that Resident #1's last care plan meeting was held on 2/10/26 with his former RR in attendance.On 8/19/26 at 12:50 PM, during an interview MDS Nurse confirmed that care plan meetings were usually held every three (3) months following Quarterly (or Annual) MDS assessments and as needed upon significant change of resident condition/plan of care or resident or RR request.On 8/19/26 at 3:20 PM, during an interview the Administrator revealed that she was aware that the RR for Resident #1 had changed in January or February 2026. She confirmed that Resident #1 had quarterly MDS assessment in May 2026 and that care plan meetings were normally scheduled every three months following the MDS assessment. She confirmed that she had received requests from Resident #1's current RR for a care plan meeting and that none had been conducted or scheduled until August 2026. She confirmed that Resident #3 had a significant change of condition in July 2026. She confirmed that residents and/or their RRs had the right to participate in care planning activities.On 8/19/26 at 3:50 PM, interview with the Social [NAME] Director, (SSD) revealed that she scheduled quarterly care plan meetings with the resident and/or their RRs, usually following the quarterly MDS assessment or as needed or upon request of the resident or their RR. She confirmed that the last care plan meeting for Resident #1 was held 2/10/26 and attended by his former RR. Record review of the admission Record for Resident #1 revealed an admission date of 12/11/24 with an original admission date of 8/07/23 with diagnoses that included hemiplegia and hemiparesis and aphasia following cerebral infarction (stroke).

Based on observation, interview, record review, and policy review, the facility failed to maintain a safe, functional, and comfortable kitchen environment for staff and failed to ensure the kitchen's air-conditioning system was repaired promptly. The deficient practice had the potential to affect all residents served by the facility's dietary department and all dietary staff required to work in the kitchen while the air-conditioning system remained inoperable. Findings include: Review of the facility policy titled, Capital Improvements dated 08.2021 (August 2021) revealed, It is the standard of this facility to adhere to applicable Federal Health care program requirements.pertaining to capital equipment and supplies.The Plant Operations Manager or designee conducts or obtains certain maintenance and repair functions according to regular schedule or as the need is determined .During Environmental Observations on 7/15/26 at 11:55 AM and 7/16/26 at 1:00 PM SA determined that the facility kitchen air conditioner was not working, and the dietary department staff were required to substitute hot menu items with food items that could be prepared/served cold due to excessive heat in the kitchen. On 7/15/26 fried chicken was not served.On 7/16/26 at 1:05 PM observation and interview with [NAME] #1 and [NAME] #2 revealed there was a large industrial fan positioned toward the open doorway to direct cool air from the dining room into the kitchen. When asked why the fan was there kitchen and how long it had been there, both explained that the A/C unit in the kitchen was not working properly and the fan had been there since Monday 7/13/26. Both described the heat in the kitchen as oppressive. When SA expressed concern and cautioned against getting too hot, [NAME] #2 reported that she became unwell following her shift in the kitchen on 7/12/26 and missing work on 7/13/26. Both confirmed that the excessive outdoor heat with the heat index reaching into the triple digits were not helping matters. When asked why fried chicken was removed from the menu on 7/15/26, they explained that food items had to be substituted to prevent overheating the kitchen by use of heat-generating appliances for food preparation. While neither staff member sought SA to report complaints, they answered questions with open demeanors. On 7/16/26 at 1:23 PM interview with the Plant Operations Manager (Maintenance Supervisor) revealed that the malfunction of the kitchen A/C unit was an ongoing problem for which he had sought repair services. He said that the unit may need to be replaced. He confirmed that the large industrial fan positioned toward the propped open doorway to direct cool air from the dining room into the kitchen had been placed there by maintenance staff to help prevent overheating the kitchen. He said he didn't always attend the morning meetings due to emergent needs elsewhere in the facility and was unaware that the menu items had been substituted to help prevent overheating the kitchen. He confirmed that he was aware of federal and state regulations that stated that the facility was required to provide a safe and functional environment for residents and staff.On 7/16/26 at 2:30 PM interview with the Dietary Manager revealed that she had reported hot conditions in the kitchen during the morning meetings and that one dietary staff member who had worked during the day on Sunday 7/12/26 had called in to report she was unable to work on Monday 7/13/26 due to illness. She reported that the excessive heat in the kitchen due to the malfunction of the A/C unit had resulted in 1.) dietary having to take frequent breaks to go outside or into the dining room to ensure they didn't overheat and 2.) dietary services had to begin serving food item substitutions to residents in an effort to prevent generation of additional heat in the kitchen by heat-generating appliances, such as the deep fryer, steam table, oven and stove. She specified that the menu had been changed for 7/15/26 and 7/16/26. She confirmed that the door between the dining room and kitchen had been propped open and a large industrial fan positioned toward the open doorway to direct cool air from the dining room into the kitchen on 7/15/26 and 7/16/26, trying to make sure the staff don't overheat.On 7/16/26 at 2:35 PM interview with the Director of Nurses (DON) confirmed that the Dietary Manager had reported increased temperature (heat) in the kitchen during morning meetings in June and July 2026. She confirmed that the door between the dining room and kitchen had been propped open and a large industrial fan positioned toward the open doorway to direct cool air from the dining room into the kitchen on 7/15/26 and 7/16/26. On 7/16/26 at 3:00 PM interview with the Administrator revealed that the facility had been aware of the issues with the kitchen air conditioning (A/C) unit since 6/22/26 and that the contract air conditioning service company that was on their vendors' list had visited the facility the week of 6/22/26 and addressed the problem. The Administrator confirmed that the repair had not completely corrected the issue and that the problems with the unit had resumed. She said she had been on vacation 7/13/26 through 7/15/26 and was aware on 7/10/26 that there was a malfunction with the air conditioning unit in the kitchen. She stated that because the facility contract A/C service had visited several times and the unit was still not working properly, she was attempting to get another contract A/C service added to the facility's approved vendors' list but that had not happened. She was not sure when the last time the current A/C service had been contacted to come to the facility to evaluate and repair the kitchen A/C unit. Record review of the weather report at https://www.msn.com/en-us/weather/monthlyforecast/in-[NAME],MS and the National Weather Service outdoor high temperature on 7/15/26 was 90 degrees Fahrenheit with a heat index, a measure of temperature as perceived by humans that combines actual air temperature and humidity and on 7/16/26 it was 91 to 92 degrees Fahrenheit and the city had an active heat alert in effect.Record review of the invoice dated 7/16/26 from the contracted A/C service revealed Invoice 21114 stated, Kitchen A/C not working.unit not coming on due to bad delay timer for compressor. Bypassed timer. Then checked operation of unit. Checked pressures, supply and return temps. Operating normal at this time.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure the call lights were within reach for two (2) of five (5) residents, Resident #1 and Resident #2.Findings Included:Review of the facility policy titled Call Light Standard with revision date 03.2019 (March 2019) revealed, The purpose of this standard is to assure the facility is adequately equipped with a call light at each resident's bedside .to allow residents to call for assistance .1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light .5. With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed . On 7/15/26 at 12:22 PM observation of Resident #1 and Resident #2 revealed the call light system devices were not accessible to either resident while in their beds, as the devices were laying on the floor between their beds. Resident #2 attempted to reach his call light and was unable to locate or reach it.On 7/15/26 at 4:10 PM observation of Resident #1 and Resident #2 in their room revealed the call light system devices were laying coiled on the floor between their beds beneath the call light system outlet. Neither resident was able to reach his call light device or its cord from their respective beds, where they were resting.On 7/16/26 at 12:55 PM observation of Resident #1 and Resident #2 with the Administrator in their room revealed both residents were resting on their respective beds and the call light system devices were laying coiled on the floor between their beds beneath the call light system outlet. Neither resident was able to reach his call light device or its cord. The Administrator positioned each resident's call light within their reach.On 7/16/26 at 2:40 PM interview with Licensed Practical Nurse (LPN) #1 revealed she stated that all residents call light system devices were supposed to be positioned within their reach to summon assistance as needed.On 7/16/26 at 2:50 PM interview with Certified Nursing Assistant (CNA) #1 revealed she said call lights should be kept within reach of the resident.so if they need help, they will be able to call. She said that she made rounds every two hours to check on her assigned residents. On 7/16/26 at 2:57 PM interview with Registered Nurse (RN) #1 revealed call lights were to be left within reach of each resident. She confirmed that the nurses were responsible for supervising resident care and that all staff were responsible for call lights being left within residents' reach upon the conclusion of each interaction and during regular rounds. On 7/16/26 at 3:00 PM interview with the Administrator revealed she stated that all residents call light system devices were supposed to be positioned within their reach to summon assistance as needed. She said that all staff were responsible for making sure that residents could reach their call lights. Record review of the admission Record for Resident #1 revealed the facility admitted him on 5/20/25 and he had diagnoses of dysphagia, gastrostomy, type 2 diabetes, chronic obstructive pulmonary disease (COPD) and repeated falls.Record review of the Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 4/24/26 for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of 07, which indicated severe cognitive impairment, and that the resident was dependent for toilet hygiene, and required partial/moderate assistance for chair/bed to chair transfers and could not walk without assistance.Record review of the admission Record for Resident #2 revealed the facility admitted him on 7/11/26 and he had diagnoses of malignant neoplasm of hypopharynx, anemia, COPD, lack of coordination, abnormal gait and weakness.Record review of the Quarterly MDS with ARD 6/15/26 for Resident #2 revealed a BIMS score of 10, which indicated moderate cognitive impairment, and he was dependent for toilet transfers.

Based on observation, interviews, record reviews and facility policy review the facility failed to prevent the possibility of spreading infection during Activities of Daily Living (ADL) care for one (1) of four (4) care observations. Resident #7.Findings Include:Record review of facility policy Hand Hygiene with a revision date of 5/2023 revealed, .Staff involved in direct resident contact shall perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors.On 5/27/26 at 3:00 PM, an observation of Activities of Daily Living (ADL) care was conducted for Resident #7 with Certified Nursing Assistant (CNA) #1. CNA #1 entered the resident's room carrying supplies and was not wearing a gown. She did not perform hand hygiene upon entering the room. CNA #1 donned (put on) gloves, informed the resident she would be providing care, adjusted the bed using the bed remote, and pulled back the bed sheet while wearing the same gloves. CNA #1 then removed her gloves and exited the room. CNA #1 returned to the room accompanied by the Respiratory Therapist (RT). Both staff members were wearing gowns upon reentry. CNA #1 did not perform hand hygiene upon entering the room before applying a new pair of gloves. While wearing clean gloves, she adjusted the bed using the bed remote and removed the television remote from the resident's bed. The RT changed the resident's tracheostomy dressing and assisted CNA #1 with turning the resident. CNA #1 removed the resident's gown, turned the resident onto his left side, and performed peri care. During the care, the resident's brief was observed to be soiled with urine. CNA #1 folded the soiled brief and tucked it underneath the resident. She subsequently adjusted the bed using the same contaminated gloves. A lift pad underneath the resident was observed to be yellow and soiled with urine. CNA #1 did not perform hand hygiene before providing care, during glove changes, or after completion of care. Upon completion, she removed her gloves, gathered supplies, and exited the room without performing hand hygiene.On 5/27/26 at 3:27 PM, during an interview, CNA #1 stated she did not know why she provided care in that manner and acknowledged she had made a mistake during peri care. CNA #1 stated the care she provided was an infection control concern and confirmed the resident could become ill as a result. She further confirmed she failed to perform hand hygiene before, during, and after resident care.On 5/27/26 at 4:44 PM, during an interview, Registered Nurse (RN) #1, who also served as the Infection Preventionist, stated CNA #1 had received training regarding hand hygiene. RN #1 stated CNA #1 should have performed hand hygiene upon entering the room, during care when contamination occurred, and upon exiting the room. RN #1 further stated the care observed could place the resident at risk for urinary tract infections, moisture associated skin damage, fungal infections, and cellulitis. RN #1 stated staff were expected to follow infection control practices and provide baseline standards of care.On 5/27/26 at 5:22 PM, during an interview, the Director of Nursing (DON) stated CNA #1 should have performed hand hygiene upon entering the room, during care activities, and after completion of care. The Director of Nursing stated when staff touch environmental surfaces or equipment while wearing contaminated gloves, they should remove the gloves, perform hand hygiene, and don clean gloves before resuming resident care. The DON confirmed residents could develop skin infections, wounds, and bacterial contamination when proper infection control practices are not followed. The DON stated she expected staff to provide care correctly to prevent residents from becoming ill.Record review of Resident #7's admission Record revealed an admission date of 4/17/26 with diagnoses that included tracheostomy status and dysphagia, oropharyngeal phase.Record review of Resident #7's Order Summary Report with active orders as of 5/27/26 revealed an order dated 4/17/26, Trach size #6 [NAME] flex tracheostomy with disposable inner cannula and an additional order for enteral feeding with Jevity 1.5 at 50 milliliters (ml) per hour with 100 ml water flushes every three hours.Record review of Resident #7's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/30/26 revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. Resident #7 was dependent upon staff for care.

Based on facility policy review, record review, and interviews the facility failed to evaluate, assess and identify potential injury for one (1) of four (4) residents who experienced a fall. Resident #1. Findings Included:Record review of the facility policy titled Falls Standard with Revision Date February 2018 revealed the policy stated, When a resident is found on the floor the facility is responsible for investing the reason for this.PROCEDURE POST-FALL.Obtain blood pressure and pulse while resident is on the ground.Do neuro-checks (assessment of resident's pupil equality and level of consciousness) for witnessed head injury or unwitnessed fall with or without injury. Move resident in bed or chair only if no obvious injury. Nursing to complete: Fall Risk Assessment form, Incident report.Accident/incident report, Post Fall Investigation report.MEDICAL RECORD DOCUMENTATION GUIDELINES The INITIAL NOTE/ASSESSMENT SHOULD CONTAIN THE FOLLOWING AND INCLUDE A DESCRIPTION OF WHAT WAS DONE: A. Vital signs.Document who was notified and time of notification for all attempts to do so (e.g., physician, family, state agency, as appropriate).At a minimum documentation is to be done every shift.Any negative change needs to be reported immediately.All incidents and accidents are reviewed in the daily morning clinical meeting to ensure the documentation and notification guidelines have been followed. FALLS STANDARD stated that EVENT of unwitnessed fall GUIDANCE included, Neurological assessment: Every 15 minutes X 2 hours then Every 30 minutes X 2 hours and then Every shift X 72 hours. Post Fall Process.Family is notified of event. Record review of the facility Incident Report dated 12/28/25 for Resident #1 revealed the incident was categorized as an unwitnessed fall on 12/27/25 as reported by Resident #1. The Director of Nursing (DON) was notified on 12/28/25 at 9:23 AM. Resident #1's Resident Representative (RR) was notified on 12/28/25 at 9:46 AM, and the Primary Healthcare Provider (Nurse Practitioner #1) was notified on 12/28/25 at 9:54 AM. The Incident Report included immediate action taken included some swelling to right forehead and tenderness and notification of ambulance service for transport with resident transported to acute care facility at 10:20 AM on 12/28/25. Record review of the Facility Investigation dated 1/02/26 revealed Resident #1 reported to the Wound Care Nurse on 12/28/25 that she had fallen on the evening of 12/27/25 resulting in Resident #1's transportation to the local emergency department for assessment and evaluation with radiographic diagnostics Computed Tomography (CT) scan of the head. A statement written statement by Certified Nursing Assistant (CNA) #2 in the Facility Investigation revealed she stated that at approximately 7:48 PM on 12/27/25 she responded to call for help and observed Resident #1 on her stomach on the floor.On 1/07/26 at 11:20 AM, during a telephone interview the RR for Resident #1 stated she disapproved of and was disappointed with the facility nursing staff due to their failure to notify her of a fall experienced by Resident #1 on the evening of 12/27/25 that she was not notified about until after 9:30 AM on 12/28/25. She stated that she was very concerned because Resident #1 had a bump on her right forehead and she had not received assessments or treatment until the following morning.On 1/07/26 at 2:25 PM, during an interview with the Unit Manager, revealed that she was notified on 12/28/25 at approximately 9:20 AM by the Wound Care Nurse that Resident #1 reported that she had fallen and two staff had picked her up from the floor and put her back in the bed on the evening of 12/27/25 but the resident was unsure of the time. She stated that her immediate reaction was to conduct a body audit and pain assessment on the resident, who reported forehead tenderness at the site of swelling over right eye and that she had hit her head during the fall. The Unit Manager stated that she observed some swelling above the resident's right eye. She stated that neuro-checks and vital sign checks were initiated according to the facility policy and procedure for unwitnessed falls. She stated that Resident #1's Primary Healthcare Provider Nurse Practitioner (NP) #1 was notified of the fall at approximately 9:54 AM on 12/28/25 and the RR was notified of the fall at approximately 9:26 AM on 12/28/25. The Unit Manager stated that all of the actions and notifications were accomplished on 12/28/25 after the resident reported the fall to the Wound Care Nurse should be done on 12/28/25 as soon as possible following the fall. She confirmed that monitoring should have included neuro-checks, pain assessment and vital signs monitoring, which were not performed or documented following the incident during the 3:00 PM to 11:00 PM shift on 12/27/25, or during the 11:00 PM to 7:00 AM shift.On 1/07/26 at 2:50 PM, during an interview the Wound Care Nurse revealed she was notified by Resident #1 on 12/28/25 at approximately 9:18 AM that Resident #1 had fallen on the evening of 12/27/25 but was not able to recall the time and that she had hit her head on the floor and indicated the area by touching her forehead above her right eye. She stated that falls had to be reported and documented on the Twenty-Four-Hour Report, with an incident report completed in the resident's medical record for continuity of care and assessments, and included vital signs and neurological checks, for residents who had fallen. She stated that if a resident fell the RR should be notified right away as change of condition. She confirmed that the facility provided in-service training regarding Resident Rights and Facility Fall Policy and Procedure at least every month and that the in-service for Residents' Rights included notification of the Resident's RR in case of change of condition or incident or accident.On 1/07/25 at 3:00 PM, during an interview with Resident #1 and her RR in the resident's room revealed Resident #1 reported that on the evening of 12/27/25 (she was unsure of the time) she fell from her bed when she reached down to get something off the floor and that she bumped her head. Resident #1 reported that staff responded to her call for help and assisted her back into bed. She said she told the Wound Care Nurse the next morning around 9:00 AM and was subsequently transported to the hospital for evaluation. The RR stated that she was not notified of the fall on 12/27/25 but was notified on 12/28/25 after Resident #1 reported the fall to the Wound Care Nurse. The RR confirmed that she observed a slightly swollen area on Resident #1's forehead just above her right eye on 12/28/25.On 1/07/26 at 3:20 PM, during an interview with the DON revealed that she was notified on 12/28/25 at approximately 9:23 AM by the Unit Manager via telephone that Resident #1 had reported to the Wound Care Nurse that she had fallen on the evening of 12/27/25 and hit her head and that the resident had a raised (inflamed/swollen), tender area on her right forehead. She stated she instructed that a body audit and neurological assessments (every 15 minutes X4, every 30 minutes X4 and then every hour X8 and then every shift) be completed with on-going assessment for seventy-two hours after fall per facility policy and procedure/fall protocol. She stated the RR for Resident # 1, telephoned her on the morning of 12/28/25 and was upset and crying and said she had been notified on the morning of 12/28/25 that the resident had fallen. The DON stated that the facility initiated and completed an investigation into the incident because the resident fell. The DON confirmed that failure to report incidents and provide assessments and care as needed according to facility policy and procedure for falls could result in the resident having unrelieved pain, complications, or negative unidentified results from falls. She confirmed that the correct procedure in case of a resident fall was to assess the resident including body/skin audit and pain assessment, if safe assist the resident to a position of comfort, begin routine neurological assessments (neuro-checks) and vital sign monitoring for seventy-two hours, notify the resident's Primary Healthcare Provider (PHP) and RR, the DON and Administrator and the ambulance if needed. The DON stated that the primary health care provider (PHP) for Resident #1 ordered radiographic diagnostics. The DON stated that Resident Rights included notification of resident RR upon change of condition, incident or accident. The DON stated that the failure of the facility nursing staff delayed notification of Resident #1's PHP. She confirmed that the Staff Educator initiated in-service training on 12/28/25 for all nursing staff that included Resident Rights and facility fall policy and procedure because of the 12/27/25 incident that included instructions regarding notification of resident representatives of all falls and correct protocol following falls to include assessments, evaluation, documentation and reporting.On 1/08/25 at 3:15 PM, during an interview CNA#1 reported that she was on duty at approximately 7:45 PM on 12/27/25 and observed Resident #1 lying on her face on the floor next to her bed. She stated that Licensed Practical Nurse (LPN) #1 instructed her and CNA #2 to assist the resident back into her bed. On 1/08/25 at 4:28 PM, an interview with the Administrator revealed she had been notified shortly after 9:00 AM on 12/28/25 by the DON that Resident #1 reported that she had a fall and bumped her head on the evening of 12/27/28. She stated she had interviewed Resident #1, who she confirmed had no cognitive or memory impairment, and that the resident confirmed that she had fallen and her head came in contact with the floor. The Administrator confirmed that there was no documentation of fall or appropriate assessment or evaluation, and nursing staff had not followed facility policy or protocol for falls and had not reported the fall to the RR or PHP.Record review of the admission Record for Resident #1 revealed the facility admitted the resident on 7/18/25 with diagnoses that included paraplegia and reduced mobility and lack of coordination.Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/25/25 for Resident #1 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS review revealed the resident was dependent for transfers and non-ambulatory (unable to walk).

Based on facility policy review, record review and interview the facility failed to notify the Resident Representative (RR) of a change in condition for one (1) of four (4) sampled residents with falls. Resident #1. Findings Included:Record review of the facility provided Nursing Home Residents' Rights, undated, revealed Residents of nursing homes have rights that are guaranteed to them under Federal and State laws.Choice about designating a representative to exercise his or her rights.Right to be Fully Informed of.Changes to the plan of care, or in medical or health status.Record review of the facility policy titled, Resident Rights & Dignity Management with a revision date of September 2025 revealed .3. The resident has the right to be informed of, and participate in, his or her treatment, including c. The right to be fully informed.of his or her total health status, including but not limited to, his or her medical condition.The right to participate in the planning process.The right to be informed in advance, of the care to be furnished.Record review of the facility policy titled Falls Standard with Revision Date February 2018 revealed the policy stated, MEDICAL RECORD DOCUMENTATION GUIDELINES The INITIAL NOTE/ASSESSMENT SHOULD CONTAIN THE FOLLOWING AND INCLUDE A DESCRIPTION OF WHAT WAS DONE: A. Vital signs.Document who was notified and time of notification for all attempts to do so (e.g., physician, family, state agency, as appropriate) and Post Fall Process.Family is notified of event. Record review of the Facility Incident Report dated 12/28/25 for Resident #1 revealed the incident was categorized as an unwitnessed fall on 12/27/25 reported by Resident #1 with Resident #1's RR notified on 12/28/25 at 9:46 AM,Record review of the Facility Investigation dated 1/02/26 revealed Resident #1 reported to the Wound Care Nurse on 12/28/25 that she had fallen on the evening of 12/27/25 resulting in Resident #1's transportation to local emergency department for assessment and evaluation with radiographic diagnostics (CT scan of head). A written statement by Certified Nursing Assistant (CNA) #2 included in the Facility Investigation revealed that at approximately 7:48 PM on 12/27/25 she responded to call for help and observed Resident #1 on her stomach on the floor.On 1/07/26 at 11:20 AM during a telephone interview, the RR for Resident #1 stated she disapproved of and was disappointed with the facility nursing staff due to their failure to notify her of a fall experienced by Resident #1 on the evening of 12/27/25 and that she was not notified about until after 9:30 AM on 12/28/25. She stated that she was very concerned because Resident #1 had a bump on her right forehead and she had not received assessments or treatment until the following morning.On 1/07/26 at 2:25 PM, an interview with the Unit Manager, revealed that she was notified on 12/28/25 at approximately 9:20 AM by the Wound Care Nurse that Resident #1 reported that she had fallen and two staff had picked her up from the floor and put her back in the bed on the evening of 12/27/25 but the resident was unsure of the time. She stated that Resident #1's RR was notified of the fall at approximately 9:26 AM on 12/28/25. The Unit Manager stated that all of the actions and notifications were accomplished on 12/28/25 after the resident reported the fall to the Wound Care Nurse but should have been done on 12/27/25 as soon as possible following the fall.On 1/07/26 at 2:50 PM, during an interview the Wound Care Nurse revealed she was notified by Resident #1 on 12/28/25 at approximately 9:18 AM that Resident #1 had fallen on the evening of 12/27/25 but was not able to recall the time and that she had hit her head on the floor and indicated the area by touching her forehead above her right eye. She stated that if a resident fell the RR should be notified right away as change of condition. She confirmed that the facility provided in-service training regarding Resident Rights and Facility Fall Policy and Procedure at least every month and that the in-service for Residents' Rights included notification of the Resident's RR in case of change of condition or incident or accident.On 1/07/25 at 3:00 PM, during an interview with Resident #1 and her RR in the resident's room, revealed Resident #1 reported that on the evening of 12/27/25 (she was unsure of the time) she fell from her bed when she reached down to get something off the floor and that she bumped her head. Resident #1 reported that staff responded to her call for help and assisted her back into bed. She said she told the Wound Care Nurse the next morning around 9:00 AM and was subsequently transported to the hospital for evaluation. The RR stated that she was not notified of the fall on 12/27/25 but was notified on 12/28/25 after Resident #1 reported the fall to the Wound Care Nurse. The RR confirmed that she observed a slightly swollen area on Resident #1's forehead just above her right eye on 12/28/25.On 1/07/26 at 3:20 PM, during an interview the Director of Nursing (DON) revealed that she was notified on 12/28/25 at approximately 9:23 AM by the Unit Manager via telephone that Resident #1 had reported to the Wound Care Nurse that she had fallen on the evening of 12/27/25 and hit her head and that the resident had a raised (inflamed/swollen), tender area on her right forehead. She confirmed that the correct procedure in case of a resident fall included notification of the resident's RR. The DON stated that Resident Rights included notification of resident RR upon change of condition, incident or accident.On 1/08/25 at 3:15 PM, during an interview CNA #1 reported that she was on duty at approximately 7:45 PM on 12/27/25 and observed Resident #1 lying on her face on the floor next to her bed. She stated that Licensed Practical Nurse (LPN) #1 instructed her and CNA #2 to assist the resident back into her bed. On 1/08/25 at 4:28 PM, during an interview with the Administrator she revealed she had been notified shortly after 9:00 AM on 12/28/25 by the DON that Resident #1 reported that she had a fall and bumped her head on the evening of 12/27/28. She stated she had interviewed Resident #1, who she confirmed had no cognitive or memory impairment, and that the resident confirmed that she had fallen and her head hit the floor. The Administrator confirmed that there was no documentation of notification of Resident #1's RR of 1/27/25 fall until 12/28/25 at 9:46 AM.Record review of the admission Record for Resident #1 revealed the facility admitted the resident on 7/18/25 and the resident had diagnoses of paraplegia and reduced mobility and lack of coordination.Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 10/25/25 for Resident #1 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS review revealed the resident was dependent for transfers and non-ambulatory (unable to walk).

Based on record review, interview, and facility policy review, the facility failed to ensure the resident environment was free of accident hazards by failing to follow secure a wheelchair during van loading, which resulted in an avoidable accident that caused a scapular fracture and multiple rib fractures for one (1) of three (3) sampled residents (Resident #1).Findings Included:Review of the facility's policy Facility Vehicle Standard revised October 2025, revealed .Van Operation Standard The facility shall provide safe transportation for residents. Procedures.2. Loading and unloading residents.E. Follow manufacturer's instructions for operating the lift. 1. Load wheelchair onto lift.b. Lock brakes.C. In the event of a health emergency, the following steps will be followed: 1. The driver will call 911 and provide any necessary emergency first aid until trained medical personnel arrive and take over.Record review of the admission Record revealed the facility admitted Resident #1 on 5/16/25 with diagnoses including Hemiplegia, unspecified affecting right dominant side.Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/30/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated she was cognitively intact. Further review revealed she could not walk and required a wheelchair for mobility/locomotion. Record review of the facility' investigation with a Subject of Unwitnessed Fall, dated 11/8/25, revealed that on 11/03/25 at approximately 12:53 PM, Certified Nurse Aide (CNA) #3 contacted Licensed Practical Nurse (LPN) #1 via cellphone to report that Resident #1 experienced a fall. The CNA reported that the incident occurred while loading the resident onto the liftgate of the facility van. He reported that the left wheelchair wheel was locked, but the right wheel was not, causing the wheelchair to roll backward, resulting in the resident falling back onto her back. She was assisted back into the wheelchair. LPN #1 instructed the CNA to return the resident to the facility for assessment. The resident arrived back at the facility at approximately 1:03 PM and was assessed. There were no visible injuries, and the resident denied pain at that time. Tylenol was administered as a precaution, and the Responsible Party (RP) was notified. Later that evening, the resident began complaining of back pain and was transported to a local hospital at approximately 9:31 PM. During the investigation by the Administrator and the Director of Nursing (DON), CNA #3 reiterated that he had failed to lock both wheelchair wheels before lifting the resident onto the van's liftgate. He confirmed that the fall occurred while on the ground, not during lift movement. Following a complete investigation, it was determined that CNA #3 failed to properly secure and lock the resident's wheelchair, resulting in an unsafe fall while under his supervision. CNA #3 was terminated. Record review of a handwritten statement signed by CNA #3, undated but attached to the facility's investigation, revealed, .I locked the right wheel and did not the left. I let the platform up and she rolled back and fell back. I pick her up and put her back in her chair.I talked to the nurse.She instructed me to bring her to the facility.Record review of the acute hospital's Emergency Department (ED) records, dated 11/03/25, revealed Resident #1 had a Chief Complaint of Fall, Back Pain and that she States her whole back hurts. Hit her head but did not lose consciousness. Review of the computed tomography (CT) scan revealed Findings of .Partially imaged acute right scapular fracture. Acute mildly displaced posterior right 3rd through 8th rib fractures. On 12/08/25 at 2:54 PM, during an interview with Licensed Practical Nurse (LPN) #1, she explained that while on duty on 11/03/25, she received a telephone call on her personal cellular device from CNA #3. She reported that CNA #3 informed her that Resident #1 had experienced a fall during transport and asked what actions should be taken, including whether the resident should be sent to the emergency department. LPN #1 reported that she initially misunderstood the information provided and believed Resident #1 and CNA #3 were located in the facility's parking lot. She stated she notified the Director of Nursing (DON) and proceeded toward the parking lot to assess the situation, at which time she realized the resident and CNA were not at the facility. She confirmed that Resident #1 later returned to the facility, and shortly thereafter, CNA #3 transported the resident to the front nurses' station and then to the resident's room. LPN #1 confirmed that CNA #3 informed her he had failed to lock both wheelchair wheels.On 12/08/25 at 3:05 PM, during an interview with Licensed Practical Nurse (LPN) #2, she reported that at approximately 1:05 PM on 11/03/25, CNA #3 transported Resident #1 to her room following dialysis. She explained that CNA #3 told her the resident's dialysis treatment had been completed and that he was preparing to use the lift to return Resident #1 to the van while she was seated in her wheelchair. She reported that CNA #3 acknowledged he failed to lock one of the wheelchair wheels, which caused the wheelchair to roll and tip backward. LPN #2 stated she specifically asked whether the lift was elevated at the time of the incident, and CNA #3 denied that the lift was off the ground. She further reported that CNA #3 told her the resident did not fall out of the wheelchair and did not hit her head, stating the wheelchair handles stopped the backward movement. LPN #2 confirmed that LPN #3 completed a body audit of the resident. She added that immediately after returning from dialysis, Resident #1 went to the shower room and did not voice any complaints during her shift, which ended at 3:00 PM.On 12/08/25 at 3:40 PM, during a telephone interview with Resident #1, she explained that following her dialysis treatment on 11/03/25, CNA #3 failed to lock both wheels of her wheelchair. She reported that while the facility van lift platform was being elevated, with her seated in the wheelchair on the platform, the wheelchair rolled backward off the platform, causing her to fall backward while still in the wheelchair and land on her right side on the concrete driveway. She stated that CNA #3 did not call emergency services or seek assistance from qualified personnel to evaluate her. Instead, she reported that CNA #3 repositioned the wheelchair upright with her still seated, loaded her onto the van, and transported her back to the facility. She stated that she informed facility staff upon return that she was in pain and had struck her head during the fall. She reported that her pain was not relieved by as-needed over-the-counter analgesics and that she remained in pain until approximately 9:35 PM on 11/03/25, when she was transported to a local acute care hospital. She confirmed that she was diagnosed with six fractures to her right ribs and a fracture of the right scapula (shoulder) and stated that she remained hospitalized at the time of the interview.On 12/09/25 at 2:54 PM, during a telephone interview with CNA #2, she explained that she was assigned to Resident #1 during the 3:00 PM through 11:00 PM (3-11) shift on 11/03/25. She reported that she was informed the resident had experienced a fall while attending her routine renal dialysis appointment during the 7:00 AM through 3:00 PM (7-3) shift. She reported that during her shift, the resident complained of pain to her right side and shoulder. She further reported observing that the resident's respirations appeared irregular and described them as weird. CNA #2 confirmed that she reported the resident's complaints of pain and her observation of irregular respirations to the nurse.On 12/09/25 at 3:00 PM, during a telephone interview with LPN #4, she explained that upon Resident #1's return from dialysis treatment on 11/03/25, the van driver informed her that the resident had experienced a fall. She reported that she assessed Resident #1 for pain and administered an over-the-counter analgesic. She further reported that she reassessed the resident for effectiveness of the analgesic and that the resident continued to report pain. LPN #4 stated she notified Nurse Practitioner (NP) #1 of the resident's pain unrelieved by the available pain medication, and NP #1 ordered diagnostic testing. She reported that, based on the resident's and family's preference, NP #1 ordered the resident to be transported to a local acute care hospital for further evaluation and treatment as needed.On 12/09/25 at 3:20 PM, during an interview with the Maintenance Supervisor, he explained that when loading or unloading residents into or out of the facility van, the lift platform should not be raised or lowered unless the resident's wheelchair wheels are locked. He confirmed that failure to ensure the wheels are locked increases the risk that the wheelchair could move and potentially fall from the platform.On 12/09/25 at 3:30 PM, during an interview with the Administrator, she explained that the conclusion of her investigation was that CNA #3 failed to lock the wheels of Resident #1's wheelchair during the loading process at the renal dialysis center prior to transporting the resident back to the facility. She confirmed that CNA #3 did not follow facility policy or procedure for loading residents into the facility van. She further confirmed that these actions directly resulted in Resident #1 falling from the facility van lift platform onto the concrete driveway at the dialysis center on 11/03/25, landing on her right side and sustaining a scapular and rib fractures.

Based on observations, interviews, record review and facility policy review, the facility failed to ensure residents were provided with activities designed to meet their physical and mental needs and interest for two (2) of (2) residents reviewed for activities. (Resident #1 and Resident #2).Findings include:A review of the facility policy titled Resident Rights & Dignity Management, revised 5/22, stated on page 32: 6. Self-Determination. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to (a). The resident has the right to choose activities . consistent with his or her interest, assessments, and plan of care .During an observation on 9/3/25, between 9:33 AM and 11:30 AM, the State Agency (SA) observed Resident #1 in a Geri-chair and Resident #2 in a wheelchair sitting in the dayroom with no care planned or structured activity present. Neither resident participated in an activity observed in the activity room at 10:35 AM.During an observation on 9/3/25 at 12:20 PM, observed Resident #1 and Resident #2 return from lunch and again sat in the dayroom with no activities present. Later, at 1:25 PM, the SA observed a music activity occurring on the front patio; however, Resident #1 and Resident #2 were not present. The SA confirmed they remained in the dayroom, where they could neither see nor hear the activity. Following the music event, residents gathered for bingo. Staff transported Resident #1 to the dining room to sit with others during bingo. Observation revealed Resident #1 slouched in her Geri-chair, eyes closed, and not interacting. Resident #2 remained in the dayroom with no activities observed until 4:00 PM.During an observation on 9/4/25 at 8:27 AM, the SA observed Resident #2 again sitting at an empty table in the dayroom with her back to the television and no structured activity occurring.During an interview on 9/4/25 at 10:01 AM, Certified Nursing Assistant (CNA) #1 confirmed she had cared for Resident #1 for over a year. She stated that Resident #1 is nonverbal but appears to enjoy music when her family plays the radio in her room. She explained that bingo is not appropriate for her due to her inability to comprehend or participate meaningfully.During an interview on 9/4/25 at 10:14 AM, the Activities Director confirmed Resident #1 did not attend the music activity on 9/3/25 and stated, That was an oversight. She acknowledged the resident cannot comprehend bingo and said she only brought her to the game so she could be there.During an interview on 9/4/25 at 10:41 AM, the Director of Nursing (DON) confirmed the SA's observation that Resident #2 had not been engaged in any activities and had been seated with her back to the television for several hours. The DON stated, She definitely needs to be in stimulating activities, and acknowledged a lack of follow-through by staff.During an interview on 9/4/25 at 10:48 AM, the Administrator stated that activities should occur daily for all residents.Resident #1A record review of the admission Record revealed Resident #1 was admitted on [DATE] with diagnoses including Unspecified Focal Traumatic Brain Injury with Loss of Consciousness of 30 Minutes or Less, Sequela.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/14/25 revealed a Brief Interview for Mental Status (BIMS) score of 0, indicating the resident could not participate in the interview.Resident #2A record review of the admission Record revealed Resident #2 was admitted on [DATE] with diagnoses including Unspecified Dementia and Unspecified Psychosis.A record review of the Quarterly MDS with an ARD of 7/16/25 revealed a BIMS score of 0, also indicating the resident could not participate in the interview.

Based on observation, interview, record review and facility policy review, the facility failed to implement the care plan for two (2) of (2) sampled residents related to participation in structured activities. (Resident #1 and Resident #2).Findings Include:A record review of the facility policy, Resident Rights & Dignity Management, revised 5/22, revealed on page 30: 1. The resident has a right to a dignified existence, self-determination and .3. Planning and Implementing Care .iv. The right to receive the services and/or items included in the care plan.On 9/3/25, between 9:33 AM and 11:30 AM, the State Agency (SA) observed Resident #1 in a Geri-chair and Resident #2 in a wheelchair sitting in the dayroom with no care planned or structured activity present. Neither one of the residents participated in an activity observed in the activity room at 10:35 AM.On 9/3/25 at 12:20 PM, both residents returned from lunch and again sat in the dayroom with no activities present. Later, at 1:25 PM, the SA observed a music activity occurring on the front patio; however, Resident #1 and Resident #2 were not present. The SA confirmed they remained in the dayroom, where they could neither see nor hear the activity. Following the music event, residents gathered for bingo. Staff transported Resident #1 to the dining room to sit with others during bingo. Observation showed her slouched in her Geri-chair, eyes closed, and not interacting. Resident #2 remained in the dayroom with no activities observed until the SA exited the facility at approximately 4:00 PM.On 9/4/25 at 8:27 AM, SA observed Resident #2 again sitting at an empty table in the dayroom with her back to the television and no structured activity occurring.On 9/4/25 at 10:01 AM, in an interview, Certified Nursing Assistant (CNA) #1 confirmed she had cared for Resident #1 for over a year. She stated that Resident #1 is nonverbal but appears to enjoy music when her family plays the radio in her room. She explained that bingo is not appropriate for her due to her inability to comprehend or participate meaningfully.On 9/4/25 at 10:14 AM, the Activities Director confirmed Resident #1 did not attend the music activity on 9/3/25 and stated, That was an oversight. She acknowledged the resident cannot comprehend bingo and said she only brought her to the game so she could be there.On 9/4/25 at 10:41 AM, during an interview, the Director of Nursing (DON) confirmed the SA's observation that Resident #2 had not been engaged in any activities and had been seated with her back to the television for several hours. The DON stated, She definitely needs to be in stimulating activities, and acknowledged a lack of follow-through by staff.On 9/4/25 at 10:48 AM, during an interview, the Administrator stated she expects structured activities to be provided daily for all residents, and that staff are expected to follow each resident's care plan, including the activities section.On 9/4/25 at 1:48 PM, during an interview, Licensed Practical Nurse (LPN) #1, who is responsible for care planning development, explained that the care plan is designed to meet residents' individualized needs and should be followed by all staff, including interventions related to activities. She stated that failure to follow the care plan could result in residents not receiving appropriate care.Resident #1A record review of the Care Plan Report with a date initiated of 7/15/22 for Resident #1 revealed Focus: She (Resident #1) enjoys visits from her sister and other family members, listening to music, devotions.Interventions: Encourage family visits and patient participation in daily group activities/programs with music therapy, movies, conversation.A record review of the admission Record revealed Resident #1 was admitted on [DATE] with diagnoses including Unspecified Focal Traumatic Brain Injury with Loss of Consciousness of 30 Minutes or Less, Sequela.A record review of the Quarterly MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of 6/14/25 revealed a Brief Interview for Mental Status (BIMS) score of 0, indicating the resident could not participate in the interview.Resident #2A record review of the Care Plan Report revealed a care plan with a date initiated of 8/23/22 for Resident #2 Focus: (Proper name of Resident) takes pleasure in listening to classical music . Interventions.Staff will provide therapeutic activities for the resident to bring about a change.A record review of the admission Record revealed Resident #2 was admitted on [DATE] with diagnoses including Unspecified Dementia and Unspecified Psychosis.A record review of the Quarterly MDS with ARD of 7/16/25 revealed a BIMS score of 0, also indicating the resident could not participate in the interview.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide adequate supervision, monitoring, and preadmission risk assessment to prevent a resident from exiting the facility unsupervised and without staff awareness or intervention for one (1) of twenty-four (24) sampled residents. (Resident #211). This failure resulted in Resident #211 eloping from the building on 6/4/25, for an estimated 600 feet, and being found seated on the back of a trailer in a public intersection surrounded by traffic, thereby placing the resident in Immediate Jeopardy (IJ) for serious injury, harm, impairment, or death. This situation was determined to be IJ and Substandard Quality of Care (SQC), which began on 06/04/25 when Resident #211 eloped from the facility. The State Agency (SA) notified the Administrator of the Immediate Jeopardy on 06/05/25 at 11:40 AM and provided an IJ template. The facility provided an acceptable Removal Plan on 06/05/25, in which they alleged all corrective actions to remove the IJ were completed on 06/05/2025 and the IJ removed on 06/05/2025. The SA validated Removal Plan on 06/06/25, and determined that the IJ was removed on 06/05/25, prior to SA exit. Therefore, the scope and severity for CFR 483.25(d)(1)(2) Accidents/Hazards - F689 was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: A review of the facility's policy titled Wandering/Elopement Risk (Revised November 2017) revealed It is the standard of this facility to identify those residents at risk for wandering/elopement and to take the appropriate steps to minimize the risk of elopement. All residents are assessed for the potential to wander prior to or upon admission. A record review of the admission Record for Resident #211 revealed an admission date of 06/03/25 with diagnoses including Unspecified Dementia and Altered Mental Status. During an observation on 06/04/25 at approximately 3:15 PM, the SA observed several staff running through the facility parking lot. It was later confirmed that Resident #211 exited the facility through the front door after the receptionist pushed the door release button. The resident was found seated on the back of a trailer at the intersection near the facility, an estimated 600 feet from the front entrance of the facility. The resident was combative, yelling, I want to go home, and had to be carried by staff until a wheelchair arrived. Record review of weather records from [NAME], MS on 06/04/25 at 3:15 PM documented a temperature of 86°F and clear skies. During an interview on 06/04/25 at 3:27 PM, Licensed Practical Nurse (LPN) #2 stated she was at the nurses' station receiving report when she heard a Certified Nursing Assistant (CNA) yell, The new lady is out. She ran outside with other staff and saw the resident being retrieved, but did not witness the elopement. On 06/04/25 at 3:30 PM, LPN #3 stated she heard shouting and followed staff outside, confirming the resident was found at the intersection but she did not witness her leaving the building. On 06/04/25 at 3:37 PM, the Director of Nursing (DON) stated she was in the Administrator's office when she heard yelling. She ran outside and saw the resident sitting on the trailer in traffic. The DON confirmed the resident was combative, refused to return, and had to be physically carried while another staff retrieved a wheelchair. During an interview on 06/04/25 at 4:10 PM, the Administrator stated she heard someone yelling The lady and ran to the front door. She saw the resident sitting in the middle of the street on a trailer attached to a pickup truck. The resident was yelling, I want to go home, and Don't touch me. The Administrator confirmed the resident was carried until a wheelchair was brought. She stated the resident would be transferred to a geriatric psychiatric unit. During an interview on 06/04/25 at 4:17 PM, Certified Nursing Assistant (CNA) # 1 stated she was clocking out by the laundry area when she heard yelling. She ran to the front and joined other staff in retrieving the resident from the intersection. She described the resident as hysterical and combative. During an inteview on 06/05/25 at 8:32 AM, the Administrator confirmed that video surveillance showed the receptionist unlocking the door, allowing the resident to exit without being accompanied by staff. During an interview on 06/05/25 at 8:40 AM, the Receptionist stated she pushed the release button for the front door when Resident #211 approached, and she did not recognize the resident because she had been admitted the previous evening after the receptionist's shift. On 06/06/25 at 9:21 AM, the Resident Representative stated she was notified of the elopement and told the receptionist to let the resident out, not realizing she was a new admission. She stated it had only been 24 hours since her mother's admission and she wanted to ensure her mother's safety. During an interview on 06/06/25 at 9:46 AM, the Receptionist recalled unlocking the door for the resident between 3:00 PM and 4:00 PM during shift change. During an interview on 06/06/25 at 9:51 AM, the Administrator stated that when a new resident is admitted , the assigned nurse, DON, Assistant Director of Nurses (ADON), and Nurse Supervisor are responsible for safety monitoring until a care plan is developed. During an interview on 06/06/25 at 10:30 AM, the Family Nurse Practitioner (FNP) stated she was notified of the elopement and ordered the resident to be transferred to a local hospital for evaluation. She confirmed she does not participate in preadmission screening. On 06/05/25 at 9:56 AM, the admissions Coordinator stated she forwarded the resident's preadmission information to the DON, ADON, Administrator, Business Office, and Respiratory Director. She did not identify any concerning information at the time, although she recalled that the daughter mentioned the resident had become difficult to manage at home. During an interview on 06/06/25 at 10:53 AM, the DON stated that the facility's Wandering Risk Screen and Elopement Evaluation were completed by RN #1. She stated that all staff are responsible for monitoring newly admitted residents until a care plan is in place. During an interview on 06/06/25 at 11:20 AM, RN #1 stated she assessed the resident as confused but attributed it to a Urinary Tract Infection (UTI). She acknowledged the resident addressed her as if she were her daughter but denied knowing about the history of wandering reported by the family. During an interview on 06/06/25 at 12:18 PM, the Social Services Director (SSD) #1 stated that she is responsible for updating the facility's wandering book based on nursing assessments. She confirmed that Resident #211 had not yet been added because she was off work at the time of admission. During an interview on 06/06/25 at 1:10 PM, the SSD #1 confirmed that she added Resident #211 to the wandering binder on 06/04/25 with a photograph. Removal Plan: Corrective Actions Implemented Immediately Resident Assessment: Upon re-entry, a comprehensive full-body assessment was completed. No injuries were noted. There were no signs of bruising, bumps, skin tears, or lacerations. When asked about any discomfort, Resident #211 reported that her feet felt a little sore. The Director of Nursing (DON) removed the residents' socks and observed no redness or open areas. Acetaminophen (Tylenol) was administered in accordance with the physician's order. Vital signs were obtained and found to be within normal limits. Resident #211 became tearful and expressed a strong desire to return home, stating that her daughter was not adequately caring for her grandchildren and that she needed to be there for them. The Nurse Practitioner was promptly notified and provided an order for the Resident #211 to be transferred to the emergency room for further evaluation at a higher level of care. Resident #211's Responsible Party (RP) was contacted and informed of the situation and the new medical order. An emergency response was called, and the resident was transported by ambulance and taken to the local emergency department. Resident #211 departed the facility on a stretcher at approximately 4:15 PM. At 5:40 PM, a follow-up call was placed to the emergency department, where it was confirmed that the Resident #211 had been admitted to the Geri psych unit for continued evaluation and treatment. Implementation Date: 6/4/2025 o Official report called to the State Agency on June 4, 2025 o Emergency Quality Assurance and Performance Improvement (QAPI) meeting held on June 4, 2025, with leadership to review failures and prevention strategies. Staff in attendance were Administrator, DON, ADON, Infection Preventionist/RN Educator, Maintenance Director, Medical Director via telephone, Social Services #1, Social Services #2, MDS Coordinator, Wound Care, Wound Care Nurse, Rehab Manager, Environmental Services, Activities Director, RNA, Central Supply, Medical Records, Human Resources, Business Office, Staffing, Treatment Nurse Nurse Educator will conduct in-service training for all staff on wandering and elopement (new admits at risk) protocols on June 4, 2025. o Social Services will complete a 100% audit of the wandering binders to ensure all qualifying residents are included and that color photographs are added on June 4, 2025. o Central Supply Clerk, will order neon green armbands to identify residents at risk of wandering or elopement on June 4, 2025 o Maintenance Department will change the front entrance/exit door codes to prevent unauthorized exits on June 4, 2025. o DON and ADON will conduct elopement drills on every shift once a week for four weeks, then monthly thereafter, beginning on June 4, 2025. o DON and ADON will complete a 100% audit of care plans for residents identified as elopement risks to ensure their accuracy and completeness on June 4, 2025. o DON and ADON will complete a 100% audit of all resident assessments to identify those who meet criteria for wandering risk on June 4, 2025. o ADON will complete a 100% audit of the total number of residents in the facility on June 4, 2025. *No employees will be permitted to work until the assigned in-services have been completed. Validation: The SA validated on 06/06/25 through interview and record review that all actions to remove the immediacy were completed on 06/05/25. The Immediate Jeopardy was removed on 06/05/25 prior to the SA exit.

Based on observation, interviews, record review, and facility policy review, the facility failed to protect the resident's rights to be free from neglect when the resident eloped from the facility unsupervised and unmonitored and made her way to the middle of a busy intersection for (1) of 24 residents sampled. Resident #211 The facility's failure to ensure that Resident #211 was unable to exit the facility unsupervised resulted in her running into the middle of a busy intersection located at an intersection near the facility, placing the resident in a situation that was likely to cause serious injury serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 6/4/25, when Resident #211 exited the facility. The State Agency (SA) notified the Administrator of the IJ on 6/5/25 at 11:40 AM. The State Agency (SA) validated the Removal Plan on 6/6/2025 and determined that the IJ was removed on 6/5/25, prior to exit. Therefore, the scope and severity for CFR §483.12 Freedom from Abuse, Neglect, and Exploitation - F600 - Scope/Severity Jwas lowered to D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's policy, Freedom of Abuse, Neglect and Exploitation, November 2019, revealed, .This facility shall not condone any acts of resident .neglect .Neglect means failure of the facility, its employees, .to provide .services to a resident that are necessary to avoid physical harm . On 6/4/2025 at 3:15 PM, the State Agency (SA) observed several staff running across the parking lot. It was later determined that Resident #211 had eloped from the front door of the facility. The SA observed the resident had reached the intersection of two adjoining streets near the facility. The distance from the front door of the facility to the intersection is estimated to be 600 feet. Resident #211 was sitting on the back of a trailer that was attached to a pick-up truck that was stopped at the traffic light. Approximately seven (7) cars were observed to be in the street at the time Resident #211 sat in the intersection. Several staff were engaged in removing the resident from the truck's trailer and getting her back to the facility. The resident was initially carried by the staff, but a wheelchair was brought from the facility for the remainder of the trip back. The weather was 86 degrees and sunny. On 6/4/2025 at 3:27 PM an interview with Licensed Practical Nurse (LPN) #2 revealed she was starting her shift and was located at the nursing station, receiving information from the day shift nurse about another resident. LPN #2 stated at approximately 3:15 PM, she heard a Certified Nursing Assistant (CNA) yell, The new lady is out. LPN #2 reported she proceeded to run after the resident with the other nurses. LPN #2 noted the resident was back in the facility at approximately 3:20 PM. LPN #2 denied seeing Resident #211 exit the building. On 6/4/2025 at 3:30 PM an interview with LPN #3 revealed she was at the nursing station providing information on another resident to the evening shift nurse. LPN #3 stated that at approximately 3:10 PM she heard yelling and some saying, She's gone. LPN #3 reported seeing staff running out of the building and she ran behind them. LPN #3 noted she did not see Resident #211 leave the building. On 6/4/2025 at 3:37 PM an interview with the Director of Nursing (DON) revealed at approximately 3:00 PM she was in the Administrators office when she heard someone yell The lady. The DON noted she ran outside with the other staff and went to the intersection to retrieve the resident and bring her back to the facility. The DON noted the resident refused to come with the staff and yelled and kicked them. The DON noted the staff had to physically pick up the resident and carry her while yelling for someone to bring a wheelchair for her. The DON reported that her assessment of the resident revealed no injuries. During the interview the Emergency Medical Transport (EMT) arrived. The DON noted the resident will be sent to a geri-psych unit. On 6/4/2025 at 3:49 PM, an interview with Assistant Director of Nursing (ADON) revealed she was in the Administrator's office when at approximately 3:15 PM she heard an inaudible yelling coming from the hallway. The ADON stated she walked out of the office and saw people running toward the door. The ADON noted she ran after them and noticed the resident at the intersection near the facility. The ADON reported the Resident #211 was combative and held on tightly to the trailer on which she was sitting. The ADON noted the resident yelled that she did not live at the facility and that she wanted to go home. The ADON noted the resident was returned to the facility at approximately 3:25 PM. On 6/4/2025 at 4:10 PM, an interview with the Administrator revealed she was in her office when at approximately 3:15 PM she was alerted by someone screaming, The Lady from the hallway. The Administrator stated she ran to the front door and then to the location of the resident. The Administrator stated the resident was found at the intersection near the facility, sitting the back of a trailer that was attached to a pickup truck in the middle of the street. The Administrator stated Resident #211 was combative and resistant to coming back to the facility with the staff. The Administrator stated the resident was yelling, I want to go home, Don't touch me. The Administrator confirmed the resident was initially carried by the staff but was later placed in a wheelchair to get her back to the facility. The Administrator affirmed the resident was back in the facility at approximately 3:21 PM. The Administrator stated Resident #211 will be going to a geri psych unit. On 6/4/2025 at 4:17 PM an interview with CNA #1 revealed that at approximately 3:15 PM she was at the back door, near the laundry room, clocking out when she saw the resident walking and heard another staff member yell She got out. CNA #1 stated she ran back to the front of the building yelling for help. CNA #1 reported she ran out of the front door and proceeded to go along with the other staff toward the resident. CNA #1 confirmed the resident was located at the intersection near the facility, in the middle of the street, sitting on the back of a truck trailer. CNA #1 noted Resident #211 hysterical and combative. CNA #1 affirmed the resident was back in the building by approximately 3:20 PM. On 6/5/2025 at 8:32 AM an additional interview with the Administrator revealed she had reviewed the surveillance video and confirmed that the resident was able to exit the facility through the front door because the receptionist pushed the button that unlocks the door, allowing Resident #211 to walk out. The Administrator acknowledged that no other staff or visitors were surrounding the resident at the time she exited the facility. On 6/5/2025 at 8:40 AM, an interview with the Receptionist acknowledged that on 6/4/25 she was located at the receptionist desk when Resident #211 approached the door. The Receptionist stated she then pushed the button that unlocked the door and Resident #211 was able to walk out. The Receptionist affirmed that she did not recognize the resident because she was admitted to the facility the previous day after she left work. On 6/06/25 at 10:30 AM, an interview with the Family Nurse Practitioner (FNP) revealed she was made aware of the incident and ordered the resident sent to the hospital for physical and mental evaluation. The FNP noted she does not take part in the preadmission process. On 06/05/25 at 09:56 AM an interview with the Admissions Coordinator (AC) revealed when she receives pre-admission information for a resident, she forwards the information to the DON, ADON, the Administrator, the Business office and the Director of Respiratory to review the information. The AC affirmed that no information in Resident #211's preadmission documents stood out to her as worthy of concern for the resident. The AC confirmed that the resident's daughter mentioned that the resident had become more difficult to have at home. On 06/06/25 at 9:21 AM, during a phone interview with the Resident Representative (RR) revealed she was contacted by the facility staff regarding her mother's elopement from the facility on 6/4/25. The RR affirmed that the facility explained that the receptionist let her out, not knowing she was a resident. The RR stated it had only been 24 hours since her mother was admitted to the facility, and she wants her mother to be safe. The RR stated she has no other plan for her mother's care. On 06/06/25 at 9:46 AM, an additional interview with The Receptionist revealed she recalled buzzing the resident out the front door at time between 3:00 PM and 4:00 PM. The Receptionist recalled it was during the shift change and the second shift had already arrived. On 6/06/25 at 9:51 AM, an additional interview with the Administrator revealed when a resident is admitted to the facility it is the responsibility of the nurse assigned to that resident as well as the DON, ADON and the Nurse Supervisor to keep the resident safe until a care plan has been done. The Administrator confirmed that from the front door of the facility to the intersection where the resident was found was 250 steps approximately 600 feet. On 6/06/25 10:53 AM, an interview with the DON revealed the facility's Wandering Risk Screen and Elopement Evaluation for resident #211 was completed by Registered Nurse (RN) #1. The DON noted all staff are responsible for monitoring newly admitted residents for safety until they have a care plan. On 6/06/25 at 11:20 AM a phone interview RN #1 acknowledged that she is responsible for completing the Elopement Evaluation and the Wandering Risk Screen for Resident #211. RN #1 noted at the time of admission her impression of the resident came from the diagnoses of Altered Mental Status and Urinary Tract Infection (UTI). RN #1 stated she noticed the resident behaving in a confused state and even addressing her as if she were her daughter. RN #1 reported she believed Resident #211's confusion was due to the UTI. RN #1 affirmed that she did not have knowledge of the RR's statement regarding Resident #211 leaving home and wandering in the streets. On 06/06/25 at 12:18 PM, during an interview the Social Services Director (SSD) #1 acknowledged that she is responsible for updating the book that contains residents who are prone to wander. SSD #1 confirmed that the book was not updated to include Resident #211 at the time of her elopement from the facility on 6/4/2025. SSD #1 stated that she adds residents who are prone to wander to the book based on the assessment from the nursing staff at the time of admission. SSD noted that at the time the resident was admitted on [DATE] she was off work and had planned to do the assessment the next day. SSD #1 reported she is not shown preadmission paperwork to assess prior to admission. On 06/06/25 at 1:10 PM, an additional Interview with SSD #1 revealed she updated the wandering binder and included color photographs on 6/4/25. A record review of the Admissions Record revealed the facility admitted Resident #211 on 6/3/25 with diagnoses including Unspecified Dementia and Altered mental status. Removal Plan: Corrective Actions Implemented Immediately Resident Assessment: Upon re-entry, a comprehensive full-body assessment was completed. No injuries were noted. There were no signs of bruising, bumps, skin tears, or lacerations. When asked about any discomfort, Resident #211 reported that her feet felt a little sore. The Director of Nursing (DON) removed the residents' socks and observed no redness or open areas. Acetaminophen (Tylenol) was administered in accordance with the physician's order. Vital signs were obtained and found to be within normal limits. Resident #211 became tearful and expressed a strong desire to return home, stating that her daughter was not adequately caring for her grandchildren and that she needed to be there for them. The Nurse Practitioner was promptly notified and provided an order for the Resident #211 to be transferred to the emergency room for further evaluation at a higher level of care. Resident #211's Responsible Party (RP) was contacted and informed of the situation and the new medical order. An emergency response was called, and the resident was transported by ambulance and taken to the local emergency department. Resident #211 departed the facility on a stretcher at approximately 4:15 PM. At 5:40 PM, a follow-up call was placed to the emergency department, where it was confirmed that the Resident #211 had been admitted to the Geri psych unit for continued evaluation and treatment. Implementation Date: 6/4/2025 o Official report called to the State Agency on June 4, 2025 o Emergency Quality Assurance and Performance Improvement (QAPI) meeting held on June 4, 2025, with leadership to review failures and prevention strategies. Staff in attendance were Administrator, DON, ADON, Infection Preventionist/RN Educator, Maintenance Director, Medical Director via telephone, Social Services #1, Social Services #2, MDS Coordinator, Wound Care, Wound Care Nurse, Rehab Manager, Environmental Services, Activities Director, RNA, Central Supply, Medical Records, Human Resources, Business Office, Staffing, Treatment Nurse Nurse Educator will conduct in-service training for all staff on wandering and elopement (new admits at risk) protocols on June 4, 2025. o Social Services will complete a 100% audit of the wandering binders to ensure all qualifying residents are included and that color photographs are added on June 4, 2025. o Central Supply Clerk, will order neon green armbands to identify residents at risk of wandering or elopement on June 4, 2025 o Maintenance Department will change the front entrance/exit door codes to prevent unauthorized exits on June 4, 2025. o DON and ADON will conduct elopement drills on every shift once a week for four weeks, then monthly thereafter, beginning on June 4, 2025. o DON and ADON will complete a 100% audit of care plans for residents identified as elopement risks to ensure their accuracy and completeness on June 4, 2025. o DON and ADON will complete a 100% audit of all resident assessments to identify those who meet criteria for wandering risk on June 4, 2025. o ADON will complete a 100% audit of the total number of residents in the facility on June 4, 2025. *No employees will be permitted to work until the assigned in-services have been completed. Validation: The SA validated on 06/06/25 through interview and record review that all actions to remove the immediacy were completed on 06/05/25. The Immediate Jeopardy was removed on 06/05/25 prior to the SA exit.

Based on observation, interview, record review, and facility policy review, the facility failed to prevent the possibility of the spread of infection during Percutaneous Endoscopic Gastrostomy (PEG) care for Resident #14 and during suprapubic catheter care for Resident #62 for two (2) of five (5) care observations. Findings include: A record review of the facility's policy Incontinence Management Suprapubic Catheter Care with a revision date of 1/2020 revealed Objective To promote hygiene, comfort, and reduce migration of infectious organisms to the bladder .Procedure: 8. Clean around the area where the catheter enters the abdomen in a circular motion, moving in a bullseye pattern out to 2-3 inches beyond where catheter enters abdomen . A record review of the facility policy Infection Control Enhanced Barrier Precautions dated 2024 revealed .The Centers for Disease control and Prevention (CDC) recommends using Enhanced Barrier Precautions (EBP) with residents, regardless of Multidrug-resistant Organisms (MDRO) status, who have . an indwelling medical device such as a feeding tube .Post signs outside of residents 'rooms that state the required precautions and Personal Protective Equipment (PPE) and the resident care activities that need a gown and gloves . Resident #14 On 6/4/25 at 12:08 PM, during an observation Licensed Practical Nurse (LPN) #4, administered medications to Resident #14 via the PEG tube. LPN #4 did not don (put on) a gown as indicated on EBP prior to medication administration. On 6/4/25 at 12:22 PM, an interview with LPN #4 confirmed that she did not put on a gown before giving medication via PEG tube. She stated she was supposed to put on a gown prior to giving medication. She stated the reason for the gown is to protect the residents from her. She confirmed she had been trained on EBP and forgot to apply the gown. On 6/6/25 at 2:25 PM, during an interview with Registered Nurse #2 (RN)/Infection Preventionist (IP), she stated LPN #4 should have put on a gown prior to giving medication via PEG tube. She stated that by not wearing a gown, the nurse becomes a host and can transmit all types of infection from herself to other residents. On 6/6/25 at 3:24 PM, during an interview with the Director of Nursing (DON), she stated it was an infection control issue. She confirmed that LPN #4 should have worn a gown prior to beginning PEG tube care. She stated the gown prevents possible spread of infection and expects all staff to follow infection control guidelines. A record review of Resident # 14's admission Record revealed an admission date of 4/6/22 with diagnoses of dysphagia following unspecified cerebrovascular disease. A record review of Resident #14's MDS with an ARD of 3/15/25 revealed a BIMS score of 99, which indicated the resident was unable to complete the interview. Resident #62 On 6/4/25 at 10:38 AM, during an observation of LPN #5 providing catheter care for Resident #62 revealed LPN #5 began care using a wet soaped washcloth and cleaned the area at the entrance of the suprapubic catheter in a circular motion. She went around the site three times, flipped the cloth, and continued to clean in a circular motion two more times. She flipped the towel again and continued cleaning the site. On 6/4/25 at 10:53 AM, an interview with LPN #5 confirmed that she used the cloth in a circular motion several times before flipping to a clean section. She stated that performing care in this manner could transfer bacteria back into the clean area and increase risk of urinary tract or bladder infection. She stated she had been trained in catheter care. On 6/6/25 at 2:24 PM, during an interview with RN #2/IP nurse, she stated LPN #5 should have wiped once in a circular motion, then folded the washcloth to a clean section for each wipe. She stated that the technique used by LPN #5 could increase the chance of Resident #62 developing an infection, fever, or chills. On 6/6/25 at 3:18 PM, during an interview with the DON, she stated LPN #5 should have flipped the washcloth with each wipe. She confirmed that the method used placed the resident at increased risk for infection. A record review of Resident #62's admission Record revealed an initial admission date of 7/15/22 with diagnoses including neuromuscular dysfunction of bladder. A record review of Resident # 62's Medication Review Report dated 6/6/25 revealed an order dated 7/24/2023 Suprapubic Cath (catheter) care - Clean with soap and H20 (water) every shift. A record review of Resident # 62's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/25/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact.

Based on observation, interviews, record reviews and facility policy review the facility failed to implement a comprehensive care plan for two (2) of 24 residents reviewed. Resident # 41 and Resident #98. Findings include: A record review of the Comprehensive Care Plan Policy, revised 4/2025, revealed .Standard It is the standard of this facility to develop and implement to a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Resident #98 Record review of the Care Plan Report revealed Focus: The resident has bladder incontinence .Interventions/Task .Incontinent care q (every) 2 hours and prn (as needed); Keep skin clean and dry . Record review of the Care Plan Report revealed Focus: The resident has an ADL (activities of daily living) Self-Care Performance Deficit .Interventions/Task .Incontinent care q 2 hours and prn with total assist . During an observation of peri care on 6/5/25 at 10:25 AM, after wound care by Certified Nursing Assistant (CNA) #2 and assisted by CNA #4 revealed Resident # 98 had on a heavily soiled brief, turn pad, and draw sheet. All were was soaked with putrid odor of yellow and brown stain of urine. On 06/05/25 at 2:32 PM an interview with CNA #2 stated that Resident # 98 was not her resident today. She stated that the resident sometimes requests her care, because she is used to her doing her care. She stated CNA #4 was the resident CNA for today. She confirmed that the resident was heavily soiled with foul smelling urine. She confirmed the care plan was not followed. On 6/5/25 at 2:40 PM an interview with CNA #4 confirmed that Resident # 98 was heavily soiled in urine. She stated the wound could get infection from being soaked in urine. She stated the resident prefers CNA #2 to give care. She stated that her CNA #2 is sometimes exchange resident. She stated she had not done peri care today on Resident #98. She confirmed the care plan was not followed. On 06/06/25 at 3:02 PM, during an interview the Director of Nursing (DON) stated that when a resident is left unclean and heavily soiled with urine, they are at risk of a possible infection. She stated peri care should be done every two hours. Resident #41 A record review of the Care Plan Report with initiated date of 1/22/24 revealed Focus: The resident has an ADL (activities of daily living) Self Care Performance Deficit .Interventions . The resident requires 2 staff participation to reposition and turn in bed At 11:33 AM on 6/3/25 PM, in an interview with CNA #2, explained that Resident #41 asked her to turn her over on her side before leaving her room. She replied yes and proceeded to do so. She said she got on the side of the resident and grabbed the pad up under her to pull, helping assist the resident with repositioning on her side. When the resident was all the way over to her side, the resident began to scream indicating the mattress up under her was sliding, she then looked and saw too that it was sliding off onto the floor. She said she immediately grabbed the resident upper body, to help brace the fall as much as possible but her low body hit the floor with her landing on her buttock. She says the care plan they look at shows that the resident requires two people when turning or repositioning her and that it was her fault the resident fell because she should have gone to get help instead of doing it alone. A record review of the admission Record revealed the facility admitted Resident #41 on 1/22/24 with diagnosis including Guillain-Barre Syndrome, Paraplegia, Restlessness and Agitation, Lack of Coordination and Muscle Weakness. A record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/27/25 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact On 6/5/25 at 9:15 AM an interview with the Licensed Practical Nurse (LPN) who works as the Minimum Data Set (MDS) Nurse revealed the purpose of the care plan is for staff to determine the needs of the residents therefore, it should be followed by everyone. She says not following the care plan would not turn out good for the residents and maybe even the staff.

Based on record reviews and interviews, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place in December 2023. This was for two (2) recited deficiencies originally cited in December 2023 on an annual recertification survey. The deficiencies were in the area of the care plan not being followed and infection control. The continued failure during two surveys shows a pattern of the facility's inability to sustain an effective QAPI Committee for two (2) of seven (7) deficient practice citations. Findings Include: Record review of the facility's policy, Quality Assessment and Performance Improvement, September 2019, revealed, .It is the standard of this facility to .c. Develop and implement appropriate plans of action to correct identified quality deficiencies . F656: Based on interviews, record reviews, and a review of facility policy, the facility failed to ensure a Certified Nursing Assistant followed the comprehensive care plan when repositioning one (1) of 24 sampled residents Resident #41 F880 Based on observation, interview, record reviews, and facility policy review, the facility failed to prevent the possibility of the spread of infection during Percutaneous Endoscopic Gastrostomy (PEG) care for Resident #14 and during suprapubic catheter care for Resident #62 for two (2) of five (5) care observations. Record review of the Statement of Deficiencies and Plan of Correction (Form 2567) from the previous annual survey in December 2023, revealed F656 was cited due failure to implement a care plan directive and F880 was cited regarding improper catheter care. On 06/06/25 at 3:04 PM, an interview with the Administrator revealed she affirmed that deficiencies from the previous annual survey were found during this survey. The Administrator stated there will be a plan of correction to address the deficiencies and her expectation is to maintain improvement and increase quality of care.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to provide incontinent care in an appropriate manner to related to bowel and bladder care for one (1) of 24 residents reviewed. Resident #98. Findings include: A record review of the facility's policy Perineal Care with a revision date of 12/20 revealed the purpose of the procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation . On 06/04/25 at 11:20 AM, during an observation of perineal care provided by Certified Nursing Assistant (CNA) 2 and assisted by CNA #3 revealed the CNAs performed perineal care and applied a clean brief. The State Agency (SA) asked CNA #2 to remove the clean brief and recheck the resident for cleanliness. CNA #2 removed the clean brief and wiped the anus area a total of seven additional times. Each time, the peri wipe was smeared with a brown substance. On 6/4/25 at 11:33 AM, an interview with CNA #3 confirmed that CNA #2 did not provide proper care. She stated that CNA #2 should wipe until the peri cloth is clean. On 6/4/25 at 11:38 AM, an interview with CNA #2 confirmed that she did not clean Resident #98 thoroughly. She stated that she should keep wiping until the wipe is clean. She acknowledged that the resident could get a urinary tract infection, yeast infection, or skin breakdown. An observation of perineal care for Resident #98 on 6/5/25 at 10:25 AM, after wound care was completed, revealed CNA #2, assisted by CNA #4, removed Resident #98's heavily soiled brief, turn pad, and draw sheet. All were soaked and had a putrid odor with yellow and brown staining from urine. On 06/05/25 at 2:32 PM, an interview with CNA #2 revealed that Resident #98 was not her assigned resident that day. She stated that the resident sometimes requests her care because she is used to her performing it. She stated that CNA #4 was the resident's assigned CNA for the day. CNA #2 confirmed that the resident was heavily soiled with foul-smelling urine. On 6/5/25 at 2:36 PM, an interview with Resident #98's Licensed Practical Nurse (LPN) revealed she had never been told that Resident #98 refused care. She stated only the nurse can change room assignments and she did not make any changes to the CNA schedule that day. On 6/5/25 at 2:40 PM, an interview with CNA #4 confirmed that Resident #98 was heavily soiled in urine. She stated the wound could get infected from being soaked in urine. She said the resident prefers CNA #2 to provide care and that CNA #2 is sometimes exchanged as the resident's caregiver. She stated she had not provided perineal care on Resident #98 that day. On 06/06/25 at 3:02 PM, an interview with the Director of Nursing (DON) stated CNA #2 should have continued to wipe until the resident was clean and used a clean wipe each time. She stated that when a resident is left unclean and heavily soiled with urine, they are at risk of a possible infection. She further stated that perineal care should be performed every two hours. A record review of Resident #98's admission Record revealed an admission date of 4/7/25 with a diagnosis of pressure ulcer of sacral region, stage 4. A record review of Resident #98's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 4/14/25 revealed a Brief Interview for Mental Status (BIMS) score of 6, which indicates severely impaired cognition. Section GG revealed Resident #98 is dependent for hygiene toilet care.

Based on observation, interview, record review, and policy review, the facility failed to provide wound care in a manner to promote healing and prevent infection for one (1) of three (3) residents reviewed for wound care. Resident #98. Findings Include: A record review of the facility's policy titled Skin Management Standards, revised April 2021, revealed Bacteria are present on all skin surfaces. When the primary defense provided by intact skin is lost, bacteria will reside on the wound surface. Follow infection control policies to prevent self-contamination and cross-contamination in individuals with pressure ulcers. Record review of the facility policy Skin Management Standards dated 04/2021 revealed .Protocol .3. Change dressing as ordered per physician . An observation and interview on 06/05/25 at 9:45 AM, revealed Licensed Practical Nurse (LPN) #1, assisted by LPN #6, providing wound care for Resident #98. LPN #6 removed the resident's bed linens and brief, which were heavily soiled with yellow and brown urine. LPN #1 removed the wound vacuum and dressing, which was saturated with urine and completed the wound care as ordered. Following the procedure, LPN #1 stated he had not noticed the soiled brief and linens until after completing care. He acknowledged that peri-care should have been performed prior to wound care and that failure to do so could result in infection, deterioration of the wound bed, and delayed healing. He further stated that the urine appeared to have been present for a prolonged period, indicating the resident had not been changed recently. On 06/05/25 at 2:30 PM, Resident #98 stated she was typically changed only once at night and could not recall when she was last changed. She stated that staff do not check on her during the night, and she remains wet for long periods. On 06/05/25 at 2:50 PM, an interview with LPN #6 (wound care nurse) revealed she did not check the resident's brief prior to the procedure. She stated that wound care was initiated despite the resident being visibly soiled and confirmed that care is typically performed with CNA assistance to provide peri-care beforehand. She acknowledged that proceeding with wound care prior to hygiene could result in infection. On 06/06/25 at 3:09 PM, the Director of Nursing (DON) confirmed that peri-care should have been completed before wound care and that failure to do so could lead to contamination and further skin breakdown. She stated that all wound care should be provided per facility policy. Record review of the Order Summary Report with active orders as of 6/3/25 revealed an order dated 4/07/25 for wound vacuum application to the sacral ulcer with normal saline cleansing, pat dry, and dressing changes twice weekly and PRN (as needed) for dislodgement. Documentation of wound vac output was to be recorded each shift. A record review of the admission Record for Resident #98 revealed an admission date of 04/07/25 with diagnoses including a stage 4 pressure ulcer to the sacral region. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/14/25 revealed a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment.

Based on interview, record review, and facility policy review, the facility failed to ensure comprehensive care plan interventions were implemented regarding a resident's behavior during care for one (1) of five (5) sampled residents when Certified Nurse Aide (CNA) #1 used physical force with Resident #1, who was cognitively impaired and had right Hemiparesis, was observed with purplish-red discoloration under the right eye, abrasions on the nose, and a hematoma on the forehead following an incident in which CNA #1 admitted to pressing down on Resident #1's left arm (the only functional arm) and using physical force on his face to prevent the resident from hitting her during care. Findings included: A review of the facility's policy, Comprehensive Care Plan, dated 03/2019, revealed, .It is the policy of this facility to .implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs .Policy Explanation and Compliance Guidelines .4. The care planning process will include an assessment of the resident's strengths and needs . A record review of the comprehensive care plan for Resident #1 revealed a Focus, initiated on 6/12/2023 of (Proper Name) has impaired cognitive function and impaired thought processes with an Intervention of COMMUNICATION: Use the residents name identify yourself at each interaction, Face The resident when speaking and make eye contact .the resident understands consistent, simple, directive sentences. Provide The resident with necessary cues - stop and return if agitated initiated on 6/12/2023, with the Position listed as CNA. A record review of the facility's investigation, dated 2/14/25, revealed that at approximately 1:30 AM on 1/9/2025, Licensed Practical Nurse (LPN) #1 reported that Resident #1 made an allegation of abuse related to CNA #1. The resident was immediately evaluated and interviewed by LPN #1 and sent out to the hospital for further evaluation. CNA #1 was questioned and sent home pending the outcome of the investigation. The staff wrote statements. The resident returned to the facility at 4:30 AM and was evaluated. He had bruising noted to right eye and hematoma noted to right side of head. Resident #1 stated that he hit the CNA first and he bit her after she hit him. The DON conducted a phone interview with Resident #1 who stated that she entered the room to help the resident prepare for bed and he needed to be changed. When she explained that he needed to be changed, he became aggressive and started swatting at her. She again explained to the resident the importance of getting cleaned up. She asked the resident to roll over so she could finish providing care and that's when the resident hit the CNA the first time. CNA #1 stated she put her hand up to prevent him from hitting her again. She admitted she did apply pressure to his arm. Resident #1 continued to be difficult. She stated at this time she called for help from CNA #2 was in the room assisting the resident's roommate. As she was calling for help, the resident bit her finger. CNA #1 said she placed her right hand up the resident's nose to see if he would let her finger go from his mouth. CNA #1 said the resident bit harder and then finally let go and she left the room. Resident #1 was interviewed and stated that he hit her first and bit her after she hit me. When asked what caused the event to happen, resident pointed to his private area. He then stated he did not want to be changed. Internal investigator revealed the allegation of abuse cannot be substantiated because Resident #1 was the aggressor, and staff was attempting to prevent the resident from hitting her again. A record review of the acute hospital documentation, dated 2/9/25, revealed, .Reportedly concern for patient being struck by an individual at nursing home facility. Patient has abrasion over right side of face as well as dried blood to left nostril .Discharge Diagnosis: Assault . A record review of the clinical profile revealed the facility admitted Resident #1 on 6/28/23 and he had diagnoses including Hemiplegia and Hemiparesis following Cerebral Infraction Affecting Right Dominant Side. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/28/24 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated his cognition was severely impaired. A review of Section B revealed his speech was unclear, and he is usually understood regarding his ability to express ideas and wants, and he usually understands verbal content from others. A review of Section E revealed he did not exhibit physical or verbal behaviors toward others and he had not exhibited any behaviors related to rejection of care. A review of Section GG revealed he had impairment on one side for the upper and lower extremity and he was dependent on staff for toileting hygiene. A review of Section H revealed he is always incontinent of urine. A review of Section I revealed a diagnosis of Hemiplegia or Hemiparesis. During a phone interview on 02/25/2025 at 9:53 AM, CNA #1 stated that when she entered Resident #1's room on 2/9/25, she was changing his brief and turned him on his side, but he repeatedly put his left arm in the way. CNA #1 explained that she applied her arm to his left forearm to prevent him from putting his hand in his genital area. She stated that Resident #1 continued to try to free his arm, and she applied more pressure to his forearm to complete the care. She noted that Resident #1 did not say anything during this interaction but continued to resist. While she was holding his forearm down, Resident #1 managed to get her finger into his mouth and began biting down on her finger. To get him to release her finger, CNA #1 stated that she placed her hand on his nose, hoping he would release her finger to breathe through his mouth, but instead, he bit down harder. CNA #1 stated that she had been trained to leave the room and notify the nurse if a resident refuses care. She reflected that, in hindsight, she should have stopped providing perineal care and left the room. On 02/26/2025 at 12:01 PM, during an interview, LPN #3, who is also responsible for MDS and Care Planning, stated that staff are expected to follow the resident's comprehensive care plan when providing care. She explained that Resident #1's comprehensive care plan directs staff to stop providing care if the resident becomes agitated and to return later to complete the care. She stated that CNA #1 did not follow the care plan as outlined. She emphasized that the care plan is resident-centered and individualized to meet the specific needs of the resident. On 02/26/2025 at 12:06 PM, during an interview, Registered Nurse (RN) #1, the MDS Coordinator, stated that the comprehensive care plan provides a detailed overview of the resident's care needs. She explained that it guides staff by providing a picture of the resident's specific needs and care requirements. On 2/26/25 at 12:55 PM, during an interview, the Director of Nursing (DON) stated CNA #1 should have left Resident #1's room when he became agitated and returned later to provide perineal care. The DON confirmed that CNA #1 did not implement the comprehensive care plan intervention to stop and return if agitated. She stated she expected the staff to follow the care plan to ensure residents get the highest quality of care they can based on the residents' medical conditions.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to be free from physical abuse for one (1) of five (5) sampled residents when Certified Nurse Aide (CNA) #1 used physical force with Resident #1, who was cognitively impaired and had right hemiparesis, was observed with purplish-red discoloration under the right eye, abrasions on the nose, and a hematoma on the forehead following an incident in which CNA #1 admitted to pressing down on Resident #1's left arm (the only functional arm) and using physical force on his face to prevent the resident from hitting her. Findings Included: A review of the facility's policy, Freedom of Abuse, Neglect and Exploitation Standard, revised 11/2019, revealed, .The purpose of this written Freedom of Abuse .Standard is to outline the preventive and action steps taken to reduce the potential for abuse, mistreatment and neglect of residents .Standard Statement This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse .by any facility staff member .Definitions .Abuse means the willful infliction of injury .with resulting physical harm, pain or mental anguish .Willful means the individual means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Physical Abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment . A record review of the clinical profile revealed the facility admitted Resident #1 on 6/28/23 and he had diagnoses including Hemiplegia and Hemiparesis following Cerebral Infraction Affecting Right Dominant Side. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/28/24 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated his cognition was severely impaired. A review of Section B revealed his speech was unclear, and he is usually understood regarding his ability to express ideas and wants, and he usually understands verbal content from others. A review of Section E revealed he did not exhibit physical or verbal behaviors toward others, and he had not exhibited any behaviors related to rejection of care. A review of Section GG revealed he had impairment on one side for the upper and lower extremity and he was dependent on staff for toileting hygiene. A review of Section H revealed he is always incontinent of urine. A review of Section I revealed a diagnosis of Hemiplegia or Hemiparesis. A record review of the facility's investigation, dated 2/14/25, revealed that at approximately 1:30 AM on 1/9/2025, Licensed Practical Nurse (LPN) #1 reported that Resident #1 made an allegation of abuse related to CNA #1. The resident was immediately evaluated and interviewed by LPN #1 and sent out to the hospital for further evaluation. CNA #1 was questioned and sent home pending the outcome of the investigation. The staff wrote statements. The resident returned to the facility at 4:30 AM and was evaluated. He had bruising noted to right eye and hematoma noted to right side of head. Resident #1 stated that he hit the CNA first and he bit her after she hit him. The DON conducted a phone interview with Resident #1 who stated that she entered the room to help the resident prepare for bed and he needed to be changed. When she explained that he needed to be changed, he became aggressive and started swatting at her. She again explained to the resident the importance of getting cleaned up. She asked the resident to roll over so she could finish providing care and that's when the resident hit the CNA the first time. CNA #1 stated she put her hand up to prevent him from hitting her again. She admitted she did apply pressure to his arm. Resident #1 continued to be difficult. She stated at this time she called for help from CNA #2 who was in the room assisting the resident's roommate. As she was calling for help, the resident bit her finger. CNA #1 said she placed her right hand up the resident's nose to see if he would let her finger go from his mouth. CNA #1 said the resident bit harder and then finally let go and she left the room. Resident #1 was interviewed and stated that he hit her first and bit her after she hit me. When asked what caused the event to happen, resident pointed to his private area. He then stated he did not want to be changed. Internal investigator revealed the allegation of abuse cannot be substantiated because Resident #1 was the aggressor, and staff was attempting to prevent the resident from hitting her again. A record review of the Employee/Witness Statement Report, dated 2/9/25, revealed Resident #2, who is Resident #1's roommate stated, The other CNA was giving me care. I heard some scuffling, and I heard a loud pop. A record review of a handwritten statement, dated 2/9/25, and signed by CNA #2 revealed she was assisting with Resident #1's roommate into bed and heard Resident #1 resisting care and while going to assist with care, noticed resident was holding tight to the CNA. Once separated, CNA #1 exited the room. A record review of a handwritten statement, dated 2/9/25, and signed by LPN #1, revealed CNA #1 approached the nurse's station to report that Resident #1 became combative during perineal care. CNA #1 presented her finger to LPN #1 and stated that Resident #1 bit down on her finger and wouldn't let go. Finger noted red and swollen with purple spotted discoloration at the base. LPN #1 offered to help due to her stating the resident was giving us a hard time. CNA#1 assured LPN #1 that everything was under control. After approximately 20 minutes, CNA's #3 and #4 approached LPN #1 and reported that Resident #1 stated that the girls that just left hit him. The CNA's also reported that his roommate stated he heard a lot of commotion from the other side of the room, followed by a loud pop. The CNAs stated they noted swelling under [NAME] his right eye and a bloody nose, with a knot to right temple. LPN #1 immediately went to Resident #1's room and observed purplish-red discoloration under his right eye. Light red scratches along the perimeters of the discoloration beneath right eye. Scratches noted to bridge of Resident #1's nose on the right side. Dry blood noted at right inner nostril. Spotted drops of blood noted to sheet covering Resident #1's lap. [NAME] sized knot noted at right temple. LPN #1 notified the DON of the allegation and was advised to interview the resident more thoroughly. Resident pointed towards the doorway and LPN #1 asked resident if someone had hit him and he nodded his head up and down. Asked who and the resident stated the girl and pointed to his doorway. Resident stated he hit her and she hit him. Resident indicated he was hit in the nose. Resident shook his head No when asked if he was hit in the eye. Resident was noted to be wide-eyed and pressed for words at this time LPN #1 interviewed Resident #2 (Roommate for Resident #1) and he stated he heard a lot of commotion while CNA #2 was assisting him and then CNA #2 rushed over to intervene. The resident denied hearing a pop as stated earlier by CNA #3 and #4. Resident #2 shook his head no and shrugged his shoulders when asked if he felt anything malicious was going on between the CNAs and Resident #1. LPN #1 asked Resident #1 four (4) times if he was hit by a staff member, which he confirmed verbally and with gestures each time. LPN #1 asked CNA #2 what she knew concerning Resident #1 and she stated that Resident #1 began to resist care and became combative when she ran over to assist. She stated Resident #1 was noted biting down on CNA #1's finger. LPN #1 asked CNA #1 what she knew concerning the changes observed on Resident #1's face and bloody nose. CNA #1 stated that he (Resident #1) gripped her finger with his teeth and refused to let go. CNA #1 stated she grabbed the resident around the bridge of his nose in an attempt to make him open his mouth and that he only began to bite harder. LPN #1 told CNA #1 that Resident #1 stated he was hit in the nose and CNA #1 stated that she did not hit him the nose. A record review of the Employee/Witness Statement Report, dated 2/10/25, revealed CNA #1 went in to provide care and he was putting his hands down in front of him messing with himself. CNA #1 asked a few times for him to move his hands and let her finish changing him. She only had to put the brief between his legs and fasten it on the right side, but he continued to do it and starting hitting at CNA #1. CNA#1 put her arm up over his hand to keep him from hitting her and he continued to hit at her so she kept her arm up. CNA #1 stated she was pressing down to keep him from swinging out to hit her and his arm was over his chest at the time. The next thing she knew he was biting her finger on the right hand would not let go. She thought he was going to bite it completely off. She asked him to let go at this time and CNA #2 came to help her. She was telling the resident to her go and he bit down harder so she tried to put her left hand up and put her fingers over his nose and he bit down even harder. He finally let go and she grabbed her right hand with the left hand making a loud clapping noise and left the room. She notified the nurse. She stated that at no point during the encounter she thought it would be better for her to leave out because she was trying to provide care the resident needed and she denied hitting the resident. A record review of the acute hospital documentation, dated 2/9/25, revealed, .Reportedly concern for patient being struck by an individual at nursing home facility. Patient has abrasion over right side of face as well as dried blood to left nostril .Discharge Diagnosis: Assault . A record review of a Progress Note, dated 2/9/25 at 19:00 (7 PM) revealed, .noted swelling underneath right eye pink color . A record review of a Progress Note, dated 2/9/25 at 14:24 (2:24 PM) revealed, .Report called from (Proper Name of Acute Hospital) .Resident does have a hematoma on the forehead . A record review of a Progress Note, dated 2/10/24 at 16:20 (4:20 PM), for Resident #1, authored by LPN #2, revealed, .Small red bruise noted under right eye . A record review of a Progress Note, dated 2/10/24 at 8:51 AM, by LPN #1, revealed, late entry for 2/9/25 at 2045 PM (8:45 PM) - Resident observed sitting upright in wc (wheelchair) .Pink color remains noted under right eye . On 02/24/2025 at 5:22 PM, during an interview, Resident #2 stated that on 02/09/2025, while CNA #2 was assisting him, he heard a hitting sound but did not see anyone hitting Resident #1 when he looked over. He stated that CNA #1 entered the room to check if Resident #1 was wet, and he heard the sound of hitting again while CNA #2 remained with him on the other side of the room. Resident #2 recalled that CNA #2 asked CNA #1 if she needed help. He confirmed that he did not see CNA #1 hit Resident #1, nor did he see Resident #1 hit CNA #1. He stated that he only saw Resident #1's eye injury after both CNAs left the room. Resident #2 also stated that he had never observed Resident #1 refuse care or act aggressively toward staff. On 02/25/2025 at 9:53 AM, during a phone interview, CNA #1 stated that when she entered Resident #1's room on 2/9/25, she asked him if he was ready to lie down, and he nodded in agreement. At that time, CNA #2 entered the room to provide perineal care to Resident #2. CNA #1 stated that she began providing care by pulling down Resident #1's pants, removing his shoes, and placing a clean brief and draw sheet under him. She noted that Resident #1 placed his hands in his buttocks area, and when she asked him to move his hands, he complied. CNA #1 stated that Resident #1 then placed his hands in the front of his brief in the genital area. She repeatedly told him to stop, and while he would momentarily comply, he continued to place his hands in the genital area. She stated that she continued to provide perineal care and turned the resident on his side, but he repeatedly put his left arm in the way. CNA #1 explained that she applied her arm to his left forearm to prevent him from putting his hand in his genital area. She stated that Resident #1 continued to try to free his arm, and she applied more pressure to his forearm to complete the care. She noted that Resident #1 did not say anything during this interaction but continued to resist. While she was holding his forearm down, Resident #1 managed to get her finger into his mouth and began biting down on her finger. To get him to release her finger, CNA #1 stated that she placed her hand on his nose, hoping he would release her finger to breathe through his mouth, but instead, he bit down harder. At this point, CNA #2 approached and told Resident #1 to let go of CNA #1's finger. CNA #1 stated that her fingernails were longer than they were supposed to be, and she believed that she may have accidentally scratched Resident #1's nose during the incident. CNA #1 stated that she had been trained to leave the room and notify the nurse if a resident refuses care. She reflected that, in hindsight, she should have stopped providing perineal care and left the room. She explained that Resident #1 had previously cursed at staff, called them names, and hit at CNAs. CNA #1 stated that during the incident, she never yelled for help and that CNA #2 came over on her own to assist. She confirmed that Resident #1 did not break the skin on her finger but continued to bite down. She denied causing any injury to Resident #1's eye but acknowledged that his nose was scratched by her nails. She reiterated that she did not yell for help at any point during the incident. On 02/25/2025 at 12:17 PM, during an observation, Resident #1 was seen in the hallway. His right hand and arm were contracted, and he was using his left hand to maneuver his wheelchair. On 02/25/2025 at 12:47 PM, during a phone interview, Certified Nursing Assistant (CNA) #2 stated that on 2/9/25 at the time of the incident, she was assisting with Resident #2 and heard CNA #1 say stop. CNA #2 went over to the Resident #1's side of the room and observed Resident #1 holding onto CNA #1's shirt collar but did not see Resident #1 biting CNA #1's finger or any hitting between them. She stated that CNA #1 was holding both of Resident #1's arms in her hands. She did not know what had occurred to cause Resident #1 to grab CNA #1's shirt collar. She stated that she had been trained to leave the room if a resident refuses care. She observed a small amount of blood near Resident #1's nose but did not notice any injury to his eye. She stated that by his facial expression, she could tell that Resident #1 was agitated. She gave Resident #1 a paper towel for his bloody nose. She confirmed that CNA #1 never called for help or yelled during the incident. She stated that Resident #1 has a contracted right arm and is unable to use his right hand or arm. She explained that if she were in that situation, she would have left the room and returned later. She also stated that Resident #1 had never yelled, cursed, or tried to hit her or any other CNAs that she was aware of. On 02/25/2025 at 1:37 PM, during a phone interview, LPN #1 stated she went to Resident #1's room on 2/9/25 after CNA #3 and CNA #4 reported he had injuries to his face, and he had stated he had been hit. Resident #1 was sitting on the side of the bed appearing frightened, nervous, and wide-eyed. She stated that Resident #1 immediately tried to verbally communicate with her. She observed redness above his right eye, a small abrasion near his eye and on the bridge of his nose, and a dime-sized knot on the right side of his face. LPN #1 stated that when she spoke to Resident #1, he pointed to his nose area and stated that the girl hit me. She noted that he continued to point and make facial gestures throughout the interview. LPN #1 assessed Resident #1 and obtained an order from the Nurse Practitioner to send him to the emergency room for evaluation. She stated that Resident #1 is usually not upset, but during the incident, he appeared visibly upset by his facial expressions. She explained that she had seen Resident #1 twice during her shift and did not observe any injuries before the incident. She stated that Resident #1 had never exhibited behavioral issues such as cursing, yelling, or hitting staff, and no CNA had ever reported that he refused care or hit staff members. She noted that approximately 20 minutes before CNA #3 and CNA #4 approached her with the report of the resident's injuries, CNA #1 had told her that Resident #1 had bitten her finger hard, but that everything was under control. She stated that she did not go to the room immediately at that time because CNA #1 indicated that the situation was resolved. LPN #1 stated that CNA #1 never mentioned that Resident #1 had hit her or that she had hit him. She confirmed that CNA #1 did not yell out for help during the incident. LPN #1 also noted that Resident #1's room is located near the nurse's station. On 02/25/2025 at 2:08 PM, during an interview, Resident #1 used hand gestures as he attempted to verbally communicate. When asked if he hit CNA #1, he responded yes and nodded his head in agreement. He stated that CNA #1 hit him in his eye area and pointed to his face and nose with his left hand, while his right hand remained contracted at his side. Resident #1 stated that CNA #1 was rough with him and held him down tightly, pointing to his arm to indicate where he was held. He stated that she was hurting him, which caused him to hit her, but he denied biting her finger. Resident #1 stated that CNA #1 hit him with a closed fist in his face near his right eye. On 02/25/2025 at 2:22 PM, during an interview, the Director of Nursing (DON) stated that LPN #1 called her at the time of incident and reported that Resident #1 had bitten CNA #1's finger. She stated that prior to the incident, she had never been informed of Resident #1 displaying any behavioral issues, such as cursing, yelling, or hitting staff. She stated that when she saw Resident #1, he had red discoloration under his right eye. She was informed that CNA #1 was attempting to change Resident #1's brief at the time of the incident. She explained that if a resident refuses care, staff are expected to stop and leave the room, emphasizing that staff should never hold a resident down to provide care. She stated that the facility conducted an investigation but did not substantiate abuse. On 02/26/2025 at 8:48 AM, during a phone interview, CNA #3 stated that CNA #4 asked her to look at Resident #1's swollen face on 2/9/25 after the incident occurred. She stated that when they entered the room, the light was off. Resident #1 appeared jumpy, scared, and terrified and looked around nervously. Resident #1's face was swollen and bruised, with a bruise near his right eye and a small knot on the right side of his head. Resident #1 told her that he hit CNA #1 but did not bite her finger. She stated that she reported the injuries and allegation to the nurse and stated that Resident #1 had never hit or bitten her before. On 02/26/2025 at 8:54 AM, during a phone interview, CNA #4 stated she went into Resident #1's room after the incident occurred and noticed that Resident #1's nose was bleeding. She then went outside to get CNA #3, and they both returned to the room. She stated that when they knocked on the door and re-entered the room, they observed bruising near Resident #1's eye and a small knot on his head. She stated that Resident #1 appeared very jumpy and anxious when they entered the room. They reported the resident's injuries to LPN #1. She stated that Resident #1 had never hit or yelled at her before. On 2/26/25 at 2:26 PM in an interview with the Administrator, he stated that an investigator from corporate reviewed the investigation documentation, as well as himself and the DON, and they concluded that abuse was not substantiated. He also explained that CNA #1 had not returned to work since she was sent home that night due to the injury received from the resident biting her finger.

Based on interviews, record review, and facility policy review, the facility failed to secure a resident in a mechanical lift and maintain necessary supervision during a transfer resulting in a laceration requiring staples and Emergency Department (ED) visit for one (1) of seven (7) sampled residents. Resident #1 Findings included: Review of the facility's policy, Transferring Clients with a Mechanical Lift, undated, revealed Read the manufacturer's instructions on: How to properly operate the lift .Promotes safety and To operate the lift for transfer from the bed to a chair/wheelchair: Follow the manufacturer's instructions to operate the lift .Promotes safety. Record review of the Incident Report dated 12/21/24 5:10 AM prepared by Licensed Practical Nurse (LPN) #1, revealed Incident Description: UPON NURSE ENTERING ROOM, RESIDENT BODY SLANTED SLIGHTLY UNDER BED BUT MOSTLY ON FLOOR BUT HER LEGS REMAINED OVER BOTTOM OF LIFT AND BACK OF HEAD ALSO ON LIFT WITH MODERATE AMOUNT OF BLOOD NOTED ON LIFT AND FLOOR . RESIDENT'S RP(Responsible Party) IS (RP name). CONTACTED HER AND NOTIFIED HER OF RESIDENT'S FALL AND THAT SHE WAS BEING TRANSFERRED TO (specific) HOSPITAL WHICH SHE STATED WAS HER REQUEST TO BE EVALUATED. THANKED THIS WRITER FOR CALLING. RESIDENT LEFT FACILITY AT 545 AM VIA STRETCHER PER (ambulance service) .RESIDENT REMAINED ALERT .BLEEDING NOTED FROM BACK OF HEAD .Other Info revealed, .CNA (Certified Nurse Aide) stated that she was getting resident ready to get her up. Stated she went back into room and proceeded to lift her up in the air over the bed while waiting for the other CNA to come help. Stated she noticed resident was sliding out the lift pad from the top of the left and by the time she caught this and could let her down onto the bed she had already came out of the lift pad onto the floor. Record review of the Owner's Manual for the (Proper Name of Mechanical Lift), copyright 2021, revealed, .Safety Warnings & (and) Cautions .Lift Operation .WARNING: More than one assistant is recommended for all resident lift activities . A record review of the Instructions from the acute hospital documentation, dated 12/21/2024, revealed You (Resident #1) were seen in the ED after a fall .There are two (2) staples to the back of your scalp . Record review of the Admission Record for Resident #1 revealed the facility admitted the resident on 01/22/24 and the resident had diagnoses of Paraplegia, complete. Record review of the Admission Minimum Data Set (MDS) for Resident #1 with Assessment Reference Date (ARD) 12/27/24 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Section GG revealed Resident #1 was not ambulatory and was dependent for bed to chair transfers. On 1/15/25 at 9:42 AM, during a telephone interview CNA #3 reported she was assigned to the care of Resident #1 on the morning of 12/21/24 between 5:00 AM and 6:00 AM and that following Activities of Daily Living (ADL) care she positioned the mechanical lift and elevated the resident above the mattress on her bed. She stated she was waiting for assistance with the transfer and that while the resident was in the lift sling, elevated above the mattress she went to the door of the resident's room to call for assistance and turned back to see the resident sliding out of the sling. She stated that she was unable to stop the resident from falling and the resident landed on the mattress and then slid off the mattress to the floor and landed with her legs on the left base of the lift and her head on the right base of the lift. She said LPN #1 came and conducted a body audit which revealed the back of the resident's head was bleeding. CNA #3 stated that the facility had provided in-service training for use of the floor lift and required return demonstration for safe use via competency checkoffs. She stated that the training she received included the participation of two staff members for bed to wheelchair transfers for dependent residents with the floor lift. She confirmed that when she left the resident and walked to the room door to summon second staff member for assistance the resident was elevated above the mattress in the sling, therefore left unattended. She stated that there was nothing wrong with the lift or the sling. She confirmed that there were other staff available for assistance but that she was the only staff in the resident's room at the time of the fall. On 1/15/25 at 11:50 AM, during an interview with LPN #2, who is the facility's Staff Educator, revealed CNAs were trained to use the mechanical lifts using video, demonstration and competency checkoffs during orientation upon hire and on-going. She stated that she encouraged the employment of at least two (2) staff for surface-to-surface transfers for dependent residents according to the lift owner's manual and emphasized safety precautions such as never leaving a resident suspended from a lift unattended. On 1/17/25 at 3:55 PM, during an interview the Director of Nursing (DON) confirmed that she had participated in an investigation following Resident #1's fall with injury on 12/21/24 and determined the cause of the fall was that CNA #3 failed to ensure that she had adequate staff present for a safe transfer. On 1/17/25 at 4:10 PM, during an interview the Administrator revealed that regarding provision of safety measures related to falls/accidents/incidents, he stated, Our ultimate goal is to safeguard our residents.

Based on interviews, record review, and facility policy review, the facility failed to implement comprehensive care plan interventions as evidenced by: (1) the failure to develop comprehensive care plan interventions for residents with pressure ulcers (PUs) (Resident #53 and Resident #89), (2) the failure to ensure a resident was turned and repositioned (Resident # 87), (3) the failure to ensure residents were clean and dry (Resident #1 and #31), and (4) the failure to ensure nail care was provided to dependent residents (Resident #23 and Resident #41), for six (6) of 22 care plans reviewed. The facility's failure to develop comprehensive care plan interventions related to the prevention of skin breakdown and PU care resulted in harm to Resident #53 and Resident #89 and put all other residents at risk for skin breakdown in a situation that was likely to result in serious harm, injury, impairment, or death. The facility's failure to put Resident #53, Resident #89, and all other residents who are at risk for skin breakdown at risk for serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 8/29/23 when Resident #53, who had existing PUs, was admitted to the facility, and was not assessed by a qualified nurse or practitioner until 9/18/23, causing the wound to worsen. The facility Administrator was notified of the IJ and was presented with an IJ Template on 12/1/23 at 2:55 PM. The facility provided an acceptable Removal Plan on 12/4/23, in which they alleged all corrective action to remove the IJ was completed on 12/4/23 and the IJ was removed on 12/5/23. The State Agency (SA) validated the Removal Plan on 12/5/23 and determined that the IJ was removed on 12/5/23, prior to exit. Therefore, the scope and severity for 42 CFR 483.21(b) Comprehensive Care Plans F656 was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A record review of the facility's policy Comprehensive Care Plan revised 03/2019, revealed, . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment . Resident #53 A record review of Resident #53's Comprehensive Care Plan undated, revealed a Focus: The resident has Stage 4 pressure ulcer to Left Buttocks .Desired Outcome: The resident's will Pressure ulcer will show signs of healing and remain free from infection by/through review date .Interventions/Tasks: Administer treatments as ordered and monitor for effectiveness, Monitor/document/report to MD (Medical Doctor) PRN (As Needed) changes in skin status: appearance, color, wound healing, s/sx (signs and symptoms), wound size (length X width X depth), stage, Sacrum and left buttock pressure injury State 4-clean with NS (Normal Saline), pat dry, pack with Dakin's solution 1/4 strength soaked kerlix and cover with bordered gauze daily and prn for soiled or dislodgement . There were no other interventions developed to stabilize, reduce, or remove underlying risk factors for PUs or to prevent the development of additional PUs. At 9:00 AM on 11/29/23, during an interview with Licensed Practical Nurse (LPN) #1/Wound Care Nurse, he stated that Resident #53 was admitted to the facility with a PU. A record review of the Admission Record revealed the facility admitted Resident #53 on 08/29/23 with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, and Chronic Obstructive Pulmonary Disease. A record review of the Comprehensive Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/05/23 revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated he had severe cognitive impairment. Further review revealed that he required extensive assistance with bed mobility and toilet use, was always incontinent of urine and bowel, he was at risk of developing PUs, and had one (1) unstageable PU that was present upon admission to the facility. Record review of Resident #53's Brief Interview for Mental Status (BIMS) Evaluation with an effective date of 12/02/23 revealed a BIMS Summary score of 13, which indicated Resident #53 was cognitively intact. A record review of Braden Scale for Predicting Pressure Sore Risk, dated 08/29/23, revealed Resident #53 had a score of 13, which indicated he was at moderate risk for developing a PU. Resident #89 A record review of the Comprehensive Care Plan undated, revealed a Focus : Resident is at risk for impairment to skin due to Immobility, Incontinence . Desired Outcome: Residents will remain free of complications if skin is impaired through next review date. Interventions . Preventative skin care measures . Record review of the care plan undated, revealed Focus : The resident has potential/actual impairment to skin integrity r/t (related to) Stage 4 to sacrum. Desired Outcome: The resident's pressure injury of the (sacrum) will be healed by review date. Interventions/Tasks: Identify/document potential causative factors and eliminate/resolve where possible, Keep skin clean and dry, Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, macerations etc. to MD, Wound care as ordered by MD (santyl, Calcium Alginate, bordered Foam . There were no other interventions developed to stabilize, reduce, or remove underlying risk factors for PUs or to prevent the development of additional PUs. A record review of the Admission Record revealed the facility admitted Resident #89 on 09/28/23 with diagnoses including Traumatic Subdural Hemorrhage with Loss of Consciousness of Unspecified Duration. A record review of the Comprehensive Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/05/23 revealed Resident #89 required a staff assessment of mental status, which indicated his cognitive skills were severely impaired. Further review revealed that he was dependent upon staff for functional abilities, was always incontinent of urine and bowel, he was at risk of developing PUs, and had no PUs upon admission to the facility. A record review of Resident #89's Braden Scale for Predicting Pressure Sore Risk, dated 09/28/23, revealed he had a score of 12, which indicated he was at high risk for developing a PU. A record review of the Random Skin Sweep, dated 9/28/23, the date Resident #89 was admitted to the facility, revealed he did not have any PUs. A record review of the Wound/Skin Log, dated 10/8/23, revealed Resident #89 had a PU to the sacrum. On 11/30/23 at 10:35 AM, during an interview with LPN #1, he explained that he reviewed Physician's Orders to complete treatments for the residents and he did not use or review the resident's care plans. He stated that care plan interventions are completed by the Registered Nurses (RNs) and the purpose of the interventions was to instruct the staff on how to provide care to the resident. At 11:35 AM on 11/30/23, during an interview with LPN #4/Care Plan Nurse, she explained the purpose of the care plan is to provide care for the residents, and all care plans should be resident-centered and individualized for the residents. She stated that she and Registered Nurse (RN) # 2/MDS Coordinator, build resident care plans, including interventions, by using the electronic health record care plan library. LPN #4 said they also review the Braden's Scale to help with care planning for residents at risk for PU development and for residents who currently had PUs. She explained that every staff member should use the care plan to assure adequate care was provided for the resident. LPN #4 reviewed Resident #53's PU care plan and confirmed there were no interventions that addressed prevention for further skin breakdown or the development of additional PUs. LPN #4 reviewed Resident #89's PU care plan and confirmed that although there were some preventive measures in place, the interventions did not include everything including supplements, weights, and was not resident centered. She confirmed the intervention of Preventative skin care measures was too vague and should be more specific for the staff to know how to care for the resident. At 12:00 PM on 11/30/23, during an interview with the Assistant Director of Nursing (ADON), she explained the facility had two (2) Care Plan Nurses that complete care plans for the residents. She stated that the Braden Scale was completed by staff on each resident upon admission and care plans are developed based on the results of the assessment. She reported that any resident who was at risk for a PU, or had a current PU, should have a care plan for prevention of skin breakdown or for additional PU development. She confirmed that all care plans should be resident-centered and contain interventions to provide the needs of the resident. She stated that she expected resident care plans to have appropriate interventions in place to provide adequate care to the residents. On 12/01/23 at 11:00 AM, during an interview with RN #2/MDS Coordinator/Care Plan Nurse, she explained the purpose of the care plan was to know what care the resident needed and she expected all staff to follow the care plan. She stated that she used Physician Orders and other assessments to develop care plan interventions to meet the resident's needs. RN #2 reviewed Resident #53's care plan and confirmed the PU care plan interventions did not contain measures to prevent further skin breakdown and the development of additional PUs. RN #2 reviewed Resident #89's care plan and confirmed the interventions for preventative skin care measures should be more resident centered and reported preventative skin care measures should be used for all residents. Resident # 87 A record review of Resident #87's Comprehensive Care Plan revealed a Focus of Resident is at risk for impairment to skin due to immobility and had Interventions/Tasks including Incontinent care q (every) 2 hours and as needed and Turn and reposition q 2 hours and as needed. A record review of the Admission Record revealed the facility admitted Resident #87 on 08/07/23 with diagnoses including Nontraumatic Intracerebral Hemorrhage, Chronic Respiratory Failure with Hypoxia, and Hemiplegia and Hemiparesis. On 11/27/23 at 10:27 AM, during an observation, Resident #87 was lying in bed positioned on his back with the head of the bed elevated to approximately a 45 degree angle. On 11/28/23 at 9:00 AM, during an interview with the resident's sister, she complained that the facility was not providing good care to her brother. She reported that she came to the facility to visit him daily and the staff failed to turn and reposition him. She stated that Resident #87 had been on his back for two (2) hours, since 7:00 AM. On 11/28/23 at 1:00 PM and 3:00 PM, during an observation, Resident #87 was positioned on his back with the head of the bed elevated. On 11/29/23 at 8:00 AM and 10:30 AM, during observations, Resident #87 was positioned on his back with the head of the bed elevated. On 11/29/23 at 11:00 AM, in an interview with the DON, she confirmed the facility did not have a schedule for residents to be turned. Resident #1 Record review of the care plan for Resident #1 revealed a Focus of (Proper Name of Resident #1) has bladder incontinence and is at risk for complications and Interventions/Tasks included .Check (Proper Name) every 2-3 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes . Record review of the Admission Record revealed the facility admitted Resident #1 on 8/11/23 with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left non dominant side and Morbid Severe Obesity. During an observation and interview on 11/29/23 at 5:15 AM, with CNA #13, revealed Resident #1's brief was saturated with urine and had a strong urine odor. CNA #13 stated that she was not assigned to the resident but confirmed that the resident's brief was saturated with urine and had a strong urine odor. In an interview with LPN #2/Unit Manager, on 11/29/23 at 8:49 AM, she stated that Resident #1 was incontinent of bowel and bladder, and she expected all staff to make rounds every two (2) hours to turn residents and keep them clean and dry. Resident #31 Record review of the care plan revealed Resident #31 had a Focus of The resident has bladder and bowel incontinence r/t Impaired Mobility, with Interventions/Tasks including .Change (every2 hours) and prn, and Check resident and as required for incontinence . Record review of the Admission Record revealed the facility admitted Resident #31 on 6/23/23 with a diagnosis of Traumatic Brain Injury. Record review of the Quarterly MDS with an ARD of 9/26/23 revealed Resident #31 had a BIMS score of 15, which indicated she was cognitively intact. A review of Section G revealed she was dependent upon staff for toileting hygiene. An observation and interview with Resident #31, on 11/27/23 at 2:40 PM, revealed there was a urine odor noted. Resident #31 stated that she stayed wet for long periods of time. An observation and interview with CNA #13 on 11/29/23 at 5:22 AM, Resident #31 stated that she was changed once last night before she went to sleep, and she got changed once on the 11 PM to 7 AM shift. The resident's brief was heavily soiled, and there was a strong urine odor. CNA #13 stated she was not the CNA for the resident, but she confirmed that Resident #31's brief was heavily soiled with urine and had a strong urine odor. In an interview with the DON on 11/29/23 at 10:42 AM, she stated that she expected the CNAs to complete rounds every two hours or every hour, if a resident required it more often. At 9:40 AM on 12/01/23, in an interview with CNA #1/Lead CNA, she stated that she worked on all halls and all shifts at the facility. She explained that she expected the CNAs to make rounds every two (2) hours and change the resident if needed. She stated that if a resident was found to have a heavily saturated brief and had a strong urine odor, she would think that the resident had not been changed all night. Resident #23 A record review of the care plan for Resident #23 revealed a Focus of The resident has an ADL (Activities of Daily Living) self care performance deficit r/t activity intolerance, impaired balance, Limited Mobility, with Interventions/Tasks of .Check nail length and trim and clean on bath day and as necessary, and The resident requires extensive assistance .with personal hygiene . A record review of Resident #23's Admission Record revealed she was admitted to the facility on [DATE] with diagnoses that included Muscle wasting and atrophy, Rheumatoid Arthritis, Osteoarthritis, and Muscle Weakness. A record review of the Quarterly MDS with an ARD of 9/15/22 revealed that Resident #23 had a BIMS core of 15, which indicated that the resident is cognitively intact. SECTION G revealed she is not ambulatory and requires extensive assistance for bed mobility, dressing, and personal hygiene. During an observation and interview on 11/27/23 at 10:56 AM, Resident #23's fingernails were jagged and approximately 1/4 of an inch past the tips of her fingers. Her hair was matted at the ends, appearing nappy. Resident #23 stated that she did not like her long fingernails and wished staff would comb her hair and trim her nails regularly. She indicates the staff has not cut her nails or done her hair in several weeks. During an observation on 11/28/23 at 3:42 PM, Resident #23's hair was uncombed, and her nails were long and jagged. During an observation on 11/29/23 at 8:23 AM, Resident #23's hair was not combed, and her nails were not cut. Resident #41 Record review of the care plan for Resident #41 revealed Focus (Proper Name of Resident #41) has an ADL Self Care Performance Deficit r/t Activity Intolerance, Hemiplegia, Impaired balance, Stroke .Interventions .Check nail length and trim and clean on bath day and as necessary . Record review of the care plan revealed Focus (Resident # 41's Proper Name) requires assistance with ADL's related to cognitive impairment, decreased mobility, HX (History) of Cerebral Infarction .Interventions .Staff to assist with ADL's . In an observation and interview on 11/27/23 at 12:17 PM, Resident #41 was lying in bed. His hair was not combed, fingernails were long and jagged, and his face was unshaven. Resident #41 stated that he wanted his nails clipped and to be groomed on a consistent schedule. He stated that staff have not done it as frequently as he would have liked. Record review of Resident #41's Admission Record revealed he was admitted to the facility on [DATE] with diagnoses including Lack of Coordination, Contracture of Right Hand and Stiffness in Right Hand. A record review of the Quarterly MDS with an ARD of 09/25/23 revealed that Resident #41 had a Brief Interview for Mental Status (BIMS) score of 15, which indicates that the resident is cognitively intact. In an interview with Resident #41 on 11/28/23 at 4:36 PM, he stated that staff had not cut his nails or combed his hair. During an interview on 11/29/23 at 10:02 AM, with Resident #41 and the RN #1/Unit Manager, Resident #41 reiterated that he wished to have his nails clipped, beard shaved, and hair combed every week. RN #1 said he would get this done for the resident immediately. On 11/30/23 at 11:35 AM, during an interview with Licensed Practical Nurse #4 (LPN)/Care Plan Nurse, she stated every staff member should use the care plan to assure adequate care is provided for the residents. On 11/30/23 at 12:00 PM, during an interview with the DON, she explained that she expected staff to follow the residents' care plans to provide the best care for all residents. On 12/01/23 at 11:00 AM, during an interview with RN #2/MDS Coordinator/Care Plan Nurse, she stated that she expected all staff to follow the care plans to be able to provide adequate care for the residents. The facility provided an acceptable Removal Plan on 12/4/23, in which they alleged all corrective action to remove the IJ was completed on 12/4/23 and the IJ was removed on 12/5/23 which included: On December 1st, 2023, at approximately 3:30pm Pine Forest Health and Rehabilitation received 5 Immediate Jeopardies during an Annual and Complaint Survey from the Mississippi Department of Health Licensure and Certification and provided the facility with the Immediate Jeopardy Templates. Brief Summary of Events: Pine Forest Health and Rehabilitation failed to put into place appropriate interventions to ensure proper assessment, staging, treatment and clinical care plans to treat and prevent the development and worsening of new and existing pressure ulcers. Corrective Actions: 1. An Emergency QAPI Meeting was held at approximately 12/1/2023 at 5 PM to review the cited deficient practices and to determine a root cause analysis for the lack of appropriate interventions. This meeting included the Administrator, Director of Nursing/lnfection Preventionist, Medical Director, Respiratory Director, & Business Office Manager. The following items were reviewed, coordinated, and corrected to allege compliance and remove the Immediate Jeopardy. The root cause analysis determined the cause of these occurrences was the facility's failure to be properly train staff on the policies for assessing, staging, preventing, and communicating wound and skin care issues for residents who could be at risk for skin breakdown or are already noted with skin/wound breakdown. 2. The facility did a complete policy review on Care Planning Standard, Skin Management Standard, and Employee Competency Standard. The facility conducted 100% in-services and education using outsourced, Qualified Trainers and Online Software as it pertains to each department and the correlated policies pertaining to the immediate jeopardies. The facility also did a 100% inservice on all staff on the Identification and Reporting of Resident Abuse and Neglect. No individual was allowed to work beginning at approximately 7PM on 12/1/2023 until they were able to successfully complete all prescribed In-services. 3. The facility outsourced a Qualified RN Trainer to properly train with return demonstration all individuals who are responsible for the assessment, staging, and provision of wound care for the Facility. Upon completion and approximately 7:30PM on 12/1/2023, the Facility began to conduct body audits on 100% of in-house residents to determine proper assessment, staging, and treatment of wounds and finished on 12/4/2023. All noted pressure areas were assessed, staged, and determined to have a proper assessment. The wound care physician was notified of all findings and coordinated a Telehealth Visit on all residents with pre-existing wounds to confirm appropriate assessment, staging, and treatment of all existing pressure ulcers. There were no changes noted after having concluded all consult Telehealth visits. The attending physician and facility Medical Director was then notified of all Wound Care Physician's Assessments and concurred with prescribed consultation on all noted patients. Resident #53 was determined to have a pressure ulcer in an optimal condition of healing. Resident #89 remains in the hospital. 4. Both MDS Nurses were immediately trained following the QAPI Meeting regarding the ability to properly develop and/or revise resident care plans interventions for residents with pressure ulcers, ensuring those who were admitted to the facility without pressure ulcers did not acquire pressure ulcers and that existing pressure ulcers did not get worse, or residents did not develop complications from pressure wounds. After completing each Telehealth visit from Wound Care Physician and receiving noted confirmation for Medical Director/Attending Physician on all residents with Pressure ulcers, the facility began assessing and updating all care plans on 12/1/2023 and completed 12/4/2023 on coordination with development and prevention of pressure ulcers according to the prescribed orders. Resident #53 was noted to have a proper care plan regarding his healing pressure ulcer. Resident #89 remains in the hospital. 5. The facility determined to move forward by having the trained Unit RN Managers conduct weekly body audits on all residents as it pertains to their individual Units A & B and report the assessment of those daily audits to the Wound Care Team, consisting of the Wound Care Physician, Treatment Nurse, MDS Nurse, and Director of Nursing. All new admits/readmitting residents will their initial assessment conducted by the Unit Manager, who will be responsible for communicating the results of the audit to the Wound Care Team, Consisting of the Wound Care Physician, Treatment Nurse, MDS Nurse and Director of Nursing. The Director of Nursing has been delegated to report the reconciliation of this weekly review in High Risk and monitored monthly for no less than 1 year by the QAPI Committee. 6. The Facility alleges compliance on 12/5/2023. The facility alleges that all corrective actions to remove the Immediate Jeopardy were completed on 12/4/2023 and the Immediate Jeopardy was removed on 12/5/2023. The SA validated the facility's Corrective Actions on 12/5/23: The SA validated through interviews and record review on 12/5/2023 that an Emergency QAPI meeting was held on 12/01/2023 with all members in attendance. The SA validated through interviews and record reviews all policies on Care Planning Standards, Skin Management Standards, and Employee Competency Standards were reviewed with no corrections made. The facility conducted 100% in-services and education including Identification and Reporting of Resident Abuse and Neglect. The SA validated through interviews and record reviews the facility outsourced a Qualified RN Trainer to properly train and return demonstration all individuals who are responsible for the assessment, staging, and provision of wound care for the Facility. The facility completed 100% body audits of in-house residents to determine proper assessment, staging, and treatment of wounds and finished on 12/04/23. The Wound Care Physician was notified of all findings and coordinated a Telehealth Visit on all residents with pre-exiting wounds to confirm appropriate assessment, staging, and treatment of all exiting pressure ulcers. The Medical Director was notified of all findings. Resident #53 was determined to have a pressure ulcer in an optimal condition of healing. Resident #89 remains in the hospital. The SA validated through interviews and record reviews both MDS Nurses were immediately trained following the QAPI meeting regarding the proper development and/or revise resident care plans interventions for residents with pressure ulcers, ensuring those who were admitted to the facility without pressure ulcers did not acquire pressure ulcers and that existing pressure ulcers did not get worse, or residents did not develop complications from pressure wounds. The facility assessed and updated all care plans and completed them on 12/04/23. The SA validated through interviews and record reviews the facility trained Unit RN Managers conduct weekly body audits on all resident as it pertains to their individual Units A and B and report the assessment of those daily audits to the Wound Care Team, consisting of the Wound Care Physician, Treatment Nurse, MDS Nurse, and DON. The DON has been delegated to report the reconciliation of this weekly review in High Risk and monitored monthly for no less than one (1) year by the QAPI Committee. The SA validated through interviews and record reviews and no associate can return to work until they have received this in-service training. The SA validated that all corrective actions were completed on 12/04/2023 and the IJ was removed as of 12/05/2023. 43283

Based on observation, interviews, record review, and facility policy review, the facility failed to protect the residents' right to be free from neglect for five (5) of 22 residents reviewed as evidenced by facility staff: 1. Did not provide Pressure Ulcer (PU) assessments and care and treatment to prevent complications and worsening of PUs (Resident #53 and Resident #89) 2. Turn and reposition a resident (Resident #87) 3. Ensure incontinent residents were clean and dry (Resident #1 and Resident #31). The facility's neglect to provide wound assessments, documentation, and wound care treatment resulted in harm to Resident #53 and Resident #89 and put all other residents at risk for skin breakdown in a situation that was likely to result in serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 8/29/23 when Resident #53, who had existing PUs, was admitted to the facility, and was not assessed by a qualified nurse or practitioner until 9/18/23, causing the wound to worsen. The facility Administrator was notified of the IJ and SQC and was presented with an IJ Template on 12/1/23 at 2:55 PM. The facility provided an acceptable Removal Plan on 12/4/23, in which they alleged all corrective action to remove the IJ was completed on 12/4/23 and the IJ was removed on 12/5/23. The SA validated the Removal Plan on 12/5/23 and determined the IJ was removed on 12/5/23, prior to exit. Therefore, the scope and severity for 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation F600 was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's policy Freedom of Abuse, Neglect, and Exploitation Standard, revised 11/2019, revealed . The purpose of this written Freedom of Abuse, Neglect, and Exploitation Standard is to outline the preventive and action steps taken to reduce the potential for abuse, mistreatment and neglect of residents . Neglect means failure of the facility, its employees .to provide .services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Resident #53 During an observation and interview, on 11/28/23 at 10:30 AM, Resident #53 was sitting up in his wheelchair and he stated that he had a large wound on his bottom. He commented that he thought he would have additional wounds after this past weekend, because he had to lay in bed in his bowel movements and urine for long periods of time on the night shift. At 2:00 PM on 11/28/23, during the resident council meeting, the residents complained that it took a long period of time on the night shift for staff to answer call lights and change them. Resident #53 attended the resident council meeting and stated that he could validate those complaints because it happened to him all the time. He explained that the bandage to his wound would come off and the nurses did not redo the wound care or replace the bandage. During an interview with Licensed Practical Nurse (LPN) #1/Wound Care Nurse, on 11/28/23 at 3:15 PM, he explained that when a resident was admitted to the facility, the initial body assessment was completed by Registered Nurse (RN) #3 (RN)/Admission Nurse, and she staged, measured, and documented Pressure Ulcers (PUs). LPN #1 reported that he provided a resident list to the Wound Care Physician of residents that he needed to see. The Wound Care Physician assessed and measured PUs weekly on Mondays and LPN #1 added the physician's measurements to the Wound/Skin Log. He stated that he began documenting on the Wound/Skin logs when RN #4, who was the previous wound care nurse, left the faciity on [DATE]. LPN #1 explained that a Random Skin Sweep was a skin assessment that could be used at any time to document any newly identified skin issues. He further explained that a Weekly Skin Sweep had to be completed by an RN whenever a nurse documented on the Medication Administration Record (MAR) that the resident had a skin issue. LPN #1 confirmed that Resident #53 had only one (1) PU on his bottom that he had upon admission to the facility. He reported that the resident was currently seen by the Wound Care Physician. A record review of the Admission Record revealed the facility admitted Resident #53 on 08/29/23 with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, and Chronic Obstructive Pulmonary Disease. Record review of the facility's Brief Interview for Mental Status (BIMS) Evaluation, dated 12/2/23, revealed a score of 13, which indicated Resident #53 was cognitively intact. A record review of the Random Skin Sweep dated 08/29/23, which was the date of admission, revealed Resident #28 had a Pressure area to the Left buttock that measured 8 centimeters (cm) length, 5 cm width, and 4 cm depth and a Skin Tear to the Right lateral foot that measured 3 cm length, 6 cm width, and the depth was listed as UTD (Unable To Determine). Skin Impairment Findings revealed Skin injuries as listed above. Left buttock cleaned with NS (Normal Saline), calcium alginate rope, and bordered gauze applied. Right lateral foot cleaned with NS and bordered gauze applied. (Proper Name of Wound Care Physician) to F/U (Follow Up) with resident. The document was signed by RN #4, who was the previous Wound Care Nurse for the facility and was no longer employed by the facility. A record review of Braden Scale for Predicting Pressure Sore Risk, dated 08/29/23, revealed Resident #53 had a score of 13, which indicated he had a moderate risk of developing PUs. A review of the medical record revealed there was no other Random or Weekly Skin Sweeps documented. During an interview at 4:00 PM on 11/28/23, with the Director of Nursing (DON), she explained that PU wound documentation and skin assessments were to be completed weekly on the Wound/Skin Log by LPN #1. A record review of the facility's Wound/Skin Log, dated 9/04/23, revealed Resident #53 had a Stage IV PU to his Left Buttock that measured 7 cm X 2 cm X 10.75 cm. These measurements were documented six (6) days after Resident #53's admission to the facility and indicated the PU had increased in depth. The log also indicated the resident had a Stage IV PU to his Right Lateral Foot that measured 2 cm X 1.5 cm X and the D (cm) was UTD. This wound had been classified upon admission as a Skin Tear and this was the first documentation that the area was a Pressure type and Stage IV. The Wound/Skin Log documentation did not indicate who had completed the logs and did not include a description of the PU characteristics, the progress toward healing and identification of potential complications, if infections was present, the presence of pain, or a description of dressings and treatment. A record review of the facility's Wound/Skin Log, dated 9/11/23, revealed Resident #53 had a Stage IV PU to his left buttock that measured 6.2 cm x 1.6 cm x 10.6 cm and had a Type or Stage of PVD (Peripheral Vascular Disease) to his right foot that measured 1.7 cm x 1.5 cm x UTD. The documentation of PVD was inconsistent with the Wound/Skin Log dated 9/4/23, which indicated the wound to the right foot was a PU. A record review of the Order Recap Report, with Order Date: 08/29/2023 - 11/30/2023), revealed Resident #53 had a Physician's Order, dated 9/18/23, for Wound consult with skilled wound care surgical group . A record review of a Surgical Note, dated 09/18/23, revealed Resident #53 was seen by the Wound Care Physician 20 days after he was admitted to the facility. The Physician visited the resident because he was asked for his opinion on how to manage the wound located at the left buttock and sacrum. The Wound Location was listed as Left Buttock and Sacrum, and the Etiology was listed as Pressure injury/ulcer - Wound Stage: 4 - Pressure Injury. The note also revealed that the wound area measured 6.2 cm x 1.6 cm x 10.5 cm, which was deeper than the initial measurement upon admission. The wound required the Physician to perform a muscle tissue debridement, which was the removal of dead tissue from the wound. The wound description indicated that the wound had undermining (separation of the wound edges from the surrounding healthy tissue) of 13 cm, had no odor, and had a copious amount of serosanguineous (thin fluid with a light pink tinge) exudate. The tissue of the wound was 20% slough (nonviable skin tissue), 80% granulation (development of new skin tissue), and there was no necrotic or dead tissue present in the wound. This was the first wound assessment that included a complete wound description of the PU characteristics for Resident # 53 since the resident was admitted to the facility on [DATE]. The wound progress was listed as Undetermined: first visit. The wound to the Right Lateral Foot was listed as PVD. The Assessment and Plan revealed, The patient has a wound found on the left buttock and sacrum .there was a sign of tissue decline which will entail continuing supervision and will likely require future debridement .continue offloading .turn per facility protocol. A low air loss mattress is recommended . A record review of the Order Recap Report, with Order Date: 08/29/2023 - 11/30/2023), revealed Resident #53 had a Physician's Order, dated 8/29/23 and discontinued on 9/19/23, for Sacrum pressure injury - clean with NS, Pat dry, apply Calcium Alginate and cover with bordered gauze daily and prn (as needed) for soiled or dislodgement . During an observation and interview with Certified Nurse Aide (CNA) #14 and Resident #53 at 5:05 AM on 11/29/23, she explained that she was going to change Resident #53. Resident #53 commented that was the second time he had seen staff all night and he had not been changed since about 11 PM. The observation revealed that Resident #53's brief was saturated and there was no protective bandage noted covering the PU, nor was there a bandage in his brief indicating the bandage had become dislodged during the night. CNA #14 provided incontinence care and applied a clean brief, but the PU to the sacrum/buttocks did not have a bandage on it, which left the packed wound exposed. CNA #14 confirmed that the resident's brief had been saturated and there was no bandage on the PU wound. She stated she was unsure of the last time she had changed his brief or when the bandage had come off the resident. She said would notify the nurse that the resident did not have a bandage on his PU. CNA #14 explained that they did not document when residents are turned on the tasks, but Resident #53 was good about turning himself. She confirmed that Resident #53 was incontinent of bowel and bladder. During an interview with Registered Nurse (RN) #5, at 5:25 AM on 11/29/23, she explained the CNAs should round every two (2) hours to ensure residents were clean and dry, but she did not check behind them to confirm the rounds are completed. She confirmed CNA #14 had let her know that Resident #53's bandage was off his PU site, and she advised that she would replace the dressing after she completed her medication pass. During an interview with RN #3/Admission Nurse, at 8:25 AM on 11/29/23, she explained she was not a wound care nurse. She stated that she had been helping with the assessment of new wounds, admissions, and hospital returns or any other residents the wound care nurse needed help with. She confirmed that she only measured the wounds and she attempted to assess them, but she did not feel comfortable about staging PUs. She said that the Wound Care Physician assessed all wounds until they were healed, and that LPN #1 printed the physician's assessment and that would become part of the resident's medical record. She confirmed that she had never staged PUs and that when a resident was admitted to the facility with an existing PU, the facility used the hospital's discharge wound orders and staging documentation. During an interview with the Director of Nursing, on 11/29/23 at 3:00 PM, she explained she did not know who completed the Wound/Skin Logs before LPN #1 took over after RN #4 had left. She said that different nurses had helped and had completed the logs but there was no signature or identifying information to indicate who completed the measurements. She explained that as far as she knows, those logs were completed with the measurements from the Wound Care Physician's weekly assessments which are completed when he rounds. She confirmed the logs indicated PU measurements but did not include any other assessment information regarding the wounds. She said that she received a copy of the PU logs weekly, but she did not review the logs to determine if the PUs were healing or deteriorating, and she did not keep the logs on file. The DON stated that LPN #1 provided the Wound Care Physician with a list of residents that needed to be seen during his weekly visits, but she was unsure how or who determined which residents should be seen by the physician. During an interview with LPN #1, on 11/30/23 at 10:35 AM, he explained that if a resident was admitted to the facility with an existing PU and had wound treatment orders from the hospital, he would not always refer that resident to the Wound Care Physician. He reported the facility did not have a protocol on when a resident should be seen by the Wound Care Physician. He stated that if a wound was not responding to the treatment orders, he would notify the Wound Care Physician and schedule a consultation for the next Monday. LPN #1 stated that RN #3 documented measurements on the Wound/Skin Log for the residents that the Wound Care Physician did not see. He explained that when a new wound was identified, he got an RN to assess the area and he relied on the RN to complete the Random Skin Sweep documentation. He explained when Resident #53 was admitted to the facility, he was not referred to the Wound Care Physician immediately because the resident had treatment orders for wound care that came with him from the hospital. However, when he noticed that the wound was not responding to the treatment, he referred the resident to the Wound Care Physician. He confirmed Resident #53's wound was deep with tunneling and undermining present. He was not aware that the RNs had not documented anything on the Wound/Skin logs. During an interview with the Assistant Director of Nursing (ADON), at 11:10 AM on 11/30/23, she explained she was not involved in Resident #53's wound care and had never observed his PU. The facility had a Wound Care Physician that came every Monday, and the Nurse Practitioner was in the facility Monday through Friday. She explained that a PU assessment and documentation should include the PU stage, measurement, description of the appearance of the PU, drainage, odor, and healing or deterioration of the PU. All PU wounds and notifications must be documented, and if it was not documented, then it was not completed. The ADON said that she was unsure of the protocol regarding notifying or consulting with the Wound Care Physician when a resident acquired a new PU, but she knew he was provided with a list of residents that he needed to visit. She explained that the facility conducts a Stand Up meeting every morning during the week and discussed all concerns in the facility, including PU concerns. The ADON stated she was unaware that RN #3 was not comfortable in staging PUs, but there were other RNs in the facility that could assist, and RN #3 should have asked them for help. The ADON said that if a PU was not staged or assessed appropriately, the wounds may not be treated appropriately and may worsen. During an interview with the DON, at 12:00 PM on 11/30/23, she explained she expected the nurse to call the Physician or Wound Care Physician if a wound worsened in any way. She also expected all PU assessments and findings to be documented in the medical record, and that if there was no documentation, then it was not done and that she was aware that documentation was a problem. The DON explained that any changes in a resident or a resident's PU should be documented. She confirmed that the facility did not have a system in place to determine when a resident required a consultation with the Wound Care Physician. LPN #1 was responsible for communicating with the Wound Care Physician, who was available as needed. LPN #1 completed the wound/skin logs weekly, but the DON was unaware that PUs were not completely assessed if they are not being seen by the Wound Care Physician. She thought every resident with a wound was seen by the Wound Care Physician but was not aware of the system. She was not aware that RN #3 was not comfortable with staging wounds, because she has been completing admission wound assessments for a long time. The DON said she would have put someone else in the position that was more comfortable if she had known. She confirmed that RN #3 has just recently been filling in with wound assessments other an admission assessments since RN #4 had been employed at the facility. There were other RNs in the facility that could assess and measure if RN #3 had asked for help. The DON was not aware Resident #53 was not seen by the Wound Care Physician and that his wound had gotten deeper from the time he was admitted on [DATE] until he was seen by the Wound Care Physician on 9/18/23. She reported since there was no longer a RN in wound care, other RNs assisted in completing Wound/Skin logs as necessary. Resident #89 During a phone interview with the Complainant, on 11/28/23 at 12:20 PM, she explained she became involved when the resident was admitted to an acute care hospital from the facility with a diagnosis of Sepsis (serious condition in which the body responds improperly to infection) related to a PU to the sacrum. She explained the hospital physicians were concerned that the facility's staff were not turning and repositioning the resident as often as needed and not keeping him dry and clean. She reported the resident's brother and sister had voiced concerns to her and the physicians that staff were not turning Resident #89 frequently and the resident remained wet for long periods of time. The Complainant advised that Resident #89 required wound surgery during his hospital stay and he currently remained in the acute care hospital at the time of the interview. During a phone interview with the Resident Representative (RR), on 11/28/23 at 01:00 PM, , he explained Resident #89, who was his brother, had been in the facility for six (6) weeks and had gotten a bad wound that became septic and required surgery. He explained he stayed at the facility for long periods of time to be with brother and the staff did not turn or change him enough. The staff would not touch the resident for hours, and when they finally came to change him, Resident #89 would be soaked with urine. He said that his brother did not have any wounds when he was admitted to the facility and that he did not have a catheter. He explained the facility discussed inserting a catheter on the day the resident was so sick and was transported to the hospital. The RR felt like if the facility had kept his brother dry and had turned him often, he would not have gotten the PU. A record review of the Admission Record revealed the facility admitted Resident #89 on 09/28/23 with diagnoses that included Traumatic Subdural Hemorrhage with Loss of Consciousness of Unspecified Duration. A record review of the Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/5/23, revealed Resident #89 required a Staff Assessment for Mental Status and his cognition was severely impaired. A review of Section GG revealed that Resident #89 was dependent on staff for all functional abilities. A review of Section M revealed Resident #89 was at risk for developing pressure ulcers/injuries, but he did not have any unhealed pressure ulcers/injuries. A record review of the Braden Scale for Predicting Pressure Sore Risk, dated 9/28/23, revealed Resident #89 had a score of 12 which indicated he had a high risk of developing PUs. A record review of the Nursing Random Skin Sweep, dated 09/28/23, which was the date of admission to the facility for Resident #89, revealed he had skin tears to his left ear, left upper chest, and right upper chest. The document was signed by RN #4, the previous Wound Care Nurse. There was no documentation regarding any skin or PUs to the resident's sacrum or buttocks. A record review of the Order Recap Report with Order Date: 09/28/2023 -11/30/2023 revealed Resident #89 had a Physician's Order, dated 9/28/23 for Weekly skin assessments . Review of the report revealed there were no Physician Orders that addressed any skin issues or PU treatments to the sacrum upon Resident #89's admitted [DATE]. A record review of the Wound/Skin Log, dated 10/8/23 (Sunday), which was 10 days after the Resident #89 was admitted to the facility, revealed he had a PU to the sacrum that measured 6.5 cm x 4.0 cm x UTD. The onset date was recorded as 9/28/23 which was the date of admission and conflicted with the Nursing Random Skin Sweep that was completed on 9/28/23 and the Physician's Orders. This was the first documentation that referred to the PU. The Wound /Skin Log documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. There was no indication of who had completed the wound/skin log. A record review of the Order Recap Report with Order Date: 09/28/2023 -11/30/2023 revealed Resident #89 had a Physician's Order, dated 10/10/23 and ended on 11/8/23, for Sacrum Pressure Injury - Clean with NS, Pat dry apply Zinc Oxide and cover with bordered gauze daily and prn . This order was received two (2) days after the wound/skin log, dated 10/8/23, indicated Resident #89 had a PU that measured 6.5 cm x 4.0 cm x UTD. A record review of the Weekly Skin Sweep, dated 10/12/23, revealed Resident #89 had a PU to the sacrum that measured 2.0 cm length, 1.0 cm width, and UTD for the depth. The measurements conflicted with the measurements documented on the Wound/Skin Log that had been completed four (4) days prior. The documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. The document was signed by RN #3, the Admission Nurse. A record review of the Wound/Skin Log, dated 10/16/23, revealed Resident #89 had a PU to the sacrum that measured 6 cm x 4 cm x UTD, which indicated an increase in the size of the wound from the Weekly Skin Sweep completed on 10/12/23, which was four (4) days prior. The onset date was recorded as 9/28/23. The Wound /Skin Log documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. There was no indication of who had completed the wound/skin log. A record review of the Wound/Skin Log, dated 10/23/23, revealed Resident #89 had a PU to the sacrum that measured 6.25 cm x 4 cm x UTD. The onset date was recorded as 9/28/23. The measurements indicated the wound had increased in size since the log dated 10/16/23. The Wound /Skin Log documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. There was no indication of who had completed the wound/skin log. A record review of the Wound/Skin Log, dated 11/6/23, revealed Resident #89 had a PU to the sacrum that measured 6.5 cm x 4.2 cm x UTD. The measurements indicated the wound had increased in size from the documentation on the log dated 10/23/23. The onset date was recorded as 9/28. The Wound /Skin Log documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. There was no indication of who had completed the wound/skin log. There was an additional Wound/Skin Log', dated 11/6/23, which indicated Resident #89 had a PU to the sacrum that measured 6.5 cm x 4.5 cm x UTD and the onset date was 9/28/23. A record review of the Weekly Skin Sweep, dated 11/8/23, revealed Resident #89 had a PU to the sacrum that measured 3.0 cm length, 2.0 cm width, and UTD for the depth. These measurements were inconsistent with the measurements provided two (2) days prior on the wound/skin log dated 11/6/23. A record review of the Order Recap Report with Order Date: 09/28/2023 -11/30/2023 revealed Resident #89 had a Physician's Order, dated 11/8/23, for Sacrum Pressure Injury - clean with NS, pat dry apply Santyl/Calcium Alginate and cover with bordered gauze daily and prn ., and a Physician's Order, dated 11/9/23, for Low air loss mattress for sacral wound. There was a Physician Order, dated 11/13/23, to consult skilled wound care for evaluation of sacrum wound . A record review of a Surgical Note, dated 11/13/23, revealed Resident #89 was seen by the Wound Care Physician. The Physician visited the resident for management of wounds located on the sacrum. The Wound Location was listed as Sacrum, and the Etiology was listed as Pressure injury/ulcer - Wound Stage: 4 - Pressure Injury. The note also revealed that the wound measured 6.0 cm x 4.0 cm x UTD prior to his debridement, and 6.0 cm x 4.0 cm x 0.5 cm after the debridement procedure. The wound required the Physician to perform a muscle tissue debridement with the Preoperative Indications listed as Biofilm, Devitalized tissue, and Slough. There were no signs of infection. The wound description indicated that the wound had no odor and had a moderate amount of serosanguineous exudate. The Peri wound area was unhealthy and unstable. The tissue of the wound was 80% slough and 20% granulation. This was the first wound assessment that included a complete wound description of the PU characteristics, for Resident # 89, which was 36 days after the PU was first documented on the Wound/Skin Log dated 10/8/23. During an interview with RN #3/Admission Nurse, at 8:25 AM on 11/29/23, she confirmed that she had completed the Weekly Skin Sweep for Resident #89 on 10/12/23 and that she did not stage the PU or provide descriptive characteristics of the PU. She explained that she had assumed the wound care team would follow Resident #89, but she did not follow up to ensure he was seen by the team. She explained that the wound care team at that time consisted of LPN #1 and the Wound Care Physician. She was unable to recall what the PU looked like when she had measured it. She confirmed that she only measured the PU and did not complete or document a full assessment of the wound. She said she was unaware that the Wound Care Physician was not seeing the resident when she completed the documentation on 10/12/23. During an interview with the DON, on 11/29/23 at 3:00 PM, she explained she was not aware that RN #3 had not assessed or staged the PU to the sacrum for Resident #89 and that the Wound Care Physician had not assessed or staged the PU for more than four (4) weeks after the PU was first identified by facility staff on 10/8/23. During an interview with the Administrator and the DON, at 3:10 PM on 11/29/23, the Administrator explained that he could not determine who had completed the Wound/Skin logs that were provided. He explained that RN #4 was the previous wound care nurse and her last day at the facility was 10/04/23. The DON and the Administrator were unable to explain the PU measurement inconsistencies of the Wound/Skin logs and the Weekly Skin Sweeps for Resident #89. During an interview with LPN #1, on 11/30/23 at 10:35 AM, he explained when Resident #89 was admitted to the facility, he did not have any PUs. He was unable to recall how he found out that Resident #89 had a PU, but he did recall asking RN #3 to measure the wound. LPN #1 described the PU when he first saw it as measuring approximately 2 cm x 3 cm, the area was discolored, but the skin was intact. He thought the wound was classified as Moisture Associated Skin Damage (MASD), because whenever he provided the treatments to the sacrum, Resident #89 was soiled with urine. He stated that he had instructed CNAs that the resident needed to be kept dry, changed in a timely manner, and turned more frequently, however he did not conduct and document a formal in-service. LPN #1 said that Resident #89's family would be with the resident daily and he would talk to them regarding resident's PU, but he never completed any documentation regarding the PU. LPN #1 said that when the wound was first found, the physician was notified, and new orders were received for zinc oxide, because the skin was intact. He stated that he continued to treat the PU with zinc oxide and did not notify the Wound Care Physician that the wound size was increasing. He confirmed he had no documentation of the wounds, including the progression or deterioration of the wound. When he noticed the PU to the sacrum had slough, he notified the Wound Care Physician and received orders to discontinue the zinc oxide and start a new treatment. He said that he felt like the PU measurements obtained on the Random and Weekly Skin Sweeps were accurate because he assisted RN #3/Admissions Nurse when she measured the wounds. He confirmed Resident #89's wound had deteriorated and increased in size from the time it was first identified on 9/28/23 until the time he was seen by the Wound Care Physician on 11/13/23. He confirmed that on 11/13/23, the PU to the sacrum was classified as a Stage IV. LPN #1 stated that he would not have done anything differently with the resident's wound. He confirmed that Resident #89 did not have a low air loss mattress to help with pressure reduction until 11/9/23. During an interview with the Assistant Director of Nursing (ADON), at 11:10 AM on 11/30/23, she explained she was unaware that Resident #89 had a PU because she was not involved in his care. She stated that it appeared someone dropped the ball, but she didn't know who. She explained that for a resident to develop a Stage 4 PU in less than two (2) months of admission, the resident did not receive adequate care and should have been referred to the Wound Care Physician before a month had passed, especially since the resident had comorbidities, restricted mobility, and was at a high risk for skin breakdown. During an interview with the DON, at 12:00 PM on 11/30/23, she stated she was not aware that Resident #89's PU had increased in size before the Wound Care Physician had gotten involved with his care. During a phone interview with the Nurse Practitioner (NP), at 12:45 PM on 11/30/23, she explained that she had not observed Resident #89's PU, but she would have if she were asked to do so.The NP stated that she reviewed the Wound/Skin Logs, but not in detail. During a phone interview with the Wound Care Physician, at 1:25 PM on 11/30/23, he confirmed that he saw Resident #89 on 11/13/23 for the first time. He stated the resident was not very alert or responsive and had comorbidities, restricted mobility, a tracheostomy, and had thinning skin. He said that when he observed the PU on 11/13/23, the sacrum was noted with devitalized tissue, consisting of slough and granulation, and was unstageable due to the slough. The wound was debrided and then staged as a Stage IV PU. He understood from the wound care nurse that the PU started out as MASD, but he felt the etiology of the wound was pressure due to his restricted mobility and the resident was completely depend [TRUNCATED]

Based on interviews, record review, and facility policy review, the facility failed to ensure the clinical staff were educated and trained on staging Pressure Ulcers (PUs), providing complete and accurate wound assessments, and implementing appropriate treatments for identified wounds for two (2) of four (4) residents reviewed for PU care. Resident # 53 and Resident #89. The facility's failure to ensure staff were competent with PU assessments, documentation, and treatments resulted in harm to Resident #53 and Resident #89 and put all other residents at risk for skin breakdown in a situation that was likely to result in serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 8/29/23 when Resident #53, who had existing PUs, was admitted to the facility, and was not assessed by a qualified nurse or practitioner until 9/18/23, causing the wound to worsen. The facility Administrator was notified of the IJ and was presented with an IJ Template on 12/1/23 at 2:55 PM. The facility provided an acceptable Removal Plan on 12/4/23, in which they alleged all corrective action to remove the IJ was completed on 12/4/23 and the IJ was removed on 12/5/23. The SA validated the Removal Plan on 12/5/23 and determined the IJ was removed on 12/5/23, prior to exit. Therefore, the scope and severity for 42 CFR 483.35 (a) (3) Nursing Services was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: A record review of the facility's policy, Employee Competency Standard, revised 1/2020, revealed . In-service training classes are conducted to provide associates with ongoing knowledge concerning their job responsibilities, methods, and procedures to follow when implementing assigned duties . current information regarding the provision of quality of care . Orientation includes topics and information which contribute to positive resident care . Resident #53 During an interview on 11/28/23 at 3:15 PM, with Licensed Practical Nurse (LPN) #1/Wound Care Nurse, he explained that when a resident was admitted to the facility, the initial body assessment was completed by Registered Nurse (RN) #3 (RN)/Admission Nurse, and she staged, measured, and documented Pressure Ulcers (PUs). LPN #1 reported that the Wound Care Physician assessed and measured PUs weekly on Mondays and LPN #1 added the physician's measurements to the Wound/Skin Log. He stated that he began documenting on the Wound/Skin logs when RN #4, who was the previous wound care nurse, left the faciity on [DATE]. LPN #1 confirmed that Resident #53 had only one (1) PU on his bottom that he had upon admission to the facility. LPN #1 explained that a Random Skin Sweep was a skin assessment that could be used at any time to document any newly identified skin issues. He further explained that a Weekly Skin Sweep had to be completed by an RN whenever a nurse documented on the Medication Administration Record (MAR) that the resident had a skin issue. A record review of the Admission Record revealed the facility admitted Resident #53 on 08/29/23 with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, and Chronic Obstructive Pulmonary Disease. A record review of the Random Skin Sweep dated 08/29/23, which was the date of admission, revealed Resident #28 had a Pressure area to the Left buttock that measured 8 centimeters (cm) length, 5 cm width, and 4 cm depth and a Skin Tear to the Right lateral foot that measured 3 cm length, 6 cm width, and the depth was listed as UTD (Unable To Determine). Skin Impairment Findings revealed Skin injuries as listed above. (Proper Name of Wound Care Physician) to F/U (Follow Up) with resident. The document was signed by RN #4, who was the previous Wound Care Nurse for the facility and was no longer employed by the facility. On 11/28/23 at 4:00 PM, during an interview with the Director of Nursing (DON), she explained that PU wound documentation and skin assessments were to be completed weekly on the Wound/Skin Log by LPN #1. A record review of the facility's Wound/Skin Log, dated 09/04/23, revealed Resident #53 had a Stage IV PU to his Left Buttock that measured 7 cm X 2 cm X 10.75 cm. These measurements were documented six (6) days after Resident #53's admission to the facility and indicated the PU had increased in depth. The log also indicated the resident had a Stage IV PU to his Right Lateral Foot that measured 2 cm X 1.5 cm X and the D (cm) was UTD. This wound had been classified upon admission as a Skin Tear and this was the first documentation that the area was a Pressure type and Stage IV. The Wound/Skin Log documentation did not indicate who had completed the logs and did not include a description of the PU characteristics, the progress toward healing and identification of potential complications, if infections were present, the presence of pain, or a description of dressings and treatment. A record review of the facility's Wound/Skin Log, dated 9/11/23, revealed Resident #53 had a Stage IV PU to his left buttock that measured 6.2 cm x 1.6 cm x 10.6 cm and had a Type or Stage of PVD (Peripheral Vascular Disease) to his right foot that measured 1.7 cm x 1.5 cm x UTD. The documentation of PVD was inconsistent with the Wound/Skin Log dated 9/4/23, which indicated the wound to the right foot was a PU. A record review of the Order Recap Report, with Order Date: 08/29/2023 - 11/30/2023), revealed Resident #53 had a Physician's Order, dated 9/18/23, for .Wound consult with skilled wound care surgical group . A record review of a Surgical Note, dated 09/18/23, revealed Resident #53 was seen by the Wound Care Physician 20 days after he was admitted to the facility. The Physician visited the resident because he was asked for his opinion on how to manage the wound located at the left buttock and sacrum. The Wound Location was listed as Left Buttock and Sacrum, and the Etiology was listed as Pressure injury/ulcer - Wound Stage: 4 - Pressure Injury. The note also revealed that the wound area measured 6.2 cm x 1.6 cm x 10.5 cm, which was deeper than the initial measurement upon admission. The wound required the Physician to perform a muscle tissue debridement, which was the removal of dead tissue from the wound. The wound description indicated that the wound had undermining (separation of the wound edges from the surrounding healthy tissue) of 13 cm, had no odor, and had a copious amount of serosanguineous (thin fluid with a light pink tinge) exudate. The tissue of the wound was 20% slough (nonviable skin tissue), 80% granulation (development of new skin tissue), and there was no necrotic or dead tissue present in the wound. This was the first wound assessment that included a complete wound description of the PU characteristics for Resident # 53 since the resident was admitted to the facility on [DATE]. On 11/29/23 at 5:05 AM, during an observation and interview with Certified Nurse Assistant (CNA) #14 and Resident #53, the CNA explained that she was going to change him. Resident #53 commented that was the second time he had seen staff all night and he had not been changed since about 11 PM. The observation revealed that Resident #53's brief was saturated and there was no protective bandage noted covering the PU, nor was there a bandage in his brief indicating the bandage had become dislodged during the night. CNA #14 provided incontinence care and applied a clean brief, but the PU to the sacrum/buttocks did not have a bandage on it, which left the packed wound exposed. CNA #14 confirmed that the resident's brief had been saturated and there was no bandage on the PU wound. She stated she was unsure of the last time she had changed his brief or when the bandage had come off the resident. She said would notify the nurse that the resident did not have a bandage on his PU. On 11/29/23 at 5:25 AM, during an interview with RN #5, she explained the CNAs should round every two (2) hours to ensure residents were clean and dry, but she did not check behind them to confirm the rounds are completed. She confirmed CNA #14 had let her know that Resident #53's bandage was off his PU site, and she advised that she would replace the dressing after she completed her medication pass. On 11/29/23 at 8:25 AM, during an interview with RN #3/Admission Nurse, she explained she was not a wound care nurse. She stated that she had been helping with the assessment of new wounds, admissions, and hospital returns or any other residents the wound care nurse needed help with. She confirmed that she only measured the wounds and she attempted to assess them, but she did not feel comfortable about staging PUs. She confirmed that she had never staged PUs and that when a resident was admitted to the facility with an existing PU, the facility used the hospital's discharge wound orders and staging documentation. At 3:00 PM on 11/29/23, during an interview with the DON, she explained she did not know who completed the Wound/Skin Logs before LPN #1 took over after RN #4 had left. She said that different nurses had helped and had completed the logs but there was no signature or identifying information to indicate who completed the measurements. She explained that as far as she knows, those logs were completed with the measurements from the Wound Care Physician's weekly assessments which are completed when he rounds. She confirmed the logs indicated PU measurements but did not include any other assessment information regarding the wounds. She said that she received a copy of the PU logs weekly, but she did not review the logs to determine if the PUs were healing or deteriorating, and she did not keep the logs on file. The DON stated that LPN #1 provided the Wound Care Physician with a list of residents that needed to be seen during his weekly visits, but she was unsure how or who determined which residents should be seen by the physician. At 10:35 AM on 11/30/23, during an interview with LPN #1, he explained that if a resident was admitted to the facility with an existing PU and had wound treatment orders from the hospital, he would not always refer that resident to the Wound Care Physician. He reported the facility did not have a protocol on when a resident should be seen by the Wound Care Physician. LPN #1 stated that RN #3 documented measurements on the Wound/Skin Log for the residents that the Wound Care Physician did not see. He explained when Resident #53 was admitted to the facility, he was not referred to the Wound Care Physician immediately because the resident had treatment orders for wound care that came with him from the hospital. However, when he noticed that the wound was not responding to the treatment, he referred the resident to the Wound Care Physician. He confirmed Resident #53's wound was deep with tunneling and undermining present. He was not aware that the RNs had not documented anything on the Wound/Skin logs. On 11/30/23 at 11:10 AM, during an interview with the Assistant Director of Nursing (ADON), she explained she was not involved in Resident #53's wound care and had never observed his PU. She explained that a PU assessment and documentation should include the PU stage, measurement, description of the appearance of the PU, drainage, odor, and healing or deterioration of the PU. All PU wounds and notifications must be documented, and if it was not documented, then it was not completed. The ADON said that she was unsure of the protocol regarding notifying or consulting with the Wound Care Physician when a resident acquired a new PU, but she knew he was provided with a list of residents that he needed to visit. The ADON stated she was unaware that RN #3 was not comfortable in staging PUs, but there were other RNs in the facility that could assist, and RN #3 should have asked them for help. The ADON said that if a PU was not staged or assessed appropriately, the wounds may not be treated appropriately and may worsen. On 11/30/23 at 12:00 PM, during an interview with the DON, she explained she expected the nurse to call the Physician or Wound Care Physician if a wound worsened in any way. She also expected all PU assessments and findings to be documented in the medical record, and that if there was no documentation, then it was not done and that she was aware that documentation was a problem. The DON explained that any changes in a resident or a resident's PU should be documented. She confirmed that the facility did not have a system in place to determine when a resident required a consultation with the Wound Care Physician. LPN #1 was responsible for communicating with the Wound Care Physician, who was available as needed. LPN #1 completed the wound/skin logs weekly, but the DON was unaware that PUs were not completely assessed if they are not being seen by the Wound Care Physician. She thought every resident with a wound was seen by the Wound Care Physician but was not aware of the system. She was not aware that RN #3 was not comfortable with staging wounds, because she has been completing admission wound assessments for a long time. The DON said she would have put someone else in the position that was more comfortable if she had known. She confirmed that RN #3 has just recently been filling in with wound assessments other than admission assessments since RN #4 had left employment at the facility. There were other RNs in the facility that could assess and measure if RN #3 had asked for help. The DON was not aware Resident #53 was not seen by the Wound Care Physician and that his wound had gotten deeper from the time he was admitted on [DATE] until he was seen by the Wound Care Physician on 9/18/23. She reported since there was no longer a RN in wound care, other RNs assisted in completing Wound/Skin logs as necessary. On 11/30/23 at 1:10 PM, during an interview with RN #3/Admission Nurse, she reported she did not tell the DON that she was not comfortable staging wounds. She confirmed she did not know the protocol or system for a resident being admitted with an existing PU or for a resident who acquired a PU while in the facility to be referred to the Wound Care Physician. She stated she was only filling in since there was no RN currently in the wound care role. She stated that she had not been asked to assess any wounds, but only to measure wounds. She confirmed that the facility had daily stand-up meetings, but wounds were not discussed in detail. Resident #89 At 1:00 PM, on 11/28/23 during a phone interview with the Resident Representative (RR), he explained Resident #89, who was his brother, had been in the facility for six (6) weeks and had gotten a bad wound that became septic and required surgery. He explained he stayed at the facility for long periods of time to be with his brother and the staff did not turn or change him enough. The staff would not touch the resident for hours, and when they finally came to change him, Resident #89 would be soaked with urine. He said that his brother did not have any wounds when he was admitted to the facility. The RR felt like if the facility had kept his brother dry and had turned him often, he would not have gotten the PU. A record review of the Admission Record revealed the facility admitted Resident #89 on 09/28/23 with diagnoses that included Traumatic Subdural Hemorrhage with Loss of Consciousness of Unspecified Duration. A record review of the Admission MDS, with an ARD of 10/5/23, revealed Resident #89 required a Staff Assessment for Mental Status and his cognition was severely impaired. A review of Section GG revealed that Resident #89 was dependent on staff for all functional abilities. A review of Section M revealed Resident #89 was at risk for developing pressure ulcers/injuries, but he did not have any unhealed pressure ulcers/injuries. A record review of the Nursing Random Skin Sweep, dated 09/28/23, which was the date of admission to the facility for Resident #89, revealed he had skin tears to his left ear, left upper chest, and right upper chest. The document was signed by RN #4, the previous Wound Care Nurse. There was no documentation regarding any skin or PUs to the resident's sacrum or buttocks. A record review of the Order Recap Report with Order Date: 09/28/2023 -11/30/2023 revealed Resident #89 had a Physician's Order, dated 9/28/23 for Weekly skin assessments . Review of the report revealed there were no Physician Orders that addressed any skin issues or PU treatments to the sacrum upon Resident #89's admitted [DATE]. A record review of the Wound/Skin Log, dated 10/8/23 (Sunday), which was 10 days after the Resident #89 was admitted to the facility, revealed he had a PU to the sacrum that measured 6.5 cm x 4.0 cm x UTD. The onset date was recorded as 9/28/23 which was the date of admission and conflicted with the Nursing Random Skin Sweep that was completed on 9/28/23 and the Physician's Orders. This was the first documentation that referred to the PU. The Wound /Skin Log documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. There was no indication of who had completed the wound/skin log. A record review of the Order Recap Report with Order Date: 09/28/2023 -11/30/2023 revealed Resident #89 had a Physician's Order, dated 10/10/23 and ended on 11/8/23, for Sacrum Pressure Injury - Clean with NS, Pat dry apply Zinc Oxide and cover with bordered gauze daily and prn . This order was received two (2) days after the wound/skin log, dated 10/8/23, indicated Resident #89 had a PU that measured 6.5 cm x 4.0 cm x UTD. A record review of the Weekly Skin Sweep, dated 10/12/23, revealed Resident #89 had a PU to the sacrum that measured 2.0 cm length, 1.0 cm width, and UTD for the depth. The measurements conflicted with the measurements documented on the Wound/Skin Log that had been completed four (4) days prior. The documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. The document was signed by RN #3, the Admission Nurse. A record review of the Wound/Skin Log, dated 10/16/23, revealed Resident #89 had a PU to the sacrum that measured 6 cm x 4 cm x UTD, which indicated an increase in the size of the wound from the Weekly Skin Sweep completed on 10/12/23, which was four (4) days prior. The onset date was recorded as 9/28/23. The Wound /Skin Log documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. There was no indication of who had completed the wound/skin log. A record review of the Wound/Skin Log, dated 10/23/23, revealed Resident #89 had a PU to the sacrum that measured 6.25 cm x 4 cm x UTD. The onset date was recorded as 9/28/23. The measurements indicated the wound had increased in size since the log dated 10/16/23. The Wound /Skin Log documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. There was no indication of who had completed the wound/skin log. A record review of the Wound/Skin Log, dated 11/6/23, revealed Resident #89 had a PU to the sacrum that measured 6.5 cm x 4.2 cm x UTD. The measurements indicated the wound had increased in size from the documentation on the log dated 10/23/23. The onset date was recorded as 9/28. The Wound /Skin Log documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. There was no indication of who had completed the wound/skin log. There was an additional Wound/Skin Log', dated 11/6/23, which indicated Resident #89 had a PU to the sacrum that measured 6.5 cm x 4.5 cm x UTD and the onset date was 9/28/23. A record review of the Weekly Skin Sweep, dated 11/8/23, revealed Resident #89 had a PU to the sacrum that measured 3.0 length, 2.0 width, and UTD for the depth. These measurements were inconsistent with the measurements provided two (2) days prior on the wound/skin log dated 11/6/23. A record review of the Order Recap Report with Order Date: 09/28/2023 -11/30/2023 revealed Resident #89 had a Physician's Order, dated 11/8/23, for Sacrum Pressure Injury - clean with NS, pat dry apply Santyl/Calcium Alginate and cover with bordered gauze daily and prn ., and a Physician's Order, dated 11/9/23, for Low air loss mattress for sacral wound. There was a Physician Order, dated 11/13/23, to consult skilled wound care for evaluation of sacrum wound . A record review of a Surgical Note, dated 11/13/23, revealed Resident #89 was seen by the Wound Care Physician. The Physician visited the resident for management of wounds located on the sacrum and right elbow. The Wound Location was listed as Sacrum, and the Etiology was listed as Pressure injury/ulcer - Wound Stage: 4 - Pressure Injury. The note also revealed that the wound measured 6.0 cm x 4.0 cm x UTD prior to his debridement, and 6.0 cm x 4.0 cm x 0.5 cm after the debridement procedure. The wound required the Physician to perform a muscle tissue debridement with the Preoperative Indications listed as Biofilm, Devitalized tissue, and Slough. There were no signs of infection. The wound description indicated that the wound had no odor and had a moderate amount of serosanguineous exudate. The Peri wound area was unhealthy and unstable. The tissue of the wound was 80% slough and 20% granulation. This was the first wound assessment that included a complete wound description of the PU characteristics, for Resident # 89, which was 36 days after the PU was first documented on the Wound/Skin Log dated 10/8/23. At 8:25 AM on 11/29/23, during an interview with RN #3/Admission Nurse, she confirmed that she had completed the Weekly Skin Sweep for Resident #89 on 10/12/23 and that she did not stage the PU or provide descriptive characteristics of the PU. She explained that she had assumed the wound care team would follow Resident #89, but she did not follow up to ensure he was seen by the team. She explained that the wound care team at that time consisted of LPN #1 and the Wound Care Physician. She was unable to recall what the PU looked like when she had measured it. She confirmed that she only measured the PU and did not complete or document a full assessment of the wound. She said she was unaware that the Wound Care Physician was not seeing the resident when she completed the documentation on 10/12/23. At 3:00 PM on 11/29/23, during an interview with the DON, she explained she was not aware that RN #3 had not assessed or staged the PU to the sacrum for Resident #89 and that the Wound Care Physician had not assessed or staged the PU for more than four (4) weeks after the PU was first identified by facility staff on 10/8/23. On 11/29/23 at 3:10 PM, during an interview with the Administrator and the DON, the Administrator explained that he could not determine who had completed the Wound/Skin logs that were provided. The DON and the Administrator were unable to explain the PU measurement inconsistencies of the Wound/Skin logs and the Weekly Skin Sweeps for Resident #89. At 10:35 AM on 11/30/23, during an interview with LPN #1, he explained when Resident #89 was admitted to the facility, he did not have any PUs. He was unable to recall how he found out that Resident #89 had a PU. LPN #1 described the PU when he first saw it as measuring approximately 2 cm x 3 cm, the area was discolored, but the skin was intact. He thought the wound was classified as Moisture Associated Skin Damage (MASD), because whenever he provided the treatments to the sacrum, Resident #89 was soiled with urine. He stated that he had instructed CNAs that the resident needed to be kept dry, changed in a timely manner, and turned more frequently, however he did not conduct and document a formal in-service. LPN #1 said that Resident #89's family would be with the resident daily and he would talk to them regarding resident's PU, but he never completed any documentation regarding the PU. LPN #1 said that when the wound was first found, the physician was notified, and new orders were received for zinc oxide, because the skin was intact. He stated that he continued to treat the PU with zinc oxide and did not notify the Wound Care Physician that the wound size was increasing. He confirmed he had no documentation of the wounds, including the progression or deterioration of the wound. When he noticed the PU to the sacrum had slough, he notified the Wound Care Physician and received orders to discontinue the zinc oxide and start a new treatment. He said that he felt like the PU measurements obtained on the Random and Weekly Skin Sweeps were accurate because he assisted RN #3/Admissions Nurse when she measured the wounds. He confirmed Resident #89's wound had deteriorated and increased in size from the time it was first identified on 9/28/23 until the time he was seen by the Wound Care Physician on 11/13/23. He confirmed that on 11/13/23, the PU to the sacrum was classified as a Stage IV. LPN #1 stated that he would not have done anything differently with the resident's wound. He confirmed that Resident #89 did not have a low air loss mattress to help with pressure reduction until 11/9/23. On 11/30/23 at 11:10 AM, during an interview with the Assistant Director of Nursing (ADON), she explained she was unaware that Resident #89 had a PU because she was not involved in his care. She stated that it appeared someone dropped the ball, but she didn't know who. She explained that for a resident to develop a Stage 4 PU in less than two (2) months of admission, the resident did not receive adequate care and should have been referred to the Wound Care Physician before a month had passed, especially since the resident had comorbidities, restricted mobility, and was at a high risk for skin breakdown. On 11/30/23 at 1:10 PM, during an interview with RN #3/Admission Nurse, she reported she did not tell the DON that she was not comfortable staging wounds. She confirmed she did not know the protocol or system for a resident being admitted with an existing PU or for a resident who acquired a PU while in the facility to be referred to the Wound Care Physician. She stated she was only filling in since there was no RN currently in the wound care role. She stated that she had not been asked to assess any wounds, but only to measure wounds. She confirmed that the facility had daily stand-up meetings, but wounds were not discussed in detail. On 11/30/23, at 12:00 PM during an interview with DON, she stated she was not aware that Resident #89's PU had increased in size before the Wound Care Physician had gotten involved with his care. On 11/30/23 at 01:25 PM, during a phone interview with the Wound Care Physician, he confirmed that he saw Resident #89 on 11/13/23 for the first time. The Wound Care Physician stated that he felt the etiology of the wound was pressure due to his restricted mobility and the resident was completely dependent upon staff for offloading. He stated that all wounds should be assessed by the facility's protocol. At 1:50 PM on 11/30/23, during a phone interview with the Medical Director, he explained that he never observed Resident #89's PU. He stated that wounds should be assessed daily and if there were any changes, the facility should notify the physician and document accordingly. At 10:05 AM on 12/02/23, during an interview with LPN #6 /Weekend Wound Care Nurse, she stated that Resident #89's PU started out with redness and then had slough in the wound. She confirmed that she did not notify the Wound Care Physician or the Attending Physician regarding the change in the wound. She stated that Resident #89 was dependent upon staff for turning and repositioning. The facility provided an acceptable Removal Plan on 12/4/23, in which they alleged all corrective action to remove the IJ was completed on 12/4/23 and the IJ was removed on 12/5/23. Removal Plan On December 1st, 2023, at approximately 3:30pm Pine Forest Health and Rehabilitation received 5 Immediate Jeopardies during an Annual and Complaint Survey from the Mississippi Department of Health Licensure and Certification and provided the facility with the Immediate Jeopardy Templates. Brief Summary of Events: Pine Forest Health and Rehabilitation failed to put into place appropriate interventions to ensure proper assessment, staging, treatment and clinical care plans to treat and prevent the development and worsening of new and existing pressure ulcers. Corrective Actions: 1. An Emergency QAPI Meeting was held at approximately 12/1/2023 at 5 PM to review the cited deficient practices and to determine a root cause analysis for the lack of appropriate interventions. This meeting included the Administrator, Director of Nursing/lnfection Preventionist, Medical Director, Respiratory Director, & Business Office Manager. The following items were reviewed, coordinated, and corrected to allege compliance and remove the Immediate Jeopardy. The root cause analysis determined the cause of these occurrences was the facility's failure to be properly train staff on the policies for assessing, staging, preventing, and communicating wound and skin care issues for residents who could be at risk for skin breakdown or are already noted with skin/wound breakdown. 2. The facility did a complete policy review on Care Planning Standard, Skin Management. Standard, and Employee Competency Standard. The facility conducted 100% in-services and education using outsourced, Qualified Trainers and Online Software as it pertains to each department and the correlated policies pertaining to the immediate jeopardies. The facility also did a 100% inservice on all staff on the Identification and Reporting of Resident Abuse and Neglect. No individual was allowed to work beginning at approximately 7PM on 12/1/2023 until they were able to successfully complete all prescribed In-services. 3. The facility outsourced a Qualified RN Trainer to properly train with return demonstration all individuals who are responsible for the assessment, staging, and provision of wound care for the Facility. Upon completion and approximately 7:30PM on 12/1/2023, the Facility began to conduct body audits on 100% of in-house residents to determine proper assessment, staging, and treatment of wounds and finished on 12/4/2023. All noted pressure areas were assessed, staged, and determined to have a proper assessment. The wound care physician was notified of all findings and coordinated a Telehealth Visit on all residents with pre-existing wounds to confirm appropriate assessment, staging, and treatment of all existing pressure ulcers. There were no changes noted after having concluded all consult Telehealth visits. The attending physician and facility Medical Director was then notified of all Wound Care Physician's Assessments and concurred with prescribed consultation on all noted patients. Resident #53 was determined to have a pressure ulcer in an optimal condition of healing. Resident #89 remains in the hospital. 4. Both MDS Nurses were immediately trained following the QAPI Meeting regarding the ability to properly develop and/or revise resident care plans interventions for residents with pressure ulcers, ensuring those who were admitted to the facility without pressure ulcers did not acquire pressure ulcers and that existing pressure ulcers did not get worse, or residents did not develop complications from

Based on interviews, record review, and facility policy review, the facility failed to revise resident-centered comprehensive care plan interventions for residents with Pressure Ulcers (PUs) to prevent worsening or complications from PUs for two (2) of 22 care plans reviewed. (Resident #53 and Resident #89). The facility's failure to revise comprehensive care plan interventions related to PU care put Resident #53, Resident #89, and all other residents with skin breakdown in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 8/29/23 when Resident #53, who had existing PUs, was admitted to the facility, and was not assessed by a qualified nurse or practitioner until 9/18/23, causing a PU to worsen. The facility Administrator was notified of the IJ and was presented with an IJ Template on 12/1/23 at 2:55 PM. The facility provided an acceptable Removal Plan on 12/4/23, in which they alleged all corrective action to remove the IJ was completed on 12/4/23 and the IJ was removed on 12/5/23. The State Agency (SA) validated the Removal Plan on 12/5/23 and determined that the IJ was removed on 12/5/23, prior to exit. Therefore, the scope and severity for 42 CFR 483.21(b) Comprehensive Care Plans F657 was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A record review of the facility's policy Comprehensive Care Plan revised 03/2019, revealed, . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .Policy Explanation and Compliance Guidelines .8. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set) assessment . A record review of the facility's policy Skin Management Standards, revised 04/2021, . Wound Documentation and Tracking .Procedure .4. Care plans are reviewed and revised as needed consistent with overall plan of care. Aggressive wound management with plan of healing . Resident #53 A record review of Resident #53's Comprehensive Care Plan undated revealed a Focus of The resident has Stage 4 pressure ulcer to Left Buttocks ., with Interventions/Tasks that included, Sacrum and Left Buttock Pressure Injury Stage 4-Clean with NS (Normal Saline), Pat Dry, Pack with Dakin's Solutions 1/4 strength soaked kerlix and cover with bordered gauze daily and prn (as needed) for soiled or dislodgement. The care plan did not reflect the current physician's order dated 11/1/23. A record review of the Order Recap Report, with Order Date: 08/29/2023 - 11/30/2023, revealed Resident #53 had a discontinued Physician's Order, with an order date of 10/16/23 and an end date of 11/1/23, for Sacrum and Left Buttock pressure injury Stage 4 - clean with NS, Pat dry, pack with Dakins solution 1/4 strength soaked kerlix and cover with bordered gauze daily and prn for soiled or dislodgement . The current care plan did not reflect that the order for Dakins was discontinued on 11/1/23. A record review of the Order Recap Report, with an Order Date: 08/29/2023 - 11/30/2023, revealed Resident #53 had a current Physician's Order, dated 11/1/23 for Sacrum and Left Buttock pressure injury Stage 4 - clean with NS, Pat dry, apply Calcium Alginate and cover with bordered gauze daily and prn (as needed) for soiled or dislodgement . The current care plan was not revised to include the current order dated 11/1/23 for Calcium Alginate. At 9:00 AM on 11/29/23, during an interview with Licensed Practical Nurse (LPN) #1/Wound Care Nurse, confirmed Resident #53 had a Pressure Ulcer to his sacrum that he had when he was admitted to the facility. A record review of the Admission Record revealed the facility admitted Resident #53 on 08/29/23 with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, and Chronic Obstructive Pulmonary Disease. In an interview on 11/30/23 at 10:35 AM, with LPN #1, he explained that he reviewed Physician's Orders to complete treatments for the residents and he did not use or review the resident's care plans. He stated that care plan interventions are completed by the Registered Nurses (RNs) and the purpose of the interventions was to instruct the staff on how to provide care to the resident. He reviewed Resident #53's wound care plan and confirmed the wound care plan had not been revised to include the most recent wound care orders. Resident #89 A record review of the Comprehensive Care Plan for Resident #89 revealed a Focus of Resident is at risk for impairment to skin due to Immobility, Incontinence, with Interventions/Tasks that included, 10/11/23 treatment to sacrum wound (clean with ns, pat dry, apply zinc oxide and cover with bordered gauze daily. The care plan focus intervention was not revised to reflect the current Physician's Order for wound care dated 11/8/23. The Comprehensive Care Plan also included a Focus of The resident has potential/actual impairment to skin integrity r/t (related to) Stage 4 to sacrum, which included Interventions/Tasks of Wound care as ordered by MD (Medical Doctor) (santyl, Calcium Alginate, bordered Foam, but neither care plan was revised to include the intervention of a low air loss mattress as ordered on 11/9/23. A record review of the Order Recap Report with Order Date: 09/28/2023 -11/30/2023 revealed Resident #89 had a Physician's Order, dated 10/10/23 and ended on 11/8/23, for Sacrum Pressure Injury - Clean with NS, Pat dry apply Zinc Oxide and cover with bordered gauze daily and prn . A record review of the Order Recap Report with Order Date: 09/28/2023 -11/30/2023 revealed Resident #89 had a Physician's Order, dated 11/8/23, for Sacrum Pressure Injury - clean with NS, pat dry apply Santyl/Calcium Alginate and cover with bordered gauze daily and prn ., and a Physician's Order, dated 11/9/23, for Low air loss mattress for sacral wound. A record review of Resident #89's Admission Record revealed the facility admitted resident on 09/28/23 with the diagnoses of Traumatic Subdural Hemorrhage with Loss of Consciousness of Unspecified Duration. In an interview with the Assistant Director of Nursing (ADON) at 11:10 AM on 11/30/23, she explained the facility had two (2) Care Plan Nurses that completed care plans. She stated that when a wound care order was changed, she expected the care plan to be revised to ensure proper wound care was completed because if the interventions are not updated, the wrong care could be provided. At 11:35 AM on 11/30/23, during an interview with LPN #4/Care Plan Nurse, she explained the care plans were mostly updated when the Minimum Data Set (MDS) were due, but they try to revise and update care plans as needed to provide the care for the residents. She stated that every staff member should use the care plan to assure adequate care was provided for the resident, but if the care plan was not revised or updated, inadequate care could be provided. The Care Plan Nurse reviewed the Comprehensive Care Plans and confirmed the care plan had not been revised to include the most current wound care orders. She also confirmed that Resident #89's care plan had not been revised to include the intervention of a low air loss mattress. At 12:00 PM on 11/30/23, during an interview with the Director of Nursing (DON), she explained she expected all residents' care plans to be revised and updated to provide the best care for all residents. She expected staff to revise and update the care plan any time wound care changes to assure adequate care was provided. On 12/01/23 at 11:00 AM, during an interview with RN#2 /MDS Coordinator/Care Plan Nurse, she explained she usually completed the care plans for the Skilled residents. She stated that she tried to update the care plans as needed. She explained that the purpose of the care plan was to know what care the resident needed. She confirmed that if the care plan were not revised or updated, it would be hard to follow and provide adequate care for the resident. She explained that when she developed resident care plans, she used the physician's orders and revised the care plan as new orders were entered. She stated that sometimes she may not get back to the care plan to revise it until the next MDS Assessment. RN #2 reviewed Resident #53's and Resident #89's care plans and confirmed the wound care plans did not include the most recent wound care orders and Resident #89's care plan was not revised to include the intervention of a low air loss mattress. The facility provided an acceptable Removal Plan on 12/4/23, in which they alleged all corrective action to remove the IJ was completed on 12/4/23 and the IJ was removed on 12/5/23. Removal Plan On December 1st, 2023, at approximately 3:30pm Pine Forest Health and Rehabilitation received 5 Immediate Jeopardies during an Annual and Complaint Survey from the Mississippi Department of Health Licensure and Certification and provided the facility with the Immediate Jeopardy Templates. Brief Summary of Events: Pine Forest Health and Rehabilitation failed to put into place appropriate interventions to ensure proper assessment, staging, treatment and clinical care plans to treat and prevent the development and worsening of new and existing pressure ulcers. Corrective Actions: 1. An Emergency QAPI Meeting was held at approximately 12/1/2023 at 5 PM to review the cited deficient practices and to determine a root cause analysis for the lack of appropriate interventions. This meeting included the Administrator, Director of Nursing/lnfection Preventionist, Medical Director, Respiratory Director, & Business Office Manager. The following items were reviewed, coordinated, and corrected to allege compliance and remove the Immediate Jeopardy. The root cause analysis determined the cause of these occurrences was the facility's failure to be properly train staff on the policies for assessing, staging, preventing, and communicating wound and skin care issues for residents who could be at risk for skin breakdown or are already noted with skin/wound breakdown. 2. The facility did a complete policy review on Care Planning Standard, Skin Management Standard, and Employee Competency Standard. The facility conducted 100% in-services and education using outsourced, Qualified Trainers and Online Software as it pertains to each department and the correlated policies pertaining to the immediate jeopardies. The facility also did a 100% inservice on all staff on the Identification and Reporting of Resident Abuse and Neglect. No individual was allowed to work beginning at approximately 7PM on 12/1/2023 until they were able to successfully complete all prescribed In-services. 3. The facility outsourced a Qualified RN Trainer to properly train with return demonstration all individuals who are responsible for the assessment, staging, and provision of wound care for the Facility. Upon completion and approximately 7:30PM on 12/1/2023, the Facility began to conduct body audits on 100% of in-house residents to determine proper assessment, staging, and treatment of wounds and finished on 12/4/2023. All noted pressure areas were assessed, staged, and determined to have a proper assessment. The wound care physician was notified of all findings and coordinated a Telehealth Visit on all residents with pre-existing wounds to confirm appropriate assessment, staging, and treatment of all existing pressure ulcers. There were no changes noted after having concluded all consult Telehealth visits. The attending physician and facility Medical Director was then notified of all Wound Care Physician's Assessments and concurred with prescribed consultation on all noted patients. Resident #53 was determined to have a pressure ulcer in an optimal condition of healing. Resident #89 remains in the hospital. 4. Both MDS Nurses were immediately trained following the QAPI Meeting regarding the ability to properly develop and/or revise resident care plans interventions for residents with pressure ulcers, ensuring those who were admitted to the facility without pressure ulcers did not acquire pressure ulcers and that existing pressure ulcers did not get worse, or residents did not develop complications from pressure wounds. After completing each Telehealth visit from Wound Care Physician and receiving noted confirmation for Medical Director/Attending Physician on all residents with Pressure ulcers, the facility began assessing and updating all care plans on 12/1/2023 and completed 12/4/2023 on coordination with development and prevention of pressure ulcers according to the prescribed orders. Resident #53 was noted to have a proper care plan regarding his healing pressure ulcer. Resident #89 remains in the hospital. 5. The facility determined to move forward by having the trained Unit RN Managers conduct weekly body audits on all residents as it pertains to their individual Units A & B and report the assessment of those daily audits to the Wound Care Team, consisting of the Wound Care Physician, Treatment Nurse, MDS Nurse, and Director of Nursing. All new admits/readmitting residents will their initial assessment conducted by the Unit Manager, who will be responsible for communicating the results of the audit to the Wound Care Team, Consisting of the Wound Care Physician, Treatment Nurse, MDS Nurse and Director of Nursing. The Director of Nursing has been delegated to report the reconciliation of this weekly review in High Risk and monitored monthly for no less than 1 year by the QAPI Committee. 6. The Facility alleges compliance on 12/5/2023. The facility alleges that all corrective actions to remove the Immediate Jeopardy were completed on 12/4/2023 and the Immediate Jeopardy was removed on 12/5/2023. The SA validated the facility's Corrective Actions on 12/5/23: The SA validated through interviews and record review that an Emergency QAPI meeting was held on 12/01/2023 with all members in attendance. The SA validated through interviews and record reviews all policies on Care Planning Standards, Skin Management Standards, and Employee Competency Standards were reviewed with no corrections made. The facility conducted 100% in-services and education including Identification and Reporting of Resident Abuse and Neglect. The SA validated through interviews and record reviews the facility outsourced a Qualified RN Trainer to properly train and return demonstration all individuals who are responsible for the assessment, staging, and provision of wound care for the Facility. The facility completed 100% body audits of in-house residents to determine proper assessment, staging, and treatment of wounds and finished on 12/04/23. The Wound Care Physician was notified of all findings and coordinated a Telehealth Visit on all residents with pre-exiting wounds to confirm appropriate assessment, staging, and treatment of all exiting pressure ulcers. The Medical Director was notified of all findings. Resident #53 was determined to have a pressure ulcer in an optimal condition of healing. Resident #89 remains in the hospital. The SA validated through interviews and record reviews both MDS Nurses were immediately trained following the QAPI meeting regarding the proper development and/or revise resident care plans interventions for residents with pressure ulcers, ensuring those who were admitted to the facility without pressure ulcers did not acquire pressure ulcers and that existing pressure ulcers did not get worse, or residents did not develop complications from pressure wounds. The facility assessed and updated all care plans and completed them on 12/04/23. The SA validated through interviews and record reviews the facility trained Unit RN Managers conduct weekly body audits on all resident as it pertains to their individual Units A and B and report the assessment of those daily audits to the Wound Care Team, consisting of the Wound Care Physician, Treatment Nurse, MDS Nurse, and DON. The DON has been delegated to report the reconciliation of this weekly review in High Risk and monitored monthly for no less than one (1) year by the QAPI Committee. The SA validated through interviews and record reviews and no associate can return to work until they have received this in-service training. The SA validated that all corrective actions were completed on 12/04/2023 and the IJ was removed as of 12/05/2023.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents were assessed and received care and treatment for Pressure Ulcers (PUs) to prevent complications and worsening of PUs for two (2) of four (4) residents reviewed for PUs. Resident #53 and Resident #89. The facility's failure to provide wound assessments, documentation, and wound care treatment resulted in harm to Resident #53 and Resident #89 and put all other residents at risk for skin breakdown in a situation that was likely to result in serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 8/29/23 when Resident #53, who had existing PUs, was admitted to the facility and was not assessed by a qualified nurse or practitioner until 9/18/23, causing the wound to worsen. The facility Administrator was notified of the IJ and SQC and was presented with an IJ Template on 12/1/23 at 2:55 PM. The facility provided an acceptable Removal Plan on 12/4/23, in which they alleged all corrective action to remove the IJ was completed on 12/4/23 and the IJ removed on 12/5/23. The SA validated the Removal Plan on 12/5/23 and determined the IJ was removed on 12/5/23, prior to exit. Therefore, the scope and severity for 42 CFR 483.25 (b) (1) (i) (ii) Pressure Ulcers was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Resident #53 On 11/28/23 at 10:30 AM, during an observation and interview, Resident #53 was sitting up in his wheelchair and he stated that he had one (1) large wound to his bottom. He commented that he thought he would have additional wounds after this past weekend, because he had to lay in bed in his bowel movements and urine for long periods of time on the night shift. On 11/28/23 at 3:15 PM, during an interview with Licensed Practical Nurse (LPN) #1/Wound Care Nurse, he explained that when a resident was admitted to the facility, the initial body assessment was completed by Registered Nurse (RN) #3 (RN)/Admission Nurse, and she staged, measured, and documented Pressure Ulcers (PUs). LPN #1 reported that he provided a resident list to the Wound Care Physician of residents that he needed to see. The Wound Care Physician assessed and measured PUs weekly on Mondays and LPN #1 added the physician's measurements to the Wound/Skin Log. He stated that he began documenting on the Wound/Skin logs when RN #4, who was the previous wound care nurse, left the faciity on [DATE]. LPN #1 explained that a Random Skin Sweep was a skin assessment that could be used at any time to document any newly identified skin issues. He further explained that a Weekly Skin Sweep had to be completed by an RN whenever a nurse documented on the Medication Administration Record (MAR) that the resident had a skin issue. LPN #1 confirmed that Resident #53 had only one (1) PU on his bottom that he had upon admission to the facility. He reported that the resident was currently seen by the Wound Care Physician. A record review of the Admission Record revealed the facility admitted Resident #53 on 08/29/23 with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, and Chronic Obstructive Pulmonary Disease. Record review of the facility's Brief Interview for Mental Status (BIMS) Evaluation, dated 12/2/23, revealed a score of 13, which indicated Resident #53 was cognitively intact. A record review of the Random Skin Sweep dated 08/29/23, which was the date of admission, revealed Resident #28 had a Pressure area to the Left buttock that measured 8 centimeters (cm) length, 5 cm width, and 4 cm depth and a Skin Tear to the Right lateral foot that measured 3 cm length, 6 cm width, and the depth was listed as UTD (Unable To Determine). Skin Impairment Findings revealed Skin injuries as listed above. Left buttock cleaned with NS (Normal Saline), calcium alginate rope, and bordered gauze applied. Right lateral foot cleaned with NS and bordered gauze applied. (Proper Name of Wound Care Physician) to F/U (Follow Up) with resident. The document was signed by RN #4, who was the previous Wound Care Nurse for the facility and was no longer employed by the facility. A record review of Braden Scale for Predicting Pressure Sore Risk, dated 08/29/23, revealed Resident #53 had a score of 13, which indicated he had a moderate risk of developing PUs. A review of the medical record revealed there was no other Random or Weekly Skin Sweeps documented. At 4:00 PM on 11/28/23, during an interview with the Director of Nursing (DON), she explained that PU wound documentation and skin assessments were to be completed weekly on the Wound/Skin Log by LPN #1. A record review of the facility's Wound/Skin Log, dated 09/04/23, revealed Resident #53 had a Stage IV PU to his Left Buttock that measured 7 cm X 2 cm X 10.75 cm. These measurements were documented six (6) days after Resident #53's admission to the facility and indicated the PU had increased in depth. The log also indicated the resident had a Stage IV PU to his Right Lateral Foot that measured 2 cm X 1.5 cm X and the D (depth) (cm) was UTD. This wound had been classified upon admission as a Skin Tear and this was the first documentation that the area was a Pressure type and Stage IV. The Wound/Skin Log documentation did not indicate who had completed the logs and did not include a description of the PU characteristics, the progress toward healing and identification of potential complications, if infections were present, the presence of pain, or a description of dressings and treatment. A record review of the facility's Wound/Skin Log, dated 9/11/23, revealed Resident #53 had a Stage IV PU to his left buttock that measured 6.2 cm x 1.6 cm x 10.6 cm and had a Type or Stage of PVD (Peripheral Vascular Disease) to his right foot that measured 1.7 cm x 1.5 cm x UTD. The documentation of PVD was inconsistent with the Wound/Skin Log dated 9/4/23, which indicated the wound to the right foot was a PU. A record review of the Order Recap Report, with Order Date: 08/29/2023 - 11/30/2023), revealed Resident #53 had a Physician's Order, dated 9/18/2023, for Wound consult with skilled wound care surgical group . A record review of a Surgical Note, dated 09/18/23, revealed Resident #53 was seen by the Wound Care Physician 20 days after he was admitted to the facility. The Physician visited the resident because he was asked for his opinion on how to manage the wound located at the left buttock and sacrum. The Wound Location was listed as Left Buttock and Sacrum, and the Etiology was listed as Pressure injury/ulcer - Wound Stage: 4 - Pressure Injury. The note also revealed that the wound area measured 6.2 cm x 1.6 cm x 10.5 cm, which was deeper than the initial measurement upon admission. The wound required the Physician to perform a muscle tissue debridement, which was the removal of dead tissue from the wound. The wound description indicated that the wound had undermining (separation of the wound edges from the surrounding healthy tissue) of 13 cm, had no odor, and had a copious amount of serosanguineous (thin fluid with a light pink tinge) exudate. The tissue of the wound was 20% slough (nonviable skin tissue), 80% granulation (development of new skin tissue), and there was no necrotic or dead tissue present in the wound. This was the first wound assessment that included a complete wound description of the PU characteristics for Resident # 53 since the resident was admitted to the facility on [DATE]. The wound progress was listed as Undetermined: first visit. The wound to the Right Lateral Foot was listed as PVD. The Assessment and Plan revealed, The patient has a wound found on the left buttock and sacrum .there was a sign of tissue decline which will entail continuing supervision and will likely require future debridement .continue offloading .turn per facility protocol. A low air loss mattress is recommended . A record review of the Order Recap Report, with Order Date: 08/29/2023 - 11/30/2023), revealed Resident #53 had a Physician's Order, dated 8/29/23 and discontinued on 9/19/23, for Sacrum pressure injury - clean with NS, Pat dry, apply Calcium Alginate and cover with bordered gauze daily and prn (as needed) for soiled or dislodgement . At 5:05 AM on 11/29/23, during an observation and interview with Certified Nurse Assistant (CNA) #14 and Resident #53, the CNA explained that she was going to change him. Resident #53 commented that was the second time he had seen staff all night and he had not been changed since about 11 PM. The observation revealed that Resident #53's brief was saturated and there was no protective bandage noted covering the PU, nor was there a bandage in his brief indicating the bandage had become dislodged during the night. CNA #14 provided incontinence care and applied a clean brief, but the PU to the sacrum/buttocks did not have a bandage on it, which left the packed wound exposed. CNA #14 confirmed that the resident's brief had been saturated and there was no bandage on the PU wound. She stated she was unsure of the last time she had changed his brief or when the bandage had come off the resident. She said would notify the nurse that the resident did not have a bandage on his PU. At 5:25 AM on 11/29/23, during an interview with RN #5, she explained the CNAs should round every two (2) hours to ensure residents were clean and dry, but she did not check behind them to confirm the rounds are completed. She confirmed CNA #14 had let her know that Resident #53's bandage was off his PU site, and she advised that she would replace the dressing after she completed her medication pass. At 8:25 AM on 11/29/23, during an interview with RN #3/Admission Nurse, she explained she was not a wound care nurse. She stated that she had been helping with the assessment of new wounds, admissions, and hospital returns or any other residents the wound care nurse needed help with. She confirmed that she only measured the wounds and she attempted to assess them, but she did not feel comfortable about staging PUs. She said that the Wound Care Physician assessed all wounds until they were healed, and that LPN #1 printed the physician's assessment and that would become part of the resident's medical record. She confirmed that she had never staged PUs and that when a resident was admitted to the facility with an existing PU, the facility used the hospital's discharge wound orders and staging documentation. On 11/29/23 at 3:00 PM, during an interview with the DON, she explained she did not know who completed the Wound/Skin Logs before LPN #1 took over after RN #4 had left. She said that different nurses had helped and had completed the logs but there was no signature or identifying information to indicate who completed the measurements. She explained that as far as she knows, those logs were completed with the measurements from the Wound Care Physician's weekly assessments which are completed when he rounds. She confirmed the logs indicated PU measurements but did not include any other assessment information regarding the wounds. She said that she received a copy of the PU logs weekly, but she did not review the logs to determine if the PUs were healing or deteriorating, and she did not keep the logs on file. The DON stated that LPN #1 provided the Wound Care Physician with a list of residents that needed to be seen during his weekly visits, but she was unsure how or who determined which residents should be seen by the physician. On 11/30/23 at 10:35 AM, during an interview with LPN #1, he explained that if a resident was admitted to the facility with an existing PU and had wound treatment orders from the hospital, he would not always refer that resident to the Wound Care Physician. He reported the facility did not have a protocol on when a resident should be seen by the Wound Care Physician. He stated that if a wound was not responding to the treatment orders, he would notify the Wound Care Physician and schedule a consultation for the next Monday. LPN #1 stated that RN #3 documented measurements on the Wound/Skin Log for the residents that the Wound Care Physician did not see. He explained that when a new wound was identified, he got an RN to assess the area and he relied on the RN to complete the Random Skin Sweep documentation. He explained when Resident #53 was admitted to the facility, he was not referred to the Wound Care Physician immediately because the resident had treatment orders for wound care that came with him from the hospital. However, when he noticed that the wound was not responding to the treatment, he referred the resident to the Wound Care Physician. He confirmed Resident #53's wound was deep with tunneling and undermining present. He was not aware that the RNs had not documented anything on the Wound/Skin logs. At 11:10 AM on 11/30/23, during an interview with the Assistant Director of Nursing (ADON), she explained she was not involved in Resident #53's wound care and had never observed his PU. The facility had a Wound Care Physician that came every Monday, and the Nurse Practitioner was in the facility Monday through Friday. She explained that a PU assessment and documentation should include the PU stage, measurement, description of the appearance of the PU, drainage, odor, and healing or deterioration of the PU. All PU wounds and notifications must be documented, and if it was not documented, then it was not completed. The ADON said that she was unsure of the protocol regarding notifying or consulting with the Wound Care Physician when a resident acquired a new PU, but she knew he was provided with a list of residents that he needed to visit. She explained that the facility conducts a Stand Up meeting every morning during the week and discussed all concerns in the facility, including PU concerns. The ADON stated she was unaware that RN #3 was not comfortable in staging PUs, but there were other RNs in the facility that could assist and RN #3 should have asked them for help. The ADON said that if a PU was not staged or assessed appropriately, the wounds may not be treated appropriately and may worsen. At 1:10 PM on 11/30/23, during an interview with RN #3, she reported she did not tell the DON that she was not comfortable staging wounds. She confirmed she did not know the protocol or system for a resident being admitted with an existing PU or for a resident who acquired a PU while in the facility to be referred to the Wound Care Physician. She stated she was only filling in since there was no RN currently in the wound care role. She stated that she had not been asked to assess any wounds, but only to measure wounds. She confirmed that the facility had daily stand-up meetings, but wounds were not discussed in detail until the monthly Quality Assurance (QA) meetings. At 12:00 PM on 11/30/23, during an interview with the DON, she explained she expected the nurse to call the Physician or Wound Care Physician if a wound worsened in any way. She also expected all PU assessments and findings to be documented in the medical record, and that if there was no documentation, then it was not done and that she was aware that documentation was a problem. The DON explained that any changes in a resident or a resident's PU should be documented. She confirmed that the facility did not have a system in place to determine when a resident required a consultation with the Wound Care Physician. LPN #1 was responsible for communicating with the Wound Care Physician, who was available as needed. LPN #1 completed the wound/skin logs weekly, but the DON was unaware that PUs were not completely assessed if they are not being seen by the Wound Care Physician. She thought every resident with a wound was seen by the Wound Care Physician but was not aware of the system. She was not aware that RN #3 was not comfortable with staging wounds, because she has been completing admission wound assessments for a long time. The DON said she would have put someone else in the position that was more comfortable if she had known. She confirmed that RN #3 has just recently been filling in with wound assessments other than admission assessments since RN #4 left employment at the facility. There were other RNs in the facility that could assess and measure if RN #3 had asked for help. The DON was not aware Resident #53 was not seen by the Wound Care Physician and that his wound had gotten deeper from the time he was admitted on [DATE] until he was seen by the Wound Care Physician on 9/18/23. She reported since there was no longer a RN in wound care, other RNs assisted in completing Wound/Skin logs as necessary. At 1:25 PM on 11/30/23, during a phone interview with the Wound Care Physician, he confirmed that he was a consultant for the facility and was not involved in resident care plan or facility meetings. He stated LPN #1 faxed a list to his office of residents that he needed to see when he comes to the facility. He did not know the facility's policy regarding wound care or the system the facility used to determine which residents he should see, but he felt the wound care nurse (LPN #1) knew to consult him if a wound worsened and he could be consulted at any time via Tele-Med (Telephone Medical) services. Resident #89 On 11/28/23 at 12:20 PM, during a phone interview with the Complainant, she explained she became involved when the resident was admitted to an acute care hospital from the facility with a diagnosis of Sepsis (serious condition in which the body responds improperly to infection) related to a PU to the sacrum. She explained the hospital physicians were concerned that the facility's staff were not turning and repositioning the resident as often as needed and not keeping him dry and clean. She reported the resident's brother and sister had voiced concerns to her and the physicians that staff were not turning Resident #89 frequently and the resident remained wet for long periods of time. The Complainant advised that Resident #89 required wound surgery during his hospital stay and he currently remained in the acute care hospital at the time of the interview. On 11/28/23 at 1:00 PM, during a phone interview with the Resident Representative (RR), he explained Resident #89, who was his brother, had been in the facility for six (6) weeks and had gotten a bad wound that became septic and required surgery. He explained he stayed at the facility for long periods of time to be with brother and the staff did not turn or change him enough. The staff would not touch the resident for hours, and when they finally came to change him, Resident #89 would be soaked with urine. He said that his brother did not have any wounds when he was admitted to the facility and that he did not have a catheter. He explained the facility discussed inserting a catheter on the day the resident was so sick and was transported to the hospital. The RR felt like if the facility had kept his brother dry and had turned him often, he would not have gotten the PU. A record review of the Admission Record revealed the facility admitted Resident #89 on 09/28/23 with diagnoses that included Traumatic Subdural Hemorrhage with Loss of Consciousness of Unspecified Duration. A record review of the Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/5/23, revealed Resident #89 required a Staff Assessment for Mental Status and his cognition was severely impaired. A review of Section GG revealed that Resident #89 was dependent on staff for all functional abilities. A review of Section M revealed Resident #89 was at risk for developing pressure ulcers/injuries, but he did not have any unhealed pressure ulcers/injuries. A record review of the Braden Scale for Predicting Pressure Sore Risk, dated 9/28/23, revealed Resident #89 had a score of 12 which indicated he had a high risk of developing PUs. A record review of the Nursing Random Skin Sweep, dated 09/28/23, which was the date of admission to the facility for Resident #89, revealed he had skin tears to his left ear, left upper chest, and right upper chest. The document was signed by RN #4, the previous Wound Care Nurse. There was no documentation regarding any skin or PUs to the resident's sacrum or buttocks. A record review of the Order Recap Report with Order Date: 09/28/2023 -11/30/2023 revealed Resident #89 had a Physician's Order, dated 9/28/23 for Weekly skin assessments . Review of the report revealed there were no Physician Orders that addressed any skin issues or PU treatments to the sacrum upon Resident #89's admitted [DATE]. A record review of the Wound/Skin Log, dated 10/8/23 (Sunday), which was 10 days after the Resident #89 was admitted to the facility, revealed he had a PU to the sacrum that measured 6.5 cm x 4.0 cm x UTD. The onset date was recorded as 9/28/23 which was the date of admission and conflicted with the Nursing Random Skin Sweep that was completed on 9/28/23 and the Physician's Orders. This was the first documentation that referred to the PU. The Wound /Skin Log documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. There was no indication of who had completed the wound/skin log. A record review of the Order Recap Report with Order Date: 09/28/2023 -11/30/2023 revealed Resident #89 had a Physician's Order, dated 10/10/23 and ended on 11/8/23, for Sacrum Pressure Injury - Clean with NS, Pat dry apply Zinc Oxide and cover with bordered gauze daily and prn . This order was received two (2) days after the wound/skin log, dated 10/8/23, indicated Resident #89 had a PU that measured 6.5 cm x 4.0 cm x UTD. A record review of the Weekly Skin Sweep, dated 10/12/23, revealed Resident #89 had a PU to the sacrum that measured 2.0 cm length, 1.0 cm width, and UTD for the depth. The measurements conflicted with the measurements documented on the Wound/Skin Log that had been completed four (4) days prior. The documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. The document was signed by RN #3, the Admission Nurse. A record review of the Wound/Skin Log, dated 10/16/23, revealed Resident #89 had a PU to the sacrum that measured 6cm x 4 cm x UTD, which indicated an increase in the size of the wound from the Weekly Skin Sweep completed on 10/12/23, which was four (4) days prior. The onset date was recorded as 9/28/23. The Wound /Skin Log documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. There was no indication of who had completed the wound/skin log. A record review of the Wound/Skin Log, dated 10/23/23, revealed Resident #89 had a PU to the sacrum that measured 6.25 cm x 4 cm x UTD. The onset date was recorded as 9/28/23. The measurements indicated the wound had increased in size since the log dated 10/16/23. The Wound /Skin Log documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. There was no indication of who had completed the wound/skin log. A record review of the Wound/Skin Log, dated 11/6/23, revealed Resident #89 had a PU to the sacrum that measured 6.5 cm x 4.2 cm x UTD. The measurements indicated the wound had increased in size from the documentation on the log dated 10/23/23. The onset date was recorded as 9/28. The Wound /Skin Log documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. There was no indication of who had completed the wound/skin log. There was an additional Wound/Skin Log', dated 11/6/23, which indicated Resident #89 had a PU to the sacrum that measured 6.5 cm x 4.5 cm x UTD and the onset date was 9/28/23. A record review of the Weekly Skin Sweep, dated 11/8/23, revealed Resident #89 had a PU to the sacrum that measured 3.0 cm length, 2.0 cm width, and UTD for the depth. These measurements were inconsistent with the measurements provided two (2) days prior on the wound/skin log dated 11/6/23. A record review of the Order Recap Report with Order Date: 09/28/2023 -11/30/2023 revealed Resident #89 had a Physician's Order, dated 11/8/23, for Sacrum Pressure Injury - clean with NS, pat dry apply Santyl/Calcium Alginate and cover with bordered gauze daily and prn ., and a Physician's Order, dated 11/9/23, for Low air loss mattress for sacral wound. There was a Physician Order, dated 11/13/23, to consult skilled wound care for evaluation of sacrum wound . A record review of a Surgical Note, dated 11/13/23, revealed Resident #89 was seen by the Wound Care Physician. The Physician visited the resident for management of wounds located on the sacrum. The Wound Location was listed as Sacrum, and the Etiology was listed as Pressure injury/ulcer - Wound Stage: 4 - Pressure Injury. The note also revealed that the wound measured 6.0 cm x 4.0 cm x UTD prior to his debridement, and 6.0 cm x 4.0 cm x 0.5 cm after the debridement procedure. The wound required the Physician to perform a muscle tissue debridement with the Preoperative Indications listed as Biofilm, Devitalized tissue, and Slough. There were no signs of infection. The wound description indicated that the wound had no odor and had a moderate amount of serosanguineous exudate. The Peri wound area was unhealthy and unstable. The tissue of the wound was 80% slough and 20% granulation. This was the first wound assessment that included a complete wound description of the PU characteristics, for Resident # 89, which was 36 days after the PU was first documented on the Wound/Skin Log dated 10/8/23. A low air loss mattress is recommended . At 3:00 PM on 11/28/23, during an interview with the DON, she explained Resident #89 was sent to the hospital on 11/16/23 because he was in respiratory distress. A record review of the Internal Medicine H & P (History and Physical), dated 11/16/23, revealed Resident #9's History or Present Illness (HPI) as . presents from his nursing facility with fever and tachycardia (increased heart rate) . appears to have increased work of breathing . heart rates were noted to be in the 120's to 130's . Date review of the recent labs revealed Resident #89 had an abnormal white blood cell count. The Physical Exam revealed, .Skin: Sacral ulcer covered with bandage . A review of the Assessment/Plan revealed . Sepsis, suspected secondary to sacral decubitus ulcer .Bone culture with moderate growth . Review of the Indication for Surgery was necrosis (death of body tissue) and the Procedure: sharp excisional debridement sacral wound including bone 5 x 6.5 x 3 . At 8:25 AM on 11/29/23, during an interview with RN #3/Admission Nurse she confirmed that she had completed the Weekly Skin Sweep for Resident #89 on 10/12/23 and that she did not stage the PU or provide descriptive characteristics of the PU. She explained that she had assumed the wound care team would follow Resident #89, but she did not follow up to ensure he was seen by the team. She explained that the wound care team at that time consisted of LPN #1 and the Wound Care Physician. She was unable to recall what the PU looked like when she had measured it. She confirmed that she only measured the PU and did not complete or document a full assessment of the wound. She said she was unaware that the Wound Care Physician was not seeing the resident when she completed the documentation on 10/12/23. On 11/29/23 at 3:00 PM, during an interview with the DON, she explained she was not aware that RN #3 had not assessed or staged the PU to the sacrum for Resident #89 and that the Wound Care Physician had not assessed or staged the PU for more than four (4) weeks after the PU was first identified by facility staff on 10/8/23. At 3:10 PM on 11/29/23, during an interview with the Administrator and the DON, the Administrator explained that he could not determine who had completed the Wound/Skin logs that were provided. He explained that RN #4 was the previous wound care nurse and her last day at the facility was 10/04/23. The DON and the Administrator were unable to explain the PU measurement inconsistencies of the Wound/Skin logs and the Weekly Skin Sweeps for Resident #89. On 11/30/23 at 10:35 AM, during an interview with LPN #1, he explained when Resident #89 was admitted to the facility, he did not have any PUs. He was unable to recall how he found out that Resident #89 had a PU, but he did recall asking RN #3 to measure the wound. LPN #1 described the PU when he first saw it as measuring approximately 2 cm x 3 cm, the area was discolored, but the skin was intact. He thought the wound was classified as Moisture Associated Skin Damage (MASD), because whenever he provided the treatments to the sacrum, Resident #89 was soiled with urine. He stated that he had instructed CNAs that the resident needed to be kept dry, changed in a timely manner, and turned more frequently, however he did not conduct and document a formal in-service. LPN #1 said that Resident #89's family would be with the resident daily and he would talk to them regarding resident's PU, but he never completed any documentation regarding the PU. LPN #1 said that when the wound was first found, the physician was notified, and new orders were received for zinc oxide, because the skin was intact. He stated that he continued to treat the PU with zinc oxide and did not notify the Wound Care Physician that the wound size was increasing. He confirmed he had no documentation of the wounds, including the progression or deterioration of the wound. When he noticed the PU to the sacrum had slough, he notified the Wound Care Physician and received orders to discontinue the zinc oxide and start a new treatment. He said that he felt like the PU measurements obtained on the Random and Weekly Skin Sweeps were accurate because he assisted RN #3/Admissions Nurse when she measured the wounds. He confirmed Resident #89's wound had deteriorated and increased in size from the time it was first identified on 9/28/23 until the time he was seen by the Wound Care Physician on 11/13/23. He confirmed that on 11/13/23, the PU to the sacrum was classified as a Stage IV. LPN #1 stated that he would not have done anything differently with the resident's wound. He confirmed that Resident #89 did not have a low air loss mattress to help with pressure reduction until 11/9/23. At 11:10 AM on 11/30/23, during an interview with the Assistant Director of Nursing (ADON), she explained she was unaware that Resident #89 had a PU because she was not involved in his care. She stated that it appeared someone dropped the ball, but she didn't know who. She explained that for a resident to develop a Stage 4 PU in less than two (2) months of admission, the resident did not receive adequate care and should have been referred to the Wound Care Physician before a month had passed, especially since the resident had comorbidities, restricted mobility, and was at a high risk for skin breakdown. At 12:00 PM on 11/30/23, during an interview with DON, she stated she was not aware that Resident #89's PU had increased in size before the Wound Care Physician had gotten involved with his care. At 12:45 PM on 11/30/23, during a phone interview with the Nurse Practitioner NP), she explained

Based on interviews, observation, record review, facility investigation review and policy review the facility failed to provide adequate supervision to prevent Resident #1's elopement from the facility on 10/19/21 at 8:25 PM. The facility staff did not know that Resident #1 was off the facility grounds until Licensed Practical Nurse (LPN) #1 was going to give Resident #1 medication and Resident #1 was not in her room. This concern was identified for one (1) of four (4) residents reviewed for diagnosis of Alzheimer's Disease (Resident #1). On 10/19/21, Resident #1 was allowed to exit the facility at approximately 8:25 PM, removing her screen from her window and exiting through the window. When LPN #1 was passing Resident #1's medications at 8:45 PM, LPN #1 realized the screen was out of the window and the window was open. LPN #1 alerted all staff who then began to search for Resident #1. Registered Nurse (RN) #1, LPN #1, and LPN #2 immediately went outside to the front of the facility and saw Resident #1 at the intersection of Proper Street Name #1 and Proper Street Name #2. LPN #1 and RN #1 was able to escort Resident #1 back to the facility 8:53 PM. RN #1 completed a body audit on Resident #1 and there were no adverse findings noted. Resident #1 was placed on one-one-one supervision and received constant observation until Resident #1 was transported to a local hospital, and then discharged from the facility. During the investigation of the complaint, on 11/10/21 the SA identified an Immediate Jeopardy (IJ), and Substandard Quality of Care (SQC) which occurred on 10/19/21 and existed at: 42 CFR(s):483.25(d)(1)(2)-Free of Accidents Hazards/Supervision/Devices (F689)-Scope/Severity J. The facility failed to provide supervision to prevent an elopement for Resident #1, who was diagnosed with Alzheimer's Disease and Cognitive Communication Deficit. Resident #1 was allowed to leave the facility, unnoticed and unsupervised until LPN #1, LPN #2, and RN #1 found Resident #1 standing at the corner of an intersection approximately 125 feet from the facility. This situation placed Resident #1 and other residents at risk for wandering and elopement, at risk for the likelihood of serious injury, harm, impairment, or death. Based on the facility's implementation of correction actions on 10/19/21, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed on 10/22/21, prior to the SA's entrance on 11/8/21. The SA notified the facility's Director of Nurses (DON) of the PNC IJ and SQC on 11/10/21 at 10:56 AM. Findings include: Record review of the facility's policy, Wandering/Elopement Risk, updated 11/17, revealed, .Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e. (that is), an order for discharge or leave of absence) and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being stuck by a motor vehicle. On 11/8/21 at 3:00 PM, an interview with Director of Nursing (DON) revealed Resident #1 exited the facility on 10/19/21, which was five (5) days after the facility admitted her on 10/14/21. The DON stated that upon admission, the resident was assessed for wandering and was determined to be at risk for wandering. She was also assessed for elopement and was not deemed to be an elopement risk because she had not been exit-seeking. She further stated that Resident #1 had never exhibited any behaviors or attempted to exit any of the facility doors. The DON stated the facility's investigation revealed Resident #1 was located at approximately at 8:53 PM, standing near a ditch, in the front of the building on Proper Street Name #1 approximately 125 feet from the facility's front entrance. The DON stated Resident #1 exited through the window in her room and was seen by the pharmacy delivery person at 8:25 PM. LPN #1 called a Code Purple with assistance of LPN #2 and RN #1, they immediately went outside. The female nurses calmed Resident #1 down and brought her back to the facility at 8:53 PM. RN #1 performed a head-to-toe assessment and found no scratches and/or bruises. RN #2 notified the DON who notified the Administrator, the Medical Director, the State Agency, the Maintenance Supervisor, and the Responsible Representative. RN #1 immediately placed resident on 1:1 observation, complete check on all residents that they were all accounted (which they were), in-services began (review elopement policy and reminding all staff to always monitor residents), and began conducting in-services, and no employee was allowed to work unless they attended the in-services. On 10/20/21, the DON reviewed new resident/wander binder that is located centrally at Unit A and Unit B nurses' stations. Record review of a Timeline for (Resident #1) completed by the DON dated 10/20/21, revealed, writer received a call from Registered Nurse (RN) #1 on 10/19/21 at approximately 8:53 PM, stating, that Resident #1 had gotten out of the facility by removing the screen from her window and was found down from the facility toward the red light. This occurred at approximately 8:45 PM, writer instructed RN #1 to initiate an in-service on elopement and always monitoring the residents where-abouts. Assessment of all residents were done for elopement. When writer received the call, Resident #1 was already in facility. Writer placed resident on 1:1 constant observation, full head to toe assessment was done, family was notified (10/19/21). Medical Director was notified on 10/19/21 at 8:56 PM, state that he would get patient a bed at senior care for Geri-psych eval. Administrator was notified on 10/19/21 at 9:04 PM of patient out of facility. Maintenance Supervisor was notified on 10/19/21 at approximately 9:15 PM of patient getting out of facility (oof) and need to check all windows. Spoke with Medical Director again at approximately 9:30 PM on 10/19/21, order given to send patient to local hospital emergency room for evaluation. Patient departed facility at approximately 10:00 PM per Ambulance in route to local hospital emergency room . Quality Assurance (QA) initiated on 10/20/21 in-service continued. On 11/8/21 at 3:20 PM, in an interview with LPN #2 revealed, when he was aware Resident #1 had eloped, he immediately got into his vehicle and started driving toward the end of driveway of the facility. The resident appeared next to him, and she became agitated. Resident #1 was resisting his assistance, at that time LPN #1 and RN #1 were present and they were able to calm Resident #1. RN #1 and LPN #1 brought Resident #1 back to the facility. On 11/8/21 at 3:45 PM, in an interview with RN #1, she stated when she was made aware Resident #1 had eloped, both LPN #1 and herself immediately went outside of facility. They noticed Resident #1 was on Proper Street Name #1 and Proper Street Name #2 intersection, and they were able to calm Resident #1 and bring her back to the facility. Upon bringing her to the facility, they immediately performed a head-to-toe body audit and found no signs of bruising and/or scratches noted on her body. The DON was notified of the elopement. On 11/8/21 at 4:30 PM, the SA walked throughout the facility and observed no residents wandering into other rooms or common areas. There were no residents seen standing at exits or attempting to exit the building. The staff were observed assisting residents with evening care. SA observed call lights being answered and there were no foul odors. Signs were noted on both sides of the front door reminding staff not to allow residents to exit the doors unattended. On 11/8/21 at 8:30 PM, the SA drove to the intersection at Proper Street Name #1 and Proper Street Name #2 for 30 minutes and observed seven (7) cars pass through the intersection at intervals. On 11/9/21 at 10:00 AM, an interview with the Maintenance Director revealed following the elopement incident, he checked all windows at the facility and placed a window stopper in each window so the windows can be opened only 6 inches. He further stated, in the event of a fire, the windows can be fully raised, but will make a loud noise when raised fully. On 11/9/21 at 10:30 AM SA observed the Maintenance Director opening the windows at facility which only opened 6 inches. The SA observed 12 exterior doors at the facility and all were locked. On 11/9/21 at 11:00 AM, in an interview with DON, she stated when a resident is missing, the facility calls a Code Purple. She also stated the facility performed Code Purple drills quarterly, with the last two drills being conducted on 4/30/21 and 9/29/21. The Code Purple drills are located in the Logbook Documentation. The DON confirmed Resident #1 was wearing a long sleeve shirt, pants (regular clothes not sleepers) and shoes. She also stated the weather outside on 10/19/21 was warm that night. The SA verified the weather report was correct at https://www.timeanddate.com. On 11/9/21 at 12:40 PM in an interview with LPN #1, she revealed on 10/19/21 at approximately 7:00 PM, she saw Resident #1 sitting in a chair in her room and there was no indication of any behavior issues and the resident was calm. LPN #1 stated at approximately 8:20 PM, Resident #1 was noted to be in her room. At 8:45 PM, LPN #1 stated she entered Resident #1's room and she was not in the room. After searching the room, she observed Resident #1's window was open with there was no screen. She immediately called a Code Purple in facility, then LPN #2, RN #1, and herself ran out of the facility to search outside. They saw Resident #1 immediately on Proper Street Name #1 ambulating to Proper Street Name #2. They were able to calm the resident and bring her back to the facility. LPN #1 stated she and RN #1 performed a head-to-toe assessment and saw no bruising and/or scratches on Resident #1. On 11/10/21 at 9:56 AM, in a telephone interview with the previous Administrator who was the Administrator at the time of the event revealed the resident had a psychotic episode and staff acted well and there was no harm to the resident. On 11/10/21 at 4:45 PM, in an interview with the facility Security Guard revealed he saw and watched the resident outside for about 10 minutes on 10/19/21 around 8:30 PM but did not realize she was a resident at the facility, until staff ran outside in search of the resident. Record review of Quality Assurance (QA) sign-in sheet revealed department heads and the Medical Director were in attendance for the Quality Assurance and Performance Improvement (QAPI) meeting on 10/21/21 at 4:00 PM. Record review of Logbook Documentation . Emergency Preparedness Drills: Conduct elopement drill (Missing Resident Drill) which is also known as Code Purple drills dated 4/30/21 revealed an elopement drill was conducted by Maintenance Director #2. Record review of Logbook Documentation . Emergency Preparedness Drills: Conduct elopement drill (Missing Resident Drill) dated 9/29/21 revealed an elopement drill was conducted by Maintenance Director #1. Record review of Resident #1's Admission Record revealed the facility admitted Resident #1 on 10/14/21, with diagnoses including Alzheimer's Disease, Essential Hypertension, Unsteadiness on Feet, and Cognitive Communication Deficit. Record review of Resident #1's Baseline Care Plan 2 (page 8 of 10) dated 10/14/21 revealed, C. Social Services .3. Behavioral Concerns wandering, and [CONDITION(S)] related to Alzheimer's revealed a baseline care plan was initiated when Resident #1 was admitted and there was a concern for wandering. Record review of Resident #1's (NSG)Wandering Risk Screen with an effective date of 10/15/21, completed by the Minimum Data Set (MDS) Coordinator revealed Resident #1 received a score of 5 which indicates Category: Moderate Risk for Wandering. The (NSG) Wandering Risk Screen was completed as A. Orientation .3. Forgetful/short attention span . C. Recent Experiences .3. Admission in the last month, D. Mobility . (2) Independent (no assist) . E. Diagnoses .2. Alzheimer's disease F. Medications .2. Taking antidepressants . Record review of Resident #1's COMS-Elopement Evaluation-V 2.1 dated 10/14/21, completed by the DON revealed, Score N/A which meant resident was not at risk for elopement. Record review of Resident #1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/20/21 indicated a Brief Interview for Mental Status (BIMS) summary score of 06, which indicated Resident #1 had severe cognitive impairment. Record review of Resident #1's Care Plan with a date initiated as 10/14/21, revealed a Focus as Resident is at risk for wandering related to she has diagnosis of Alzheimer's and is ambulatory. Interventions include Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and book. Identify pattern of wandering, is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? And Intervene as appropriate. Record review of Resident #1's Progress Note dated 10/19/21 (page 2) signed by LPN #1, revealed, .at approximately 2045 I was administering medication to residents and noticed Resident #1 was not in her room. I then looked in bathroom and under both beds, noticed residents room window was up/open. Then alerted charge nurse RN #1 of resident's elopement. Nursing staff (LPN #2 and RN #1) and myself then proceeded to exit the building and upon arriving outside resident was seen standing down the street on the corner.Resident calmed down and began to walk back to facility with me.Resident was escorted back into facility and placed at nurses' station. No visible wounds or scars noted. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on 11/8/21: 11/10/21 1100 a.m. Corrective Action Plan 1. On 10/19/2021, at approximately 8:45p.m., Resident #1, exited from the facility unassisted through her window. Resident #1 was assessed by Registered Nurse (RN) #1 had no injuries. She was placed on 1:1 constant observation on 10/19/21 at approximately 8:50 p.m. until she departed the facility at 10:15 p.m. 10/19/21. Through Quality Assurance (QA) the facility was able to determine how the resident exited the facility. The facility reviewed the elopement/wander/missing person standard, and in-service staff License Practical Nurse (LPN) #1, LPN #2, Certified Nurse Assistants (CNA) on elopement/wandering and monitoring residents where-abouts, also held a QA meeting 10/20/21 at 10:30a.m. The facility maintenance director inspected all windows and installed window stops to allow windows to lift/open 6 inches. Based on these steps, the facility determined that the immediate jeopardy was removed and represents past non-compliance. This event was reported to the State Agency via the hot line on 10/19/21 at approximately 9:36p.m. An elopement drill was done on 10/21/21 with all staff and no issues identified. 2. On 10/19/21 at approximately 8:45PM LPN #1 alerted RN #1 and LPN #2 of being unable to locate Resident #1 in her room and saw window open. Approximately 8: 50 PM Resident #1 was located outside on facility property approximately 120 feet from the facility entrance. Resident #1 was safely returned to the facility by LPN #1 unharmed and in no distress. At 8: 53 PM on 10/19/21 Director of Nurses (DON) was notified. On 10/19/21 at approximately 8:56 PM Medical Director, Administrator, responsible party and maintenance Supervisor were notified. 3. On 10/19/21 at 8:50 PM Resident #1 was located on the facility property and returned safely to facility. RN #1 performed a head-to-toe physical assessment on Resident #1 and found no scratches, bruises, edematous areas, or any abnormalities on 10/19/21 at approximately 8:55p.m. RN #1 and LPN #1 completed a 100% head count of all residents, and all residents were accounted for. 4. On 10/19/21 at approximately 8:53 PM Resident #1 was placed on 1:1 constant observation until she departed the facility at 10:15 PM in route to local hospital emergency room for evaluation. Resident #1 was admitted to the Geri-psych unit. On 10/20/21 all wandering/elopement risk assessments were audited by the DON on all residents with no newly found elopement or wander risks. 5. On 10/20/21 the risk wandering binder was reviewed by the Director of Nurses and returned to unit A and unit B. The facility has one wander/elopement risk resident in facility with care plan updated to check and lay eyes on resident every 2 hours. 6. On 10/20/21 at 10:00 AM Maintenance Director installed window stops to all resident windows. On 10/20/21 10:30 AM the event was reviewed and discussed in Quality Assurance Performance Improvement meeting attended by the Administrator via phone, Director of Nursing, Medical records nurse, Medical Director by phone, Minimum Data Set nurse, Maintenance Supervisor, and Social Service. Based on the meeting, it was determined that no changes were warranted to the elopement/wander/missing person standard. 7. On 10/19/21 following the incident, an in-service began on the facility standard for elopement/wandering/missing person and monitoring patients where-abouts at all times, present was 1 RN, 2 LPN, and 5 CNA. On 10/20/21 in-service continued, approximately 13 LPN's, 3 RN's, 14 CNA, 4 dietary, 4 housekeeping, 4 therapy, 3 maintenance and 1 social worker attended. On 10/21/21 in-service continued, 3 LPN's, 8 CNA's, 2 laundry and 3 dietary staff attended. No staff was allowed to work until in-services were completed. Based on the steps initiated by the facility for this event, the facility alleges that the Immediate Jeopardy was removed as of 10/22/21 and represents past non-compliance since all measures were completed prior to complaint survey entrance. VALIDATION The SA validated through record review and interviews that the facility discussed Resident #1 incident of elopement from the facility an emergency QA and Performance Improvement (QAPI) meeting on 10/20/21. The actions taken to ensure the provision of adequate supervision to meet Resident #1 needs were verified with evidenced by verification of the in-services, re-assessments, elopement drills, and audit tools. The SA validated through record review and interview on 10/19/2021, at approximately 8:45p.m., Resident #1, exited from the facility unassisted through her window. Resident #1 was assessed by Registered Nurse (RN) #1 had no injuries. She was placed on 1:1 constant observation on 10/19/21 at approximately 8:50 p.m. until she departed the facility at 10:15 p.m. 10/19/21. Through Quality Assurance (QA) the facility was able to determine how the resident exited the facility. The facility reviewed the elopement/wander/missing person standard, and in-service staff License Practical Nurse (LPN) #1, LPN #2, Certified Nurse Assistants (CNA) on elopement/wandering and monitoring residents where-abouts, also held a QA meeting 10/20/21 at 10:30a.m. The facility maintenance director inspected all windows and installed window stops to allow windows to lift/open 6 inches. Based on these steps, the facility determined that the immediate jeopardy was removed and represents past non-compliance. This event was reported to the State Agency via the hot line on 10/19/21 at approximately 9:36 p.m. The SA validated through record review and interview that on 10/19/21 at 8:50 PM Resident #1 was located on the facility property and returned safely to facility. RN #1 performed a head-to-toe physical assessment on Resident #1 and found no scratches, bruises, edematous areas, or any abnormalities on 10/19/21 at approximately 8:55p.m. RN #1 and LPN #1 completed a 100% head count of all residents, and all residents were accounted for. The SA validated through record review and interview on 10/19/21 at approximately 8:53 PM Resident #1 was placed on 1:1 constant observation until she departed the facility at 10:15 PM in route to local hospital emergency room for evaluation. Resident #1 was admitted to the Geri-psych unit. On 10/20/21 all wandering/elopement risk assessments were audited by the DON on all residents with no newly found elopement or wander risks. The SA validated through record review and interview on 10/20/21 the risk wandering binder was reviewed by the Director of Nurses and returned to unit A and unit B. The facility has one wander/elopement risk resident in facility with care plan updated to check and lay eyes on resident every 2 hours. The SA validated through record review and interview on 10/20/21 at 10:00 AM Maintenance Director installed window stops to all resident windows. On 10/20/21 10:30 AM the event was reviewed and discussed in Quality Assurance Performance Improvement meeting attended by the Administrator via phone, Director of Nursing, Medical records nurse, Medical Director by phone, Minimum Data Set nurse, Maintenance Supervisor, and Social Service. Based on the meeting, it was determined that no changes were warranted to the elopement/wander/missing person standard. The SA validated through record review and on 10/19/21 following the incident, an in-service always began on the facility standard for elopement/wandering/missing person and monitoring patients where-abouts, present was 1 RN, 2 LPN, and 5 CNA. On 10/20/21 in-service continued, approximately 13 LPN's, 3 RN's, 14 CNA, 4 dietaries, 4 housekeeping, 4 therapy, 3 maintenance and 1 social worker attended. On 10/21/21 in-service continued, 3 LPN's, 8 CNA's, 2 laundry and 3 dietary staff attended. No staff was allowed to work until in-services were completed.

Based on observation, staff interview, record review and facility policy review, the facility failed to provide premedication for pain prior to pressure ulcer care for one (1) of eight (8) pressure ulcer care observations. (Resident #1) Findings include: The facility's Daily Evaluation of Pressure/Stasis Ulcers Policy, not dated, revealed the facility would assess for pain before, during and after treatment. This policy also noted the facility would provide treatment as ordered. Resident #1 During a pressure ulcer care observation on 6/7/16 at 11:05 AM, Licensed Practical Nurse (LPN) #1 failed to provide additional measures to assure comfort and pain relief when Resident #1 audibly cried out in pain during wound care. Resident #1 moaned and cried out in pain seven (7) times during this observation with no other pain reduction interventions attempted. LPN #1 asked Resident #1 if she was in pain several times, even when she continued to yell out in pain and could not determine if Resident #1 was able to hear her when she questioned Resident #1 about her pain level. According to LPN #1, Resident #1 was very hard of hearing. When the care was completed, LPN #1 asked Resident #1 if she was ok and Resident #1 responded by loudly saying, No! On 6/7/16 at 11:50 AM an interview with LPN #1 revealed LPN #1 did not check with Resident #1's Medication Nurse this morning before providing wound care to determine if the resident had been pre-medicated for pain. When asked if she ever stops during the wound care to check to see if a resident has been pre-medicated, LPN #1 responded, We do stop and see if the nurse gives her something for pain, but confirmed she did not during this treatment observation. LPN #1 confirmed Resident #1 never said it was ok to continue with the pressure ulcer treatment when she asked her several times if the resident wanted her to stop or to continue with the care. LPN #1 confirmed Resident #1 yelled in pain numerous times during the pressure ulcer care treatment. LPN #1 stated Resident #1 was very hard of hearing and when asked if she thought Resident #1 heard her when she asked if she was in pain, LPN #1 responded, I don't know. LPN #1 stated Resident #1 had Tylenol 325 milligrams (mg) ordered for twice a day for pain. When asked LPN #1 if the Tylenol was effective in controlling Resident #1's pain during this care observations, she stated, No, she has a lot of pain with her care. When asked if LPN #1 checked this morning to see if Resident #1 had received pain medication prior to the wound care treatment, LPN #1 responded, No Ma'am, I didn't check to see if she had pain meds this morning. Review of the Cumulative physician's orders [REDACTED]. Review of a handwritten physician's orders [REDACTED]. A second pressure ulcer care observation on 6/8/16 at 2:30 PM revealed a circular wound to the left hip area measuring approximately five (5) centimeters in diameter. This wound was approximately one half (1/2) inch in depth, with slough and serosanguinous drainage noted to the wound bed. No signs or symptoms of pain were exhibited during this pressure ulcer care observation. On 6/9/16 at 2:40 PM in an interview with the Director of Nursing (DON) revealed pain during care should always be addressed by the nurse providing the care. The DON stated pain medication should be ordered for all residents experiencing pain during care and given prior to the treatment in time for the medication to work. The DON stated it is the Treatment Nurse's responsibility to assess for pain and get orders from the doctor. The DON stated it is the Treatment Nurses responsibility to add these medications and new treatments to each resident's care plan when changes are made. On 6/8/16 at 9:05 AM in an interview with the facility Nurse Practitioner (NP) revealed it will now be her responsibility to see all the residents on a regular basis to assess all needs including pain control during wound care. The facility NP stated she has been employed for one and one-half weeks. The NP stated all residents will now be pre-medicated prior to wound care and given at least 30 minutes prior to the treatments. On 6/9/16 at 12:30 PM with the Medical Director revealed he had just assumed the position on 6/1/16. The Medical Director stated he and the NP would be working closely together to assess all wounds in the facility and comfort for the residents when care is provided. Review of Resident #1's Face Sheet revealed the facility admitted Resident #1 on 6/19/15 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 3/3/16 revealed a Brief Interview for Mental Status (BIMS) of three (3), which indicated severe cognitive impairment.

Based on observation, staff interview, record review and facility policy review, the facility failed to develop a care plan with interventions related to pain associated with pressure ulcer dressing change for one (1) of eight (8) pressure ulcer care observations. (Resident #1) Findings include: Review of the facility's Comprehensive Plan of Care policy, dated 10/27/14, revealed the facility would develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment. The Plans of Care are developed by the interdisciplinary team to coordinate and communicate care approaches and goals for the resident related to clinical [DIAGNOSES REDACTED]. During an observation of pressure ulcer care on 6/7/17 at 11:05 AM, Resident #1 audibly cried out in pain seven (7) times during the course of the care. Licensed Practical Nurse (LPN) #1 continued to perform wound care without stopping to provide any interventions of pain reduction. Review of Resident #1's plan of care revealed there were no listed interventions for comfort measures during pressure ulcer care. During an interview on 6/7/16 at 11:50 AM, Licensed Practical Nurse (LPN) #1 stated a resident's care plan includes pain control and pain medication when ordered by the physician and is updated when medications are changed. LPN #1 stated the care plan for treatments included the assessments, care to be given, medications and the residents at risk for developing pressure ulcers. LPN #1 stated she would have to review Resident #1's care plan to see exactly what was on the care plan at this time. LPN #1 acknowledged Resident #1 complained of pain during the pressure ulcer dressing change. On 6/9/16 at 2:40 PM in an interview with the Director of Nursing (DON) revealed pain control should have been addressed on the care plan for Resident #1 and confirmed no interventions for pain control during wound care had been added to the care plan. The DON stated the Minimum Data Set (MDS) nurse initiates the care plan; but, the Wound Care Nurse (WCN) updates and makes changes to the care plan. The DON stated she did not know why Resident #1 did not have interventions for comfort measures during wound care but stated, It should have been. Review of Resident #1's Face Sheet revealed the facility admitted Resident #1 on 6/19/15, with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 3/3/16 revealed a Brief Interview for Mental Status (BIMS) of three (3), which indicated severe cognitive impairment.

Based on professional standards, medication order review, pharmacy delivery slip review, physician order [REDACTED]. (Resident #4, #1, #5, #6 and #7) This was evidenced by residents administered wrong medications, wrong medication strengths, and discontinued medications due to lack of protocol being followed by the nursing staff and the facility contract pharmacy. The facility's failure to use professional nursing standards when following physicians' orders, clarifying physicians' orders, administering medication, and failure to follow the facility's procedure for checking medications delivered by the contract pharmacy caused Resident #4 to be hosptalized on [DATE] when administered the wrong dose of [MEDICATION NAME] and Resident #1 to be administered twenty (20) bedtime doses of [MEDICATION NAME] instead of [MEDICATION NAME] from 09/12/14 through 10/1/14. These errors caused a situation with the likelihood of serious injury harm and/or death to all residents at the facility. This situation was determined to be an Immediate Jeopardy (IJ) identified on 11/12/14 and determined to exist on 9/12/14 when Resident #1 received [MEDICATION NAME] instead of [MEDICATION NAME]. The facility was notified of the Immediate Jeopardy on 11/12/14 and submitted a Credible Allegation of Compliance (AoC) on 11/13/14. The State Survey validated the credible AoC on 11/14/14. The State Agency determined the IJ was removed on 11/14/14 prior to exit. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.20(k)(3)(i), F281, Services Provided Meet Professional Standards was lowered to a "E" while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with the regulatory compliance. Findings include: "Nursing Skills & Procedures" by Perry and Potter (8th Edition) pages 321, 324 and 325 documented "Step 4f. Select correct drug ...Reading label first time and comparing it against transcribed order reduces errors ...This is the first check for accuracy ...k. Before going to patient's room, compare patient's name and name of medication on label of prepared drugs with MAR (Medication Administration Record). Reading labels a second time reduces errors. This is the second check for accuracy ...b. At patient's bedside again compare MAR or computer printout with names of medications on medication labels and patient name. This is the third check for accuracy and ensures that patient receives the correct medication. The facility's "Medication Administration Policy and Procedure" (no date), documented, "Purpose: To ensure the safe, appropriate, and accurate administration and handling of medications. To administer medication to residents accurately and efficiently according to Doctor's orders. Policy: Medications are administered to residents by qualified personnel RN/LPN (Registered Nurse/Licensed Practical Nurse) in compliance with federal and state laws and standards of professional practice. Procedure: Take each medication container and compare it with the resident's MAR (checking for the right patient, right medication) ...If any discrepancies occur, check the resident's orders or notify physician." The facility's "Medication Destruction Policy" dated 10/8/12 documented, Non-Narcotics: the Medication Nurse will remove discontinued or expired drugs from the med cart. Place in Discontinued Med Box ..." Resident #4 A review of the facility's investigation revealed on 11/4/14, the facility discovered a significant medication error had been made when administering medication to Resident #4. [MEDICATION NAME] 50 milligrams (mg) was administered instead of the ordered [MEDICATION NAME] 5 mg. A review of the physician's hand written order, dated 10/31/14 read, "(Change) [MEDICATION NAME] to 5 mg by mouth TID (three times daily)." The order was faxed to the pharmacy. Resident #4 was on the medication, [MEDICATION NAME] 20 mg daily, prior to this order. Review of the facility's investigation revealed on 10/31/14, the pharmacy instead delivered the previous dose of [MEDICATION NAME] 20 mg to be given TID instead of the new dosage. The investigation further revealed on 11/1/14, Licensed Practical Nurse (LPN) #2 notified the pharmacy that the order should have read [MEDICATION NAME] 50 mg three times a day. The pharmacy then delivered [MEDICATION NAME] 50 mg to the facility. A review of the facility's document entitled "Statement of Accident/Incident" handwritten by LPN #2 revealed, "I found 3 (cartridges) of [MEDICATION NAME] 20 mg TID. Writer called pharmacy to inform him that the wrong dosage was sent out. The order was then re-faxed to the pharmacy on 10/31/14. Upon my arrival on 11/1/14 to administer resident medication @ 9:00 AM, I found 3 (cartridges) of [MEDICATION NAME] 20 mg TID. Writer called pharmacy to inform him that the wrong dosage was sent out. The order was then re-faxed to the pharmacy. DR (on-call physician) was in the facility at that time et (and) reviewed order et stated that the order read [MEDICATION NAME] 50 mg TID. At the time of the survey, LPN #2 was no longer employed by the facility. The surveyor made attempts to reach her by telephone repeatedly on 11/12/14 and 11/13/14 without success. A review of the "Nurse Medication Error Report" revealed Resident #4's attending Physician was notified of the error on 11/3/14 at 11:00 AM. The Physician's statement read, "I have never ordered [MEDICATION NAME] 50 milligrams. It would take 5 pills to equal that dose, "I ordered [MEDICATION NAME] 5 mg po TID." A telephone interview on 11/24/14 at 5:30 PM, with the Prescribing Physician confirmed the [MEDICATION NAME] order was for 5 mg TID. A review of the Medication Administration Record (MAR) for November 2014 revealed [MEDICATION NAME] 50 mg was administered to Resident #4 on 11/1/14 at 5:00 PM, on 11/2/14 at 9:00 AM, 1:00 PM and 5:00 PM. Review of the Physician order [REDACTED].#4 to the local hospital on [DATE] due to decreased level of consciousness. A review of the 11/2/14 "History of Present Illness" obtained from the hospital stated, "The patient was found unresponsive at a local nursing home and brought to the emergency department. While there, the patient was noted to be hypercapnic ([MEDICAL CONDITION]). He did require mechanical intubation. The patient was further noted to be hypothermic (low body temperature). Other laboratory parameters were drawn and the patient was felt to meet [MEDICAL CONDITION] criteria. It is further reported the patient takes an excessive amount of pain medication as well as muscle spasm medication and felt that this likely contributed to his respiratory suppression." Resident #4 returned to the facility on [DATE] from the hospital, and an interview was attempted with the resident. Resident #4 was alert, but spoke in whispers and became short of breath and took great effort to reply to simple questions. Record review for Resident #4 revealed the facility admitted the resident on 10/2/14 with [DIAGNOSES REDACTED]. A review of the most current Minimum Data Set with an Assessment Reference date of 10/29/14 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Resident #1 Review of Resident #1's Physician's Telephone Orders sheet, dated 09/11/14 at 2:15 PM, revelaed the physician had ordered [MEDICATION NAME] 4 mg at hour of sleep, [MEDICATION NAME] 25 mg by mouth three times daily, and to remove Foley catheter one week after starting meds. Lippincott's "Nursing 2014 Drug Handbook" documented, [MEDICATION NAME] as a Antihypertensive Drug that also decreased smooth muscle tone in the prostate and bladder neck. A photograph of Resident #1's labeled medication cassette taken by the facility during their investigation of medication errors revealed the cassette was labeled [MEDICATION NAME] Sodium ([MEDICATION NAME]) (a blood thinner) 4 mg TAB (tablet) take 1 tab each night @ bedtime. The cassette contained [MEDICATION NAME] tablets. Review of the monthly Medication Administration Records (MAR), dated September 2014 and October 2014 documented, "[MEDICATION NAME] 4 mg 1 PO Q (every) HS (8 PM) Start Date: 9/11/14." The MAR's documented [MEDICATION NAME] 4 mg was administered by nursing staff every night from 09/12/14-10/01/2014; however, [MEDICATION NAME] was never sent to the facility by the pharmacy. [MEDICATION NAME] 4 mg was sent by the pharmacy for resident #1. There was no [MEDICATION NAME] ([MEDICATION NAME]) ordered or listed on Resident #1's September or October MAR. An interview was conducted with the facility's Dispensing Pharmacist on 10/28/14 at 1:35 PM. In the interview, he said the pharmacist who received the faxed physician's orders [REDACTED].#1. The Pharmacist confirmed the ordered medication, [MEDICATION NAME], was never sent to the facility. He added the pharmacy only learned of the medication error when they received a phone call from one of the nurses, but was not sure of the date of the phone call. An interview with Licensed Practical Nurse (LPN) #1, who discovered the medication error, was conducted on 10/27/14 at 8:55 PM. The LPN said 10/13/14 was the first time she had worked the medication cart on the 200 Hall and as she was pulling the medications for Resident #1, she saw a gray cassette that read [MEDICATION NAME] 4 mg. She said she looked at the MAR and [MEDICATION NAME] was not listed. She then reviewed the physician's orders [REDACTED]. She said there was an order for [REDACTED]. The LPN said she reported her concern to the charge nurse and they pulled the [MEDICATION NAME] cassette from the medication cart. An interview was conducted with the Quality Assurance (QA) Registered Nurse (RN) #1 on 10/28/14 at 11:16 AM. In the interview, the QA nurse said she investigated the incident with the [MEDICATION NAME] and [MEDICATION NAME]. She said her investigation revealed Resident #1 had received [MEDICATION NAME] 4 mg at 8:00 PM for approximately 20 days when she should have received [MEDICATION NAME] 4 mg at 8:00 PM. When asked how this type error could occur, the QA Registered Nurse (RN) said the 3-11 PM nurses were not comparing the label on the [MEDICATION NAME] cassette to the MAR which read [MEDICATION NAME] 4 mg. The facility admitted Resident #1 on 09/10/12. Her [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented Resident #1 as having short and long term memory problems and severely impaired cognitive skills for daily decision making. Resident #5 Review of the local hospital's "Discharge to Facility Med (medication) Reconciliation", dated 10/28/14, documented "[MEDICATION NAME] ([MEDICATION NAME]) 125 mcg (micrograms) tablet 1 tablet every day. Instructions: Discontinue." The facility's "physician's orders [REDACTED].#5's readmission to the facility on [DATE], did not include [MEDICATION NAME] as a medication to be continued for Resident #5. Review of the facility's "Nurse Medication Error Report" revealed the date of the medication error was 10/31/14 9:00 AM. The report indentified the error as [MEDICATION NAME] 125 mcg was administered after the medication was discontinued by the physician. As part of the facility's investigation, a photograph was taken by the facility of the label attached to Resident #5's [MEDICATION NAME] medication cassette. The label revealed the cassette contained [MEDICATION NAME] 125 mcg (microgram) #15 (fifteen tablets) and the fill date was 10/31/14. The facility's photograph of the medication cassette showed the first pill "Friday" had been removed from the cassette. The Licensed Practical Nurse (LPN) #1, who made the medication error, was no longer employed by the facility at the time of the survey and multiple attempts to reach her by telephone were unsuccessful. The facility initially admitted Resident #5 on 05/07/14. The facility readmitted Resident #5 from the acute care hospital on [DATE]. Her [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS), dated [DATE], documented Resident #5 had a BIMS (Brief Interview for Mental Status) score of six (6). A score of 6 indicated Resident #5 was severely cognitively impaired. Resident #6 A review of a "Nurse Medication Error Report" for Resident #6 revealed the resident had received the medication [MEDICATION NAME] 75 milligrams (mg) on 10/31/14 at 9:00 AM. A review of the handwritten "Physician's Telephone Orders" revealed the [MEDICATION NAME] had been discontinued on 10/28/14. A review of the October 2014 Medication Administration Record (MAR) revealed the [MEDICATION NAME] 75 mg had been discontinued on the MAR. The facility admitted Resident #6 on 10/24/14 with [DIAGNOSES REDACTED]. A review of the Minimum Data Set with an Assessment Reference date of 10/31/14 revealed a Brief Interview for Mental Status (BIMS) score of four (4) which indicated Resident #6 had severe cognitive impairment Resident #7 A review of a "Nurse Medication Error Report" for Resident #7 revealed the resident had an order to receive [MEDICATION NAME] 5 mg every hour of sleep. The report further stated Resident #7 did not receive the medication on 9/27/14 as ordered by the attending physician. A review of the Physician's Telephone Orders dated 9/26/14 revealed an order which read, "DC [MEDICATION NAME] Na 5 mg po q AM. Give [MEDICATION NAME] 5 mg po q HS." A review of the September 2014 Medication Administration Record (MAR) revealed the order read, [MEDICATION NAME] 5 mg po Q HS (5 milligrams by mouth every hour of sleep). Review of the label on the medication cassette read, "Take 1 tablet by mouth every other night at bedtime." The pharmacy labeled the medication incorrectly. The facility admitted Resident #7 on 9/26/14 with [DIAGNOSES REDACTED]. Review of the current Minimum Data Set with an Assessment Reference Date of 10/3/14 revealed the resident had a Brief Interview for Mental Status Score of 15 which indicated Resident #7 was cognitively intact. Resident #7 was discharged home on[DATE]. There was no documented evidence of staff or pharmacy getting clarification of the order which contained a possible discrepancy. A interview with the Director of Nursing (DON) was conducted on 11/14/14 at 4:07 PM. The DON confirmed the facility was having medication errors by not comparing the Medication Administration Record (MAR) with the medications during administration and not documenting medications on the MARs. When asked why she thought med errors had been occurring at the facility, the DON said the nurses were failing to follow the "Rights of Medication Administration." She also said the pharmacy played a big role by misreading two prescriptions. The DON said she would consider the anticoagulant, [MEDICATION NAME] being administered to Resident #1 without a physician's orders [REDACTED]. On 11/12/14 at 11:45 AM, an interview with the Unit Manager(Supervisor) RN #2 revealed the problem was that the pharmacy would refill the medications if it was close to the reorder date without checking for discontinued medication orders. She stated the facility's procedure was followed and the discontinued medications were removed from the medication cart. She stated it was the facility practice to remove discontinued meds from the cart and to fax the discontinue order to the pharmacy. RN #2 confirmed the nurse who checked the reordered medications (should have caught the discontinued medication) not have placed discontinued medications back in the medication cart where they could be administered. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 11/13/14 for the Immediate Jeopardy. Review of the facility's AoC revealed the facility took the following measures to remove the IJ. 1. At 4:53 PM on 11/12/14 an emergency QA meeting was called with the Medical Director, Administrator, Director of Nursing, QA Nurse, and Medical Records Nurse to discuss the Immediate Jeopardy status of the facility and the plan of correcting the deficient practice in order to achieve Compliance. On 11/13/14 the facility had a phone conference with Pharmacy Consultant Owner reviewing policy change and previous discrepancies. New Pharmacy services was contacted on 11/13/14 in regard to these discrepancies and the process of achieving compliance. Pharmacy Consultant and new pharmacy have established a new procedure with the medication delivery process. 2. Medication Administration Policy was revised and these revisions were reviewed in QA and approved by Medical Director on 11/12/14. Previous policy was reviewed and approved with a statement added for nurses to sign MAR after administering medication. A monitor form for medication auditing was developed and revised on 11/12/14. 3. On 11/5/14 a new contract was established and signed with a new Pharmacy Provider and facility will no longer use the previous pharmacy. On 11/5/14 and on 11/11/14, six (6) of 6 agency nursing staff, 11 of 11 LPN nursing staff, and 5 of 5 RN were In-Serviced by new Pharmacy Provider Staff. 4. On 11/12/14 at 1:25 PM an audit was conducted by Director of Nursing, QA Nurse, Medical Records Nurse, MDS Nurse and 2 RN Unit Managers. A 100 % audit process was conducted in the facility immediately of the MARs against the Physician order [REDACTED]. The facility identified 14 discrepancies out of 97 reviews. All 14 discrepancies were corrected. 5. On 11/12/14 In-Services were conducted with Director of Nursing, QA Nurse, Medical Records Nurse, MDS Nurse and 2 RN Unit Managers by QI Nurse Consultant on the following: 8 Medication Rights, Checking all new medications arriving to facility must be checked against Physician order [REDACTED]. During the In-service nurses were instructed to report discrepancies to the Director of Nursing immediately. 6. On 11/12/14 In-Services were conducted with all nursing staff by RN Unit Manager on the following: 8 Medication Rights, Checking all new medications arriving to facility must be checked against Physician order [REDACTED]. On 11/12/14, 6 of 6 agency nursing staff, 10 of 11 LPN nursing staff and 4 of 5 RNs were In-Serviced by RN Unit Manager. No Nursing Staff will be allowed to work until In-Serviced. 7. Agency #1, providing Nurses to the facility, was notified on 11/12/14 that nurses must be In-Serviced prior to their shift. Agency #1 was notified that any new nurses that have not been utilized at the facility must be oriented and In-Serviced prior to working. Agency #2, providing Nurses to the facility, was notified on 11/12/14 that nurses must be In-Serviced prior to their shift. Agency #2 was notified that any new nurses that have not been utilized at the facility must be oriented and In-Serviced prior to working. 8. On 11/4/14 LPN #2 who transcribed the order to the MAR was terminated from employment with the facility. The Mississippi Board of Nursing was contacted and LPN #2 was reported on 11/5/14. On 11/12/14 a notification was sent to Agency #1 that LPN #1 cannot return to work at the facility. The Director of Nursing resigned on 11/4/14. The Previous Director of Nursing, whom retired in 2009 and worked part-time at facility, has resumed the role as Director of Nursing. The concerns with Pharmacy #1 was reported by Administrator to the Board of Pharmacy on 11/12/14. The facility alleges the Immediate Jeopardy has been removed on 11/14/14. On 11/14/14, the State Survey Agency validated the facility had implemented the following measures to remove the Immediate Jeopardy. An Acceptable Credible Allegation of Compliance was verified by staff interviews and record review of in-services on 11/14/14 beginning at 9:00 AM through 5:45 PM. 1. Review of the Quality Assurance Meeting sign in sheets and information provided by the facility confirmed on 11/12/14, the facility held an emergency QA meeting. The Medical Director, Administrator, Director of Nursing, QA Nurse, and Medical Records Nurse attended and discussed the Immediate Jeopardy status of the facility and a plan of correction to achieve compliance. Review of facility documentation revealed the facility had a phone conference with Pharmacy Consultant Owner and the New Pharmacy Services on 11/13/14 to review policy changes and previous discrepancies, and established a new procedure with the medication delivery process. 2. Review of the facility's Medication Administration Policy confirmed the revisions approved by Medical Director on 11/12/14 to add a statement for nurses to sign MAR after administering medication. The State Agency also confirmed a monitoring form for medication auditing was developed by the facility. 3. The new contract established and signed with a new Pharmacy Provider on 11/5/14 was reviewed. The contract was confirmed to go into effect on November 14, 2014. The surveyor confirmed by review of the sign in sheets and staff interviews, the new Pharmacy Provider in-serviced six of six Agency Nurses, eleven of eleven LPNs, and five of five RNs on 11/5/14 and on 11/11/14. 4. Review of a facility list confirmed a 100% audit performed by the Director of Nursing, QA Nurse, Medical Records Nurse, MDS Nurse and 2 Unit Managers on 11/12/14 at 1:25 PM of the MARS against the Physician order [REDACTED]. The surveyor confirmed the facility identified 14 discrepancies out of 97 reviews and discrepancies were corrected. 5. Review of sign in sheets, topics, and staff interviews confirmed on 11/12/14 the facility QI (Quality Improvement) Nurse Consultant in-serviced the Director of Nursing, QA Nurse, Medical Records Nurse, MDS Nurse and 2 RN Unit Managers on the following: a. 8 Medication Rights, b. Checking of all new medications arriving to facility against Physician order [REDACTED]. c. Policy change including documentation of MAR to ensure no missing documentation occurs within facility, d. Availability of drug reference books to nurses on all 4 medication carts e. 24 hour chart checks and the process of checking the Physician order [REDACTED]. f. Process of discontinuation of medications and the responsibility of the nurse receiving the order: medication removed from the MAR and removed from the medication cart for destruction. g. Nurses are to report discrepancies to the Director of Nursing immediately. 6. Interviews with 100% of the facility nursing staff and the agency nursing staff, and review of sign in sheets and topics confirmed on 11/12/14, RN Unit Manager in-serviced 6 of 6 Agency Nurses, 10 of 11 LPNs and 4 of 5 RNs on the following: a. 8 Medication Rights, b. Checking of all new medications arriving to facility against Physician order [REDACTED]. c. Policy change including documentation of MAR to ensure no missing documentation occurs within facility, d. Availability of drug reference books on all carts for nurses to refer to when they have medication questions or need medication information, e. 24 hour chart checks and the process of checking the Physician order [REDACTED]. f. Process of discontinuation of medications and the responsibility of the nurse receiving the order to ensure the medication is removed from the MAR and the medication cart for destruction. g. Nurses are to report discrepancies to the Director of Nursing immediately. 7. Review of letters sent to Agency #1 and Agency #2, providing Nurses to the facility, confirmed the Staffing Agencies were notified on 11/12/14 that nurses must be in-serviced prior to their shift, and any new nurses that have not been utilized at the facility must be oriented and in-serviced prior to working on all new policies and procedures. 8. The surveyor confirmed by review of the personnel record that on 11/4/14, LPN #2 was terminated from employment with the facility and was reported to the Mississippi Board of Nursing on 11/5/14. The surveyor confirmed by review of a statement dated 11/12/14, a notification was sent to Agency #1 that LPN #1 could not return to work at the facility. The surveyor confirmed the Director of Nursing during the time of the discrepancies resigned on 11/4/14. Interview with the Director of Nursing, whom retired in 2009 and worked part-time at facility, confirmed she has resumed the role as Director of Nursing. Review of documentation confirmed the facility Administrator reported concerns with Pharmacy #1 to the Board of Pharmacy on 11/12/14. 9. Upon review of the staffing schedule, the surveyor confirmed no Nursing Staff had been allowed to work until in-serviced on the new facility procedures.

Based on Quality Assurance record review, policy review, staff and physician interviews, the facility failed to have an effective system to identify issues for which quality assessment and assurance activities were necessary, and failed to develop and implement appropriate plans of action to correct quality deficiencies as evidenced by repeated deficiencies related to the facility's failure to prevent medications errors for five (5) of seven (7) residents reviewed with medication errors. (Resident #1, #4, #5, #6, #7) The facility failed to have an effective system in place to ensure residents received medications as ordered by the attending physicians was evidenced by Complaint survey MS CI # of 6/24/14, the facility's failure to ensure a resident leaving the facility for therapeutic pass received medications intended and only prescribed for the resident. The resident was given medications while out on pass that were prescribed for another resident. F281 and F333 were cited. On 8/13/14, a revisit survey was conducted for MS CI # with Tags F281, F333 and F425 cited for continued non-compliance. On 9/29/14, a second revisit was conducted for MS CI # with Tags F425 and F514 cited for continued non-compliance. On 10/28/14, a complaint survey for MS CI # was conducted with Tags F333 and F431 cited. On 11/10/14, a complaint survey for MS CI # was extended along with an additional complaint MS CI # for continued medication errors. The facility's failure to identify, track, and trend facility medication errors and implement safe interventions for medication administration caused a situation that led to the hospitalization of Resident #4 with respiratory suppression and caused a situation that was likely to cause serious injury, harm, impairment or death to other residents. This situation was determined to be an Immediate Jeopardy (IJ) identified on 11/12/14 and determined to exist on 9/12/14 when Resident #1 received [MEDICATION NAME] instead of [MEDICATION NAME]. The facility was notified of the Immediate Jeopardy on 11/12/14 and submitted a Credible Allegation of Compliance (AoC) on 11/13/14. The State Survey validated the credible AoC on 11/14/14. The State Agency determined the IJ was removed on 11/14/14 prior to exit. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.75(o)(1), F520, Quality Assurance was lowered to a "E" while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with the regulatory compliance. Findings Include: A review of the facility's policy entitled "Significant Medication Error Policy and Procedure" stated, "The Director of Nursing, the Medical Director, the QA Nurse and Administrator must be notified, in order for an Emergency QA meeting to convene." On 11/12/14 at 4:00 PM, an interview with the facility's Medical Director revealed he did attend the QA meetings quarterly and was aware of facility medication errors. He stated he was unaware of an ongoing problem related to medication errors. He further stated he thought the problem had been "fixed". The Medical Director stated the QA meetings were not very proactive as far as he could see. He stated he had seen no evidence of tracking and trending for any areas discussed. He did not see anything being accomplished by the QA meetings he had attended. An interview with the Pharmacy Consultant, on 11/12/14 at 9:30 AM, revealed the she made monthly visits. The consultant stated she was aware the facility had a lot of medication errors. The consultant stated she makes written recommendations each time she visits regarding orders not being transcribed, laboratory results not being obtained and/or on the charts and discontinued medications continuing to be found in the medication carts. Review of the Pharmacy Consultant's report revealed medicaiton errors were address in June and July report and a medication pass observation was conducted with facility nurses. On 11/11/14 at 4:00 PM, an interview with the QA (Quality Assurance) Nurse revealed the QA committee had met after the medication error concerning Resident #4. The QA Nurse stated she had continuously in serviced the facility nurses on medication administration and avoiding medication errors. A review of the facility's document entitled "Emergency QA on significant medication error of (Resident #4's name)" dated 11/3/14 stated, "Problem Identified: Discovery of a Significant Medication Error- Physician ordered [MEDICATION NAME] 5 mg t.i.d. (3 times a day) (Pharmacy misread order and delivered [MEDICATION NAME] 20 mg t.i.d. on 11/1/14; Nurse (LPN #2) notified Pharmacy on 11/1/14 stating they had delivered the wrong medication, "it should be [MEDICATION NAME] 50 mg t.i.d."; Pharmacy delivered [MEDICATION NAME] 50 mg t.i.d./ give (2 & ?) 20 mg tab. On 11/3/14, Pharmacist called facility requesting a clarification order. Plan of Correction of future occurrence: Change in Pharmacy." A review of the facility's document entitled "Emergency QA on significant medication error of (Resident #1)" dated 10/16/14 stated, "Problem Identified: Discovery of a Significant Medication Error on the 3/11 shift on 10/15/14 (Pharmacy misread order and sent incorrect medication). Plan of Correction of future occurrence: In-service of Nurses Upon delivery of medications the nurse will reconcile the delivery sheet with the medication delivered and in addition will reconcile the medication with the Medication Administration Record. If any discrepancy noted the Nurse should go to the chart and review the Doctor's Order." There was no documented evidence the Medical Director or his designee was notified of and/or attended Resident #4's or Resident #7's Emergency QA Meeting. There was no documented evidence of QA meetings addressing other medication errors or the systemic failure. Resident #1 Review of facility incident reports and medication error reports revealed Resident #1 was given [MEDICATION NAME] 4 mg for 20 evening doses from 09/12/14-10/01/14 instead of the [MEDICATION NAME] 4 mg that was ordered for her by the physician. The facility admitted Resident #1 on 09/10/12. Her [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented Resident #1 as having short and long term memory problems and severely impaired cognitive skills for daily decision making. Resident #4 A review of the facility's investigation revealed on 11/4/14, the facility discovered the nurse made a significant medication error on Resident #4 when the resident was administered four (4) doses of [MEDICATION NAME] 50 mg instead of [MEDICATION NAME] 5 mg. Record review for Resident #4 revealed the facility admitted the resident on 10/2/14 with [DIAGNOSES REDACTED]. A review of the most current Minimum Data Set with an Assessment Reference date of 10/29/14 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Resident #5 The facility's "physician's orders [REDACTED].#5's readmission to the facility on [DATE], did not include [MEDICATION NAME] as a medication to be continued for Resident #5. The resident received the [MEDICATION NAME] after it was discontinued. The facility initially admitted Resident #5 on 05/07/14. The facility readmitted Resident #5 from the acute care hospital on [DATE]. Her [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS), dated [DATE], documented Resident #5 had a BIMS (Brief Interview for Mental Status) score of six (6) which indicated Resident #5 was severely cognitively impaired. Resident #6 A review of a "Nurse Medication Error Report" for Resident #6 revealed the resident had received the medication [MEDICATION NAME] 75 milligrams (mg) on 10/31/14 at 9:00 AM. A review of the handwritten "Physician's Telephone Orders" revealed the [MEDICATION NAME] had been discontinued on 10/28/14. A review of the October 2014 Medication Administration Record (MAR) revealed the [MEDICATION NAME] 75 mg had been discontinued on the MAR. The facility admitted Resident #6 on 10/24/14 with [DIAGNOSES REDACTED]. A review of the Minimum Data Set with an Assessment Reference date of 10/31/14 revealed a Brief Interview For Mental Status score of four (4) which indicated Resident #6 had severe cognitive impairment. Resident #7 A review of a "Nurse Medication Error Report" for Resident #7 revealed the resident had an order to receive [MEDICATION NAME] 5 mg (milligrams) q hs (every hour of sleep). The report further stated Resident #7 did not receive the medication on 9/27/14 as ordered by the attending physician. The facility admitted Resident #7 on 9/26/14 with [DIAGNOSES REDACTED]. Review of the current Minimum Data Set with an Assessment Reference Date of 10/3/14 revealed the resident had a Brief Interview for Mental Status Score of 15 which indicated Resident #7 was cognitively intact. Resident #7 was discharged home on[DATE]. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 11/13/14 for the Immediate Jeopardy. Review of the facility's AoC revealed the facility took the following measures to remove the IJ. 1. At 4:53 PM on 11/12/14 an emergency QA meeting was called with the Medical Director, Administrator, Director of Nursing, QA Nurse, and Medical Records Nurse to discuss the Immediate Jeopardy status of the facility and the plan of correcting the deficient practice in order to achieve Compliance. On 11/13/14 the facility had a phone conference with Pharmacy Consultant Owner reviewing policy change and previous discrepancies. New Pharmacy services was contacted on 11/13/14 in regard to these discrepancies and the process of achieving compliance. Pharmacy Consultant and new pharmacy have established a new procedure with the medication delivery process. 2. Medication Administration Policy was revised and these revisions were reviewed in QA and approved by Medical Director on 11/12/14. Previous policy was reviewed and approved with a statement added for nurses to sign MAR after administering medication. A monitor form for medication auditing was developed and revised on 11/12/14. 3. On 11/5/14 a new contract was established and signed with a new Pharmacy Provider and facility will no longer use the previous pharmacy. On 11/5/14 and on 11/11/14, six (6) of 6 agency nursing staff, 11 of 11 LPN nursing staff, and 5 of 5 RN were In-Serviced by new Pharmacy Provider Staff. 4. On 11/12/14 at 1:25 PM an audit was conducted by Director of Nursing, QA Nurse, Medical Records Nurse, MDS Nurse and 2 RN Unit Managers. A 100 % audit process was conducted in the facility immediately of the MARs against the Physician order [REDACTED]. The facility identified 14 discrepancies out of 97 reviews. All 14 discrepancies were corrected. 5. On 11/12/14 In-Services were conducted with Director of Nursing, QA Nurse, Medical Records Nurse, MDS Nurse and 2 RN Unit Managers by QI Nurse Consultant on the following: 8 Medication Rights, Checking all new medications arriving to facility must be checked against Physician order [REDACTED]. During the In-service nurses were instructed to report discrepancies to the Director of Nursing immediately. 6. On 11/12/14 In-Services were conducted with all nursing staff by RN Unit Manager on the following: 8 Medication Rights, Checking all new medications arriving to facility must be checked against Physician order [REDACTED]. On 11/12/14, 6 of 6 agency nursing staff, 10 of 11 LPN nursing staff and 4 of 5 RNs were In-Serviced by RN Unit Manager. No Nursing Staff will be allowed to work until In-Serviced. 7. Agency #1, providing Nurses to the facility, was notified on 11/12/14 that nurses must be In-Serviced prior to their shift. Agency #1 was notified that any new nurses that have not been utilized at the facility must be oriented and In-Serviced prior to working. Agency #2, providing Nurses to the facility, was notified on 11/12/14 that nurses must be In-Serviced prior to their shift. Agency #2 was notified that any new nurses that have not been utilized at the facility must be oriented and In-Serviced prior to working. 8. On 11/4/14 LPN #2 who transcribed the order to the MAR was terminated from employment with the facility. The Mississippi Board of Nursing was contacted and LPN #2 was reported on 11/5/14. On 11/12/14 a notification was sent to Agency #1 that LPN #1 cannot return to work at the facility. The Director of Nursing resigned on 11/4/14. The Previous Director of Nursing, whom retired in 2009 and worked part-time at facility, has resumed the role as Director of Nursing. The concerns with Pharmacy #1 was reported by Administrator to the Board of Pharmacy on 11/12/14. The facility alleges the Immediate Jeopardy has been removed on 11/14/14. On 11/14/14, the State Survey Agency validated the facility had implemented the following measures to remove the Immediate Jeopardy. An Acceptable Credible Allegation of Compliance was verified by staff interviews and record review of inservices on 11/14/14 beginning at 9:00 AM through 5:45 PM. 1. Review of the Quality Assurance Meeting sign in sheets and information provided by the facility confirmed on 11/12/14, the facility held an emergency QA meeting. The Medical Director, Administrator, Director of Nursing, QA Nurse, and Medical Records Nurse attended and discussed the Immediate Jeopardy status of the facility and a plan of correction to achieve compliance. Review of facility documentation revealed the facility had a phone conference with Pharmacy Consultant Owner and the New Pharmacy Services on 11/13/14 to review policy changes and previous discrepancies, and established a new procedure with the medication delivery process. 2. Review of the facility's Medication Administration Policy confirmed the revisions approved by Medical Director on 11/12/14 to add a statement for nurses to sign MAR after administering medication. The State Agency also confirmed a monitoring form for medication auditing was developed by the facility. 3. The new contract established and signed with a new Pharmacy Provider on 11/5/14 was reviewed. The contract was confirmed to go into effect on November 14, 2014. The surveyor confirmed by review of the sign in sheets and staff interviews, the new Pharmacy Provider in-serviced six of six Agency Nurses, eleven of eleven LPNs, and five of five RNs on 11/5/14 and on 11/11/14. 4. Review of a facility list confirmed a 100% audit performed by the Director of Nursing, QA Nurse, Medical Records Nurse, MDS Nurse and 2 Unit Managers on 11/12/14 at 1:25 PM of the MARS against the Physician order [REDACTED]. The surveyor confirmed the facility identified 14 discrepancies out of 97 reviews and discrepancies were corrected. 5. Review of sign in sheets, topics, and staff interviews confirmed on 11/12/14 the facility QI (Quality Improvement) Nurse Consultant in-serviced the Director of Nursing, QA Nurse, Medical Records Nurse, MDS Nurse and 2 RN Unit Managers on the following: a. 8 Medication Rights, b. Checking of all new medications arriving to facility against Physician order [REDACTED]. c. Policy change including documentation of MAR to ensure no missing documentation occurs within facility, d. Availability of drug reference books to nurses on all 4 medication carts e. 24 hour chart checks and the process of checking the Physician order [REDACTED]. f. Process of discontinuation of medications and the responsibility of the nurse receiving the order: medication removed from the MAR and removed from the medication cart for destruction. g. Nurses are to report discrepancies to the Director of Nursing immediately. 6. Interviews with 100% of the facility nursing staff and the agency nursing staff, and review of sign in sheets and topics confirmed on 11/12/14, RN Unit Manager in-serviced 6 of 6 Agency Nurses, 10 of 11 LPNs and 4 of 5 RNs on the following: a. 8 Medication Rights, b. Checking of all new medications arriving to facility against Physician order [REDACTED]. c. Policy change including documentation of MAR to ensure no missing documentation occurs within facility, d. Availability of drug reference books on all carts for nurses to refer to when they have medication questions or need medication information, e. 24 hour chart checks and the process of checking the Physician order [REDACTED]. f. Process of discontinuation of medications and the responsibility of the nurse receiving the order to ensure the medication is removed from the MAR and the medication cart for destruction. g. Nurses are to report discrepancies to the Director of Nursing immediately. 7. Review of letters sent to Agency #1 and Agency #2, providing Nurses to the facility, confirmed the Staffing Agencies were notified on 11/12/14 that nurses must be in-serviced prior to their shift, and any new nurses that have not been utilized at the facility must be oriented and in-serviced prior to working on all new policies and procedures. 8. The surveyor confirmed by review of the personnel record that on 11/4/14, LPN #2 was terminated from employment with the facility and was reported to the Mississippi Board of Nursing on 11/5/14. The surveyor confirmed by review of a statement dated 11/12/14, a notification was sent to Agency #1 that LPN #1 could not return to work at the facility. The surveyor confirmed the Director of Nursing during the time of the discrepancies resigned on 11/4/14. Interview with the Director of Nursing, whom retired in 2009 and worked part-time at facility, confirmed she has resumed the role as Director of Nursing. Review of documentation confirmed the facility Administrator reported concerns with Pharmacy #1 to the Board of Pharmacy on 11/12/14. 9. Upon review of the staffing schedule, the surveyor confirmed no Nursing Staff had been allowed to work until in-serviced on the new facility procedures.

Based on physician order [REDACTED]. The facility's contract pharmacy sent [MEDICATION NAME], a blood thinner, for Resident #1. The facility nursing staff failed to recognize the wrong medication was received. Resident #1 received twenty doses of the anticoagulant (blood thinner) medication [MEDICATION NAME] which was not prescribed for the resident before the error was discovered. The pharmacy filled the physician's orders [REDACTED]. The medication was labeled as [MEDICATION NAME]. The facility nursing staff signed the Medication Administration Record (MAR) for [MEDICATION NAME]. Resident #4 received four doses of [MEDICATION NAME] 50 milligrams (mg) instead of 5 mg as ordered by the physician. Resident #4 was transferred to the hospital on [DATE] due to decreased level of consciousness. The hospital admitted Resident #4 to the Intensive Care Unit (ICU) due to respiratory suppression. The facility's failure to document [MEDICATION NAME] and [MEDICATION NAME] 50 mg were administered, instead the nursing staff documented [MEDICATION NAME] and [MEDICATION NAME] 5 mg was administered. This failure caused a situation that resulted in the hospitalization of Resident #4 with respiratory suppression and was likely to cause serious injury, harm, impairment or death to other residents. This situation was determined to be an Immediate Jeopardy (IJ) identified on 11/12/14 and determined to exist on 9/12/14 when Resident #1 received [MEDICATION NAME] instead of [MEDICATION NAME]. The facility was notified of the Immediate Jeopardy on 11/12/14 and submitted a Credible Allegation of Compliance (AoC) on 11/13/14. The State Survey validated the credible AoC on 11/14/14. The State Agency determined the IJ was removed on 11/14/14 prior to exit. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.75 (l)(1), Complete and Accurate Medical Record, F514, was lowered to a "E" while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with the regulatory compliance. Findings Include: Resident #1 The Physician's Telephone Orders sheet, dated and timed 09/11/14 at 2:15 PM, documented [MEDICATION NAME] 4 mg was to be administered daily at the hour of sleep. The September 2014 and October 2014 Medication Administration Records (MARs) documented [MEDICATION NAME] 4 milligrams (mg) 1 every night at 8 PM. The start date was 9/11/14. The MARs revealed nursing staff had documented [MEDICATION NAME] 4 mg was administered every night from 09/12/14 through 10/01/2014; however, [MEDICATION NAME] 4 mg was actually given. [MEDICATION NAME] was not listed on Resident #1's September or October MAR. The Pharmacy Delivery Sheets documented delivery of [MEDICATION NAME] 4 mg (15 tablets) for Resident #1 on 09/18/14, 10/02/14, and 10/16/14. There was no documentation of [MEDICATION NAME] delivery for Resident #1. An interview with Licensed Practical Nurse (LPN) #1, on 10/27/14 at 8:55 PM, revealed she was pulling the medications for Resident #1 and saw [MEDICATION NAME] 4 mg. She said she looked at the MAR and [MEDICATION NAME] was not listed. She then reviewed the physician's orders [REDACTED]. The facility admitted Resident #1 on 09/10/12. Her [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #1 as having short and long term memory problems and severely impaired cognitive skills for daily decision making. An interview with the Director of Nursing (DON) was conducted on 11/14/2014 at 4:07 PM. The DON confirmed the facility was having medication errors by not comparing the Medication Administration Record (MAR) with the medications during administration and not documenting medications on the MARS. Resident #4 Resident #4 was on the medication [MEDICATION NAME] 20 milligrams daily. On 10/31/14, an order had been written which read to change the [MEDICATION NAME] to 5 milligrams three times a day. The order was faxed to the pharmacy. On 10/31/14, the pharmacy delivered [MEDICATION NAME] 20 milligrams to be given three times a day. The investigation further revealed on 11/1/14, Licensed Practical Nurse (LPN) #2 notified the pharmacy that the order should have read [MEDICATION NAME] 50 (fifty) milligrams three times a day. The pharmacy then delivered [MEDICATION NAME] 50 milligrams to the facility. Upon review of the physician's hand written order, dated 10/31/14, the order read, "(Change) [MEDICATION NAME] to 5 mg (milligrams) PO (by mouth) TID (three times daily)." The resident had previously been taking [MEDICATION NAME] 20 mg. A review of the Medication Administration Record (MAR) for November 2014 revealed [MEDICATION NAME] 50 mg was documented as being administered to Resident #4 on 11/1/14 at 5:00 PM, on 11/2/14 at 9:00 AM, 1:00 PM and 5:00 PM instead of the ordered 5 mg. Record review for Resident #4 revealed the facility admitted the resident on 10/2/14 with [DIAGNOSES REDACTED]. A review of the most current Minimum Data Set with an Assessment Reference date of 10/29/14 revealed a Brief Interview for Mental Status Score of 15 which indicated the resident was cognitively intact.

Based on review of facility medication error reports, staff interviews, and facility policy review, the facility failed to ensure residents received medications as ordered by the physician for two (2) of seven (7) residents reviewed for medication accuracy. (Resident #4 and Resident #1) Resident #1 received twenty doses of the anticoagulant medication [MEDICATION NAME] (blood thinner) which was not prescribed for the resident. The pharmacy filled the physician's orders [REDACTED]. The facility nursing staff administered the [MEDICATION NAME] and signed the Medication Administration Record (MAR) for [MEDICATION NAME]. Resident #4 received four doses of [MEDICATION NAME] 50 milligrams instead of 5 mg as ordered by the physician. These errors were significant due to [MEDICATION NAME] requiring laboratory monitoring and [MEDICATION NAME] having a side effect of respiratory suppression. The facility's failure to follow facility protocol and nursing protocol for medication administration caused a situation that caused the hospitalization of Resident #4 with respiratory suppression and was likely to cause serious injury, harm, impairment or death to other residents. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) identified on 11/12/14 and determined to exist on 9/12/14 when Resident #1 received [MEDICATION NAME] instead of [MEDICATION NAME]. The facility was notified of the Immediate Jeopardy on 11/12/14 and submitted a Credible Allegation of Compliance (AoC) on 11/13/14. The State Survey validated the credible AoC on 11/14/14. The State Agency determined the IJ was removed on 11/14/14 prior to exit. The Scope and Severity for Immediate Jeopardy and Substandard Quality of Care (SQC) at 42 CFR 483.259 (m)(2), F333, Free of Significant Medication Errors was lowered to a "E" while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with the regulatory compliance. Findings include: The facility's "Medication Administration Policy and Procedure" (no date), documented, "Purpose: To ensure the safe, appropriate, and accurate administration and handling of medications. To administer medication to residents accurately and efficiently according to Doctor's orders. Policy: Medications are administered to residents by qualified personnel RN/LPN (Registered Nurse/Licensed Practical Nurse) in compliance with federal and state laws and standards of professional practice. Procedure: ...Take each medication container and compare it with the resident's MAR (checking for the right patient, right medication) ...If any discrepancies occur, check the resident's orders or notify physician." The facility's "Significant Medication Error Policy and Procedure" (dated 7/15/14) documented, "Policy: It is the policy of this facility that all residents are free from significant medication errors. These medications may include but are not limited to anticoagulants ...Definition: Significant Errors are these types of medications that are not ordered but given or ordered meds that are given erroneously." Resident #4 A review of the facility's investigation revealed the facility discovered a significant medication error had been made on Resident #4 on 11/4/14. Resident #4 was on the medication [MEDICATION NAME] 20 milligrams daily. On 10/31/14, an order had been written which read to change the [MEDICATION NAME] to 5 milligrams three times a day. The order was faxed to the pharmacy. On 10/31/14, the pharmacy delivered [MEDICATION NAME] 20 milligrams to be given three times a day. The investigation further revealed on 11/1/14, Licensed Practical Nurse (LPN) #2 notified the pharmacy that the order should have read [MEDICATION NAME] 50 (fifty) milligrams three times a day. The pharmacy then delivered [MEDICATION NAME] 50 milligrams to the facility. A review of LPN #2's "Statement of Accident/Incident", dated 11/4/14, read, "MD (Physician's surname) wrote order for resident to (change) [MEDICATION NAME] to 50 mg (milligrams) po (by mouth) TID (three times a day) on 10/31/14. Order was faxed to pharmacy on 10/31/14. Upon my arrival on 11/1/14 to administer resident medication @ 9:00 AM, I found 3 (cartridges) of [MEDICATION NAME] 20 mg TID. Writer called pharmacy to inform him that the wrong dosage was sent out. The order was then re-faxed to the pharmacy. DR. (on-call physician) was in the facility at that time et (and) reviewed order et stated that the order read [MEDICATION NAME] 50 mg TID." A review of the "Nurse Medication Error Report" revealed Resident #4's attending Physician was notified of the error on 11/3/14 at 11:00 AM. The Physician's statement read, "I have never ordered [MEDICATION NAME] 50 milligrams. It would take 5 pills to equal that dose, "I ordered [MEDICATION NAME] 5 mg po TID." The (Nursing) Supervisor on duty (Registered Nurse #2) also reviewed order and stated the order read [MEDICATION NAME] 50 mg TID. Pharmacy did not voice any concerns regarding dosage of medication ordered. A review of the physician's hand written order, dated 10/31/14, read, "(Change) [MEDICATION NAME] to 5 mg (milligrams) PO (by mouth) TID (three times daily). A review of the Medication Administration Record (MAR) for November 2014 revealed [MEDICATION NAME] 50 mg was administered to Resident #4 on 11/1/14 at 5:00 PM, on 11/2/14 at 9:00 AM, 1:00 PM and 5:00 PM. On 11/12/14 at 11:00 AM, an interview with Unit Manager (Supervisor) Registered Nurse (RN) #2 confirmed she was the Unit Manager for the 400 hallway. RN #2 stated she did not work on the day the order was written (10/31/14); however, she stated when she returned to work on 11/1/14, LPN #2 showed her the [MEDICATION NAME] order for Resident #4. She told LPN #2 that she thought the order read "[MEDICATION NAME] 5 mg PO TID", not 50 mg. RN #2 instructed LPN #2 to call the physician to get an order clarification. RN #2 stated she never told LPN #2 that the order looked like 50 mg. RN #2 stated on 11/1/14 and 11/2/14, Resident #4 was not in respiratory distress and had no change in his level of consciousness. RN #2 stated her shift ended and when she arrived back at work on 11/3/14, Resident #4 had been sent to the hospital. The dispensing pharmacy called the facility on 11/3/14 to question the dosage of Resident #4's [MEDICATION NAME], and the facility called the prescibing physician for order clarification. The facility removed Resident #4's 50 mg [MEDICATION NAME] after speaking with the prescibing physician. On 11/24/14 at 5:30 PM, a telephone interview with the Prescribing Physician confirmed the [MEDICATION NAME] order was for 5 mg TID (three times daily). Review of a handwritten telephone order dated 11/2/14 at 10:40 PM stated, "Send to (local hospital) ER (emergency room ) for evaluation (secondary) decreased LOC (level of consciousness)." A review of the "History of Present Illness" obtained from the hospital, dated 11/2/14, stated, "The patient was found unresponsive at a local nursing home and brought to the emergency department. While there, the patient was noted to be hypercapnic ([MEDICAL CONDITION]). He did require mechanical intubation. The patient was further noted to be hypothermic (low body temperature). Other laboratory parameters were drawn and the patient was felt to meet [MEDICAL CONDITION] criteria. It is further reported the patient takes an excessive amount of pain medication as well as muscle spasm medication and felt that this likely contributed to his respiratory suppression." Review of the physician clarification order, dated 11/3/14, revealed the physician verified the [MEDICATION NAME] 5 mg three times daily as the correct dosage. On 11/12/14 at 9:30 AM, an interview with the Pharmacy Consultant revealed the she made monthly visits. The consultant stated she was aware the facility had a lot of medication errors. She stated she goes on medication pass with nurses every visit and when she is with them, the nurses always follow protocol. An interview with the Dispensing Pharmacist on 11/12/14 at 11:30 AM revealed the Dispensing Pharmacist stated to his knowledge, the original order came in on 10/31/14 about the change of dose for Resident #4. He stated the pharmacy read the order as "(Change) [MEDICATION NAME] to 20 mg TID. He stated the previous order of [MEDICATION NAME] 20 mg every day was a "non-therapeutic dose" and the pharmacy thought 20 mg TID was what was intended since that dose would be a "normal therapeutic dose". The pharmacist stated the facility nurse (LPN #2) had called the morning of 11/1/14 and told the pharmacy that the wrong dose had been sent. The nurse stated that [MEDICATION NAME] 50 mg TID should have been dispensed. The pharmacist stated the pharmacy should have been "a little more aggressive" in making sure the order was clarified prior to dispensing such a drastic change in the dose. The pharmacist stated on the morning of 11/3/14, the pharmacy did call the facility to question the order. The pharmacist further stated verbal orders were an ongoing problem with being clarified and the pharmacy did not clarify orders with the physician. He stated the pharmacy always notified the nursing home to take care of clarifications. Record review for Resident #4 revealed the facility admitted the resident on 10/2/14 with [DIAGNOSES REDACTED]. A review of the most current Minimum Data Set with an Assessment Reference date of 10/29/14 revealed a Brief Interview for Mental Status Score of 15 which indicated the resident was cognitively intact. Resident #1 Review of a Physician's Telephone Order, dated 09/11/14 at 2:15 PM, revealed an order for [REDACTED]. Review of the (Name of Pharmacy) Delivery Sheets documented [MEDICATION NAME] Sodium ([MEDICATION NAME]) (a blood thinner) 4 mg (15 tablets) were delivered for Resident #1 on 09/18/14, 10/02/14, and 10/16/14. The September 2014 and October 2014 Medication Administration Records (MARs) listed to administer [MEDICATION NAME] 4 mg 1 PO Q (every) HS (8 PM) with a start date of 9/11/14. The MAR's documented [MEDICATION NAME] 4 mg was administered by nursing staff every night from 09/12/14 through 10/01/14. No [MEDICATION NAME] was in the medication cart for Resident #1 and [MEDICATION NAME] ([MEDICATION NAME]) was not listed on Resident #1's September or October MAR. A PT([MEDICATION NAME])/INR(international normalized ratio) was obtained on Resident #1 to check blood clotting time on 10/16/14 after the facility discovered Resident #1 had been mistakenly given [MEDICATION NAME]. PT and INR blood tests are used to monitor the effectiveness of the blood thinner, [MEDICATION NAME]. Resident #1's PT results was within therapeutic range for a resident requiring [MEDICATION NAME] therapy. The result was PT 11.9 (reference range 9.6-12.6). The INR result was 1.1 (reference range 2.0-3.5). A photograph of Resident #1's labeled medication cassette taken by the facility revealed 5 [MEDICATION NAME] Sodium 4 mg tablets remained in the cassette. The cassette was labeled as [MEDICATION NAME]/[MEDICATION NAME], not [MEDICATION NAME]. An interview with LPN #3 on 11/13/14 at 3:56 PM revealed LPN #3 was named in the incident reports for the [MEDICATION NAME] errors with Resident #1. LPN #3, who worked the 3-11 PM shift, was asked about administering medications on her shift and if she always compared the medication cassette to the MAR during medication pass. LPN #3 said sometimes when she was having a busy shift, she did not compare the cassette to the MAR when giving medications. She added that she initialed she gave [MEDICATION NAME] to Resident #1 on two separate dates, but was told by the facility she had given the resident [MEDICATION NAME], not [MEDICATION NAME]. An interview was conducted with the facility's dispensing Pharmacist on 10/28/14 at 1:35 PM. In the interview, he said the pharmacist who received the faxed physician's orders [REDACTED].#1. The Pharmacist said the ordered medication [MEDICATION NAME], was never sent to the facility. He added the pharmacy only learned of the medication error when they received a phone call from one of the nurses, but was not sure of the date of the phone call. An interview with Licensed Practical Nurse (LPN) #1 who discovered the medication error was conducted on 10/27/14 at 8:55 PM. The LPN said 10/13/14 was the first time she had worked the medication cart on the 200 Hall and as she was pulling the medications for Resident #1, she saw a gray cassette that read [MEDICATION NAME] 4 mg. She said she looked at the MAR and [MEDICATION NAME] was not listed. She then reviewed the physician's orders [REDACTED]. She said there was an order for [REDACTED]. The LPN said she reported her concern to the charge nurse and they pulled the [MEDICATION NAME] cassette from the medication cart. An interview was conducted with the Quality Assurance (QA) Registered Nurse (RN) #1 on 10/28/14 at 11:16 AM. In the interview, the QA nurse said she investigated the incident with the [MEDICATION NAME] and [MEDICATION NAME]. She said her investigation revealed Resident #1 had been receiving [MEDICATION NAME] 4 mg at 8:00 PM for approximately 20 days when she should have receiving [MEDICATION NAME] 4 mg at 8:00 PM. When asked how this type error could occur, the QA RN said the 3-11 PM nurses were not comparing the label on the [MEDICATION NAME] cassette to the MAR. A interview with the Director of Nursing (DON) was conducted on 11/14/14 at 4:07 PM. The DON confirmed the facility was having medication errors by not comparing the Medication Administration Record (MAR) with the medications during administration and not documenting medications on the MARs. The DON said she would consider the anticoagulant, [MEDICATION NAME] being administered to Resident #1 without a physician's orders [REDACTED]. The facility admitted Resident #1 on 09/10/12. The resident's [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), dated [DATE], documented Resident #1 as having short and long term memory problems and severely impaired cognitive skills for daily decision making. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 11/13/14 for the Immediate Jeopardy. Review of the facility's AoC revealed the facility took the following measures to remove the IJ. 1. At 4:53 PM on 11/12/14 an emergency QA meeting was called with the Medical Director, Administrator, Director of Nursing, QA Nurse, and Medical Records Nurse to discuss the Immediate Jeopardy status of the facility and the plan of correcting the deficient practice in order to achieve Compliance. On 11/13/14 the facility had a phone conference with Pharmacy Consultant Owner reviewing policy change and previous discrepancies. New Pharmacy services was contacted on 11/13/14 in regard to these discrepancies and the process of achieving compliance. Pharmacy Consultant and new pharmacy have established a new procedure with the medication delivery process. 2. Medication Administration Policy was revised and these revisions were reviewed in QA and approved by Medical Director on 11/12/14. Previous policy was reviewed and approved with a statement added for nurses to sign MAR after administering medication. A monitor form for medication auditing was developed and revised on 11/12/14. 3. On 11/5/14 a new contract was established and signed with a new Pharmacy Provider and facility will no longer use the previous pharmacy. On 11/5/14 and on 11/11/14, six (6) of 6 agency nursing staff, 11 of 11 LPN nursing staff, and 5 of 5 RN were In-Serviced by new Pharmacy Provider Staff. 4. On 11/12/14 at 1:25 PM an audit was conducted by Director of Nursing, QA Nurse, Medical Records Nurse, MDS Nurse and 2 RN Unit Managers. A 100 % audit process was conducted in the facility immediately of the MARs against the Physician order [REDACTED]. The facility identified 14 discrepancies out of 97 reviews. All 14 discrepancies were corrected. 5. On 11/12/14 In-Services were conducted with Director of Nursing, QA Nurse, Medical Records Nurse, MDS Nurse and 2 RN Unit Managers by QI Nurse Consultant on the following: 8 Medication Rights, Checking all new medications arriving to facility must be checked against Physician order [REDACTED]. During the In-service nurses were instructed to report discrepancies to the Director of Nursing immediately. 6. On 11/12/14 In-Services were conducted with all nursing staff by RN Unit Manager on the following: 8 Medication Rights, Checking all new medications arriving to facility must be checked against Physician order [REDACTED]. On 11/12/14, 6 of 6 agency nursing staff, 10 of 11 LPN nursing staff and 4 of 5 RNs were In-Serviced by RN Unit Manager. No Nursing Staff will be allowed to work until In-Serviced. 7. Agency #1, providing Nurses to the facility, was notified on 11/12/14 that nurses must be In-Serviced prior to their shift. Agency #1 was notified that any new nurses that have not been utilized at the facility must be oriented and In-Serviced prior to working. Agency #2, providing Nurses to the facility, was notified on 11/12/14 that nurses must be In-Serviced prior to their shift. Agency #2 was notified that any new nurses that have not been utilized at the facility must be oriented and In-Serviced prior to working. 8. On 11/4/14 LPN #2 who transcribed the order to the MAR was terminated from employment with the facility. The Mississippi Board of Nursing was contacted and LPN #2 was reported on 11/5/14. On 11/12/14 a notification was sent to Agency #1 that LPN #1 cannot return to work at the facility. The Director of Nursing resigned on 11/4/14. The Previous Director of Nursing, whom retired in 2009 and worked part-time at facility, has resumed the role as Director of Nursing. The concerns with Pharmacy #1 was reported by Administrator to the Board of Pharmacy on 11/12/14. The facility alleges the Immediate Jeopardy has been removed on 11/14/14. On 11/14/14, the State Survey Agency validated the facility had implemented the following measures to remove the Immediate Jeopardy. An Acceptable Credible Allegation of Compliance was verified by staff interviews and record review of inservices on 11/14/14 beginning at 9:00 AM through 5:45 PM. 1. Review of the Quality Assurance Meeting sign in sheets and information provided by the facility confirmed on 11/12/14, the facility held an emergency QA meeting. The Medical Director, Administrator, Director of Nursing, QA Nurse, and Medical Records Nurse attended and discussed the Immediate Jeopardy status of the facility and a plan of correction to achieve compliance. Review of facility documentation revealed the facility had a phone conference with Pharmacy Consultant Owner and the New Pharmacy Services on 11/13/14 to review policy changes and previous discrepancies, and established a new procedure with the medication delivery process. 2. Review of the facility's Medication Administration Policy confirmed the revisions approved by Medical Director on 11/12/14 to add a statement for nurses to sign MAR after administering medication. The State Agency also confirmed a monitoring form for medication auditing was developed by the facility. 3. The new contract established and signed with a new Pharmacy Provider on 11/5/14 was reviewed. The contract was confirmed to go into effect on November 14, 2014. The surveyor confirmed by review of the sign in sheets and staff interviews, the new Pharmacy Provider in-serviced six of six Agency Nurses, eleven of eleven LPNs, and five of five RNs on 11/5/14 and on 11/11/14. 4. Review of a facility list confirmed a 100% audit performed by the Director of Nursing, QA Nurse, Medical Records Nurse, MDS Nurse and 2 Unit Managers on 11/12/14 at 1:25 PM of the MARS against the Physician order [REDACTED]. The surveyor confirmed the facility identified 14 discrepancies out of 97 reviews and discrepancies were corrected. 5. Review of sign in sheets, topics, and staff interviews confirmed on 11/12/14 the facility QI (Quality Improvement) Nurse Consultant in-serviced the Director of Nursing, QA Nurse, Medical Records Nurse, MDS Nurse and 2 RN Unit Managers on the following: a. 8 Medication Rights, b. Checking of all new medications arriving to facility against Physician order [REDACTED]. c. Policy change including documentation of MAR to ensure no missing documentation occurs within facility, d. Availability of drug reference books to nurses on all 4 medication carts e. 24 hour chart checks and the process of checking the Physician order [REDACTED]. f. Process of discontinuation of medications and the responsibility of the nurse receiving the order: medication removed from the MAR and removed from the medication cart for destruction. g. Nurses are to report discrepancies to the Director of Nursing immediately. 6. Interviews with 100% of the facility nursing staff and the agency nursing staff, and review of sign in sheets and topics confirmed on 11/12/14, RN Unit Manager in-serviced 6 of 6 Agency Nurses, 10 of 11 LPNs and 4 of 5 RNs on the following: a. 8 Medication Rights, b. Checking of all new medications arriving to facility against Physician order [REDACTED]. c. Policy change including documentation of MAR to ensure no missing documentation occurs within facility, d. Availability of drug reference books on all carts for nurses to refer to when they have medication questions or need medication information, e. 24 hour chart checks and the process of checking the Physician order [REDACTED]. f. Process of discontinuation of medications and the responsibility of the nurse receiving the order to ensure the medication is removed from the MAR and the medication cart for destruction. g. Nurses are to report discrepancies to the Director of Nursing immediately. 7. Review of letters sent to Agency #1 and Agency #2, providing Nurses to the facility, confirmed the Staffing Agencies were notified on 11/12/14 that nurses must be in-serviced prior to their shift, and any new nurses that have not been utilized at the facility must be oriented and in-serviced prior to working on all new policies and procedures. 8. The surveyor confirmed by review of the personnel record that on 11/4/14, LPN #2 was terminated from employment with the facility and was reported to the Mississippi Board of Nursing on 11/5/14. The surveyor confirmed by review of a statement dated 11/12/14, a notification was sent to Agency #1 that LPN #1 could not return to work at the facility. The surveyor confirmed the Director of Nursing during the time of the discrepancies resigned on 11/4/14. Interview with the Director of Nursing, whom retired in 2009 and worked part-time at facility, confirmed she has resumed the role as Director of Nursing. Review of documentation confirmed the facility Administrator reported concerns with Pharmacy #1 to the Board of Pharmacy on 11/12/14. 9. Upon review of the staffing schedule, the surveyor confirmed no Nursing Staff had been allowed to work until in-serviced on the new facility procedures.

Based on staff interviews, policy review, pharmacy delivery report review, consultant pharmacist report reviews, and facility's medication error investigation review, the facility failed to ensure medication orders were filled according to the physician's orders [REDACTED]. (Resident #1 and Resident #4) The facility's contract pharmacy incorrectly sent Coumadin, a blood thinner, for Resident #1. The facility nursing staff failed to recognize the wrong medication was received. Resident #1 received twenty doses of the anticoagulant (blood thinner) medication Coumadin which was not prescribed for the resident before the error was discovered. The pharmacy filled the physician's orders [REDACTED]. The medication was labeled as Coumadin. The facility nursing staff signed the Medication Administration Record (MAR) for Cardura. Resident #4 received four doses of Baclofen 50 milligrams (mg) instead of 5 mg as ordered by the physician. Resident #4 was transferred to the hospital on [DATE] due to decreased level of consciousness. The hospital admitted Resident #4 to the Intensive Care Unit (ICU) due to respiratory suppression. The facility's failure to ensure the facility pharmacy protocol and facility nursing protocol for medication administration was followed caused a situation that resulted in the hospitalization of Resident #4 with respiratory suppression and was likely to cause serious injury, harm, impairment or death to other residents. This situation was determined to be an Immediate Jeopardy (IJ) identified on 11/12/14 and determined to exist on 9/12/14 when Resident #1 received Coumadin instead of Cardura. The facility was notified of the Immediate Jeopardy on 11/12/14 and submitted a Credible Allegation of Compliance (AoC) on 11/13/14. The State Survey validated the credible AoC on 11/14/14. The State Agency determined the IJ was removed on 11/14/14 prior to exit. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.60 (a)(b), F425, Pharmaceutical Services was lowered to a "E" while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with the regulatory compliance. Findings include: The Pharmacy's policy on Quality Assurance (no date) documented, " ...5) Policy: In an effort to limit variances in care that may result in a medication error or other unexpected occurrence or adverse outcome, pharmacy personnel shall make every attempt to validate prescription accuracy ...v) Upon verification of prescription and corresponding patient, the prescription data shall be entered into the computerized pharmacy system and the appropriate medication label will be printed vi) Prior to medication dispensing, the technician and the pharmacist shall both review the original prescription then both shall review against the corresponding drug label ..." On 10/28/14 at 1:35 PM, an interview with the Dispensing Pharmacist admitted the pharmacist who received the faxed physician's orders [REDACTED].#1. The Pharmacist said the ordered medication, Cardura, was never sent to the facility. He added the pharmacy only learned of the medication error when they received a phone call from one of the nurses, but was not sure of the date of the phone call. An interview with the Dispensing Pharmacist on 11/12/14 at 11:30 AM revealed the Dispensing Pharmacist stated the pharmacy should have been "a little more aggressive" in making sure the order (Baclofen) was clarified prior to dispensing such a drastic change in the dose. The pharmacist stated on the morning of 11/3/14, the pharmacy did call the facility to question the order. The pharmacist further stated verbal orders were an ongoing problem with being clarified and the pharmacy did not clarify orders with the physician. He stated the pharmacy always notified the nursing home to take care of clarifications. During a post survey telephone interview, on 11/24/14 at 5:30 PM, with the Prescribing Physician, the Physician stated in his [AGE] years of practice, he had never seen an order for [REDACTED]. He stated, "You can't put all the blame on the nurse. The pharmacy should have known the order was not correct and should have questioned it." On 11/12/14 at 9:30 AM, an interview with the Pharmacy Consultant revealed she made monthly visits. The consultant stated she was aware the facility had a lot of medication errors. The consultant stated she made recommendations each time she visited regarding; orders not transcribed, laboratory results not obtained and/or on the charts, and discontinued medications continue to be found in the medication carts. She stated she goes on medication pass with nurses every visit and when she was with them, the nurses always follow protocol. Review of the consultant pharmacist reports revealed medication errors were addressed with the facility on the June and July reports, but did not include interaction with the dispensing pharmacy related to the pharmacy's misreading of orders and the delivery/removal of medications. Resident #1 Review of the (Name of Pharmacy) Delivery Sheets documented 15 tablets of Coumadin 4 mg (a blood thinner) were delivered for Resident #1 on 09/18/14, 10/02/14, and 10/16/14. The Pharmacy's "Incident Form" dated October 15, 2014, documented "Details of Incident: Order faxed to pharmacy 9/12/14. Rx's ordered - Urecholine 25 mg (milligrams) by mouth three times daily. Cardura 4 mg one at hour of sleep. Cardura 4 mg misread as Coumadin 4 mg and dispensed. Corrective action(s) taken: Coumadin discontinued when error was discovered by nursing staff. The Physician's Telephone Orders sheet dated 09/11/14 at 2:15 PM documented Cardura 4 mg at hs (hour of sleep), not Coumadin. Resident #1 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #1 as having short and long term memory problems and severely impaired cognitive skills for daily decision making. The MDS was used to assess a resident's functional capabilities. Resident #1 was also assessed as having a urinary catheter. Resident #4 A review of the facility's investigation revealed on 11/4/14, the facility discovered a medication error in which nursing staff administered Resident #4 Baclofen 50 milligrams (mg) instead of the ordered 5 mg. Record review for Resident #4 revealed the facility admitted the resident on 10/2/14 with [DIAGNOSES REDACTED]. A review of the most current Minimum Data Set with an Assessment Reference date of 10/29/14 revealed a Brief Interview for Mental Status Score of 15 which indicated the resident was cognitively intact. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 11/13/14 for the Immediate Jeopardy. Review of the facility's AoC revealed the facility took the following measures to remove the IJ. 1. At 4:53 PM on 11/12/14 an emergency QA meeting was called with the Medical Director, Administrator, Director of Nursing, QA Nurse, and Medical Records Nurse to discuss the Immediate Jeopardy status of the facility and the plan of correcting the deficient practice in order to achieve Compliance. On 11/13/14 the facility had a phone conference with Pharmacy Consultant Owner reviewing policy change and previous discrepancies. New Pharmacy services was contacted on 11/13/14 in regard to these discrepancies and the process of achieving compliance. Pharmacy Consultant and new pharmacy have established a new procedure with the medication delivery process. 2. Medication Administration Policy was revised and these revisions were reviewed in QA and approved by Medical Director on 11/12/14. Previous policy was reviewed and approved with a statement added for nurses to sign MAR after administering medication. A monitor form for medication auditing was developed and revised on 11/12/14. 3. On 11/5/14 a new contract was established and signed with a new Pharmacy Provider and facility will no longer use the previous pharmacy. On 11/5/14 and on 11/11/14, six (6) of 6 agency nursing staff, 11 of 11 LPN nursing staff, and 5 of 5 RN were In-Serviced by new Pharmacy Provider Staff. 4. On 11/12/14 at 1:25 PM an audit was conducted by Director of Nursing, QA Nurse, Medical Records Nurse, MDS Nurse and 2 RN Unit Managers. A 100 % audit process was conducted in the facility immediately of the MARs against the Physician order [REDACTED]. The facility identified 14 discrepancies out of 97 reviews. All 14 discrepancies were corrected. 5. On 11/12/14 In-Services were conducted with Director of Nursing, QA Nurse, Medical Records Nurse, MDS Nurse and 2 RN Unit Managers by QI Nurse Consultant on the following: 8 Medication Rights, Checking all new medications arriving to facility must be checked against Physician order [REDACTED]. During the In-service nurses were instructed to report discrepancies to the Director of Nursing immediately. 6. On 11/12/14 In-Services were conducted with all nursing staff by RN Unit Manager on the following: 8 Medication Rights, Checking all new medications arriving to facility must be checked against Physician order [REDACTED]. On 11/12/14, 6 of 6 agency nursing staff, 10 of 11 LPN nursing staff and 4 of 5 RNs were In-Serviced by RN Unit Manager. No Nursing Staff will be allowed to work until In-Serviced. 7. Agency #1, providing Nurses to the facility, was notified on 11/12/14 that nurses must be In-Serviced prior to their shift. Agency #1 was notified that any new nurses that have not been utilized at the facility must be oriented and In-Serviced prior to working. Agency #2, providing Nurses to the facility, was notified on 11/12/14 that nurses must be In-Serviced prior to their shift. Agency #2 was notified that any new nurses that have not been utilized at the facility must be oriented and In-Serviced prior to working. 8. On 11/4/14 LPN #2 who transcribed the order to the MAR was terminated from employment with the facility. The Mississippi Board of Nursing was contacted and LPN #2 was reported on 11/5/14. On 11/12/14 a notification was sent to Agency #1 that LPN #1 cannot return to work at the facility. The Director of Nursing resigned on 11/4/14. The Previous Director of Nursing, whom retired in 2009 and worked part-time at facility, has resumed the role as Director of Nursing. The concerns with Pharmacy #1 was reported by Administrator to the Board of Pharmacy on 11/12/14. The facility alleges the Immediate Jeopardy has been removed on 11/14/14. On 11/14/14, the State Survey Agency validated the facility had implemented the following measures to remove the Immediate Jeopardy. An Acceptable Credible Allegation of Compliance was verified by staff interviews and record review of inservices on 11/14/14 beginning at 9:00 AM through 5:45 PM. 1. Review of the Quality Assurance Meeting sign in sheets and information provided by the facility confirmed on 11/12/14, the facility held an emergency QA meeting. The Medical Director, Administrator, Director of Nursing, QA Nurse, and Medical Records Nurse attended and discussed the Immediate Jeopardy status of the facility and a plan of correction to achieve compliance. Review of facility documentation revealed the facility had a phone conference with Pharmacy Consultant Owner and the New Pharmacy Services on 11/13/14 to review policy changes and previous discrepancies, and established a new procedure with the medication delivery process. 2. Review of the facility's Medication Administration Policy confirmed the revisions approved by Medical Director on 11/12/14 to add a statement for nurses to sign MAR after administering medication. The State Agency also confirmed a monitoring form for medication auditing was developed by the facility. 3. The new contract established and signed with a new Pharmacy Provider on 11/5/14 was reviewed. The contract was confirmed to go into effect on November 14, 2014. The surveyor confirmed by review of the sign in sheets and staff interviews, the new Pharmacy Provider in-serviced six of six Agency Nurses, eleven of eleven LPNs, and five of five RNs on 11/5/14 and on 11/11/14. 4. Review of a facility list confirmed a 100% audit performed by the Director of Nursing, QA Nurse, Medical Records Nurse, MDS Nurse and 2 Unit Managers on 11/12/14 at 1:25 PM of the MARS against the Physician order [REDACTED]. The surveyor confirmed the facility identified 14 discrepancies out of 97 reviews and discrepancies were corrected. 5. Review of sign in sheets, topics, and staff interviews confirmed on 11/12/14 the facility QI (Quality Improvement) Nurse Consultant in-serviced the Director of Nursing, QA Nurse, Medical Records Nurse, MDS Nurse and 2 RN Unit Managers on the following: a. 8 Medication Rights, b. Checking of all new medications arriving to facility against Physician order [REDACTED]. c. Policy change including documentation of MAR to ensure no missing documentation occurs within facility, d. Availability of drug reference books to nurses on all 4 medication carts e. 24 hour chart checks and the process of checking the Physician order [REDACTED]. f. Process of discontinuation of medications and the responsibility of the nurse receiving the order: medication removed from the MAR and removed from the medication cart for destruction. g. Nurses are to report discrepancies to the Director of Nursing immediately. 6. Interviews with 100% of the facility nursing staff and the agency nursing staff, and review of sign in sheets and topics confirmed on 11/12/14, RN Unit Manager in-serviced 6 of 6 Agency Nurses, 10 of 11 LPNs and 4 of 5 RNs on the following: a. 8 Medication Rights, b. Checking of all new medications arriving to facility against Physician order [REDACTED]. c. Policy change including documentation of MAR to ensure no missing documentation occurs within facility, d. Availability of drug reference books on all carts for nurses to refer to when they have medication questions or need medication information, e. 24 hour chart checks and the process of checking the Physician order [REDACTED]. f. Process of discontinuation of medications and the responsibility of the nurse receiving the order to ensure the medication is removed from the MAR and the medication cart for destruction. g. Nurses are to report discrepancies to the Director of Nursing immediately. 7. Review of letters sent to Agency #1 and Agency #2, providing Nurses to the facility, confirmed the Staffing Agencies were notified on 11/12/14 that nurses must be in-serviced prior to their shift, and any new nurses that have not been utilized at the facility must be oriented and in-serviced prior to working on all new policies and procedures. 8. The surveyor confirmed by review of the personnel record that on 11/4/14, LPN #2 was terminated from employment with the facility and was reported to the Mississippi Board of Nursing on 11/5/14. The surveyor confirmed by review of a statement dated 11/12/14, a notification was sent to Agency #1 that LPN #1 could not return to work at the facility. The surveyor confirmed the Director of Nursing during the time of the discrepancies resigned on 11/4/14. Interview with the Director of Nursing, whom retired in 2009 and worked part-time at facility, confirmed she has resumed the role as Director of Nursing. Review of documentation confirmed the facility Administrator reported concerns with Pharmacy #1 to the Board of Pharmacy on 11/12/14. 9. Upon review of the staffing schedule, the surveyor confirmed no Nursing Staff had been allowed to work until in-serviced on the new facility procedures.

Based on record review, staff interview and policy review, the facility failed to meet professional standards of quality, as evidenced by the Registered Dietician (RD)recommendations were written on 11/21/12, but were not implemented until 12/8/12 for one (1) of four (4) residents reviewed in the sample (Resident # 3). The pressure ulcer progressed from a Stage 2 to a Stage 3 during the time frame of the RD's recommendations being made and actually being implemented. Findings Include: Resident # 3 Resident # 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/11 revealed that she had severely impaired decision making skills. Review of Resident #3's "physician's orders [REDACTED].@ (at) 9am, 1pm, 5pm, 9pm, 1am." Review of the "Nutritional Recommendations By R.D. (Registered Dietician) Consultant", dated 11/21/11, revealed "Increase to 292 cc (cubic centimeters) x 5, notify MD and change formula, if MD orders." Review of Resident #3's "Progress Notes", signed and dated 11/23/11 by the Family Nurse Practitioner, revealed that the change in tube feeding recommendation was not addressed. Review of Resident #3's "Dietary Managers Progress Notes", dated 12/06/11, revealed that in one (1) months time Resident #3 went from 128 pounds to 114 pounds. (Resident #3's return weight from the hospital, date documented on 11/14/11, was 128 pounds with [MEDICAL CONDITION]; no 5-10 percent loss at that time). Review of Resident #3's "Weekly Pressure Ulcer Record" revealed the following: On 11/23/11, the left lateral foot small toe area was noted as a Stage 2 (1.5 X 5). On 12/08/11, the left lateral foot small toe area was noted as a Stage 3 (2.4 X 2). Review of Resident # 3's cumulative "physician's orders [REDACTED]. Interview on 5/9/12 at 3:25 p.m. with the Director of Nursing (DON), revealed "I cannot justify the length of time it took to get the RD recommendation order because I wasn't here then". Interview on 5/9/12 at 3:45 p.m. with Registered Nurse (RN) #1, revealed "I can't understand why it took me so long to do that. I remember the previous DON was out sick, and the papers for RD recommendations were on her desk". Review of a statement on facility letterhead, signed and dated 5/9/12 by the DON, revealed "The Facility does not have a policy on MD Notification of RD recommendations, nor does the facility have a policy on MDS Coding for wounds".

Based on observation, record review, resident interview, staff interview, physician interview, medical director interview, Responsible Party interview, and policy review, the facility failed to ensure that proper systems and supervision were appropriately utilized to prevent serious injury/harm to Residents #9 and #12. Resident #9 and Resident #12 were transferred improperly without the two (2) plus person assistance and the use of the appropriate lift procedures. The facility failed to follow established transfer policies and failed to adequately assess caused harm and pain for two (2) of 16 residents (Residents #9 and #12). Findings include: Record review revealed that Resident #9 moved into the home on 11/21/05 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated Resident #9 was cognitively intact. Review of the Minimum Data Set, dated dated [DATE], revealed a BIMS score of 14 which indicated that Resident #9 was cognitively intact. Review of Resident #9's care plan Kardexes for April 2011 and May 2011 that the Certified Nurse Aides used daily to document the care provided for Resident #9 noted: " Stand Up Lift 11/1/10" and "TRANSFER Assist of 2." The ADL (Activities of Daily Living) Record for April 2011 and May 2011 documented that Resident #9 noted: "Stand-Up Lift for Transfers Start Date: 11/01/10." Record review revealed that Resident #9 ' s care plan noted: "4/19/2011 Extensive Assistance with ADL's ...Provide Assistance with All ADL's (Bathing, Dressing, Eating, Transfers, Locomotion, Bed Mobility, Toileting, and Personal Hygiene)." Record review revealed that Resident #9 had May 2011 physician's orders [REDACTED]." Review of a physician's report, dated 5/18/11, noted: "PREOPERATIVE Diagnosis: [REDACTED]. Observation and interview on 1/31/12 at 11:50 a.m. revealed that Resident #9 stated that a Certified Nurse Aide (CNA) tried to transfer him from his bed to his wheel chair and dropped him to the floor and then fell on top of him. Resident #9 stated that his hip was fractured as a result of the fall and a total hip replacement was performed in the hospital as a result of the fall in the facility on 5/17/11. Interview on 2/2/12 at 10:00 a.m. Resident #9 stated that on 5/17/11 the third (3rd) shift Certified Nurse Aide (CNA) came to his room to get him up for the day. Resident #9 stated that the CNA came in to transfer him from the bed to his wheel chair without the assistance of a lift or another CNA. Resident #9 stated that he told the CNA that she needed help and that he was unable to stand or walk and the wheel chair was too far away from the bed. Resident #9 stated that the CNA dropped him and fell on top of him causing a fracture to his hip which resulted in a total hip replacement. Resident #9 stated that he had been in a lot of pain since the fracture to his hip and the hip replacement. Resident #9 stated that he felt that if the CNA had used the proper technique in transferring him from the bed to the wheel chair and had obtained the assistance of another CNA that the incident would never have happened and he would not have fallen. Resident #9 stated that the CNA had refused to listen to him when he told her that she needed more help and that the wheel chair was positioned too far away from the bed. Resident #9 stated that the CNA had placed the wheel chair down near the foot of his bed instead of placing it up close to the center of the bed for the transfer. Resident #9 stated that the wheel chair was too far away to make a transfer with one (1) CNA. Resident #9 stated that the CNA dropped him in the floor and then she fell on top of him. Resident #9 stated that he was immediately in severe pain and he knew his hip was broken. Resident #9 stated that some of the CNA's use the lift and some do not. Resident #9 stated that it always took two (2) staff members to transfer him, with or without the use of the lift. Resident #9 stated that the CNA that dropped him and broke his hip should have listened to him and not attempted to transfer him without another staff member to assist her. Resident #9 stated that he was still in constant pain from the hip replacement. Interview on 2/2/12 at 2:50 p.m. with Certified Nurse Aide (CNA) #6 revealed that she was the CNA that had transferred Resident #9 on 5/17/11 that resulted in the fractured hip. CNA#6 stated that she had transferred Resident #9 by herself without any other assistance prior to this incident and had been successful. CNA#6 stated that Resident #9 fell to the floor during the transfer and she fell on top of him. CNA#6 stated that she had not used any type of a mechanical lift to transfer Resident #9 on 5/17/11. CNA #6 stated that she was issued verbal disciplinary action for not using a two (2) plus person method of transfer. CNA#6 stated that she was not aware at the time that Resident #9 was to be transferred using two (2) people and a mechanical lift. CNA#6 stated that she learned after the fall that she was to also use a mechanical lift and two (2) people to transfer Resident #9. CNA#6 stated that she had not been "In-Serviced" on the proper technique for transferring Resident #9 prior to the incident on 5/17/11 and did not remember an "In-Service" immediately following the fall of Resident #9 on 5/17/11. CNA#6 stated that while she was transferring Resident #9 on 5/17/11, the wheel chair moved, even though it was locked, and she was unable to sit Resident #9 down in the chair, therefore, she dropped him in the floor and fell on top of him. CNA#6 stated that the nurse that assisted her and that assessed Resident #9 on 5/17/11 was a contract nurse that was not an employee of the facility. Interview on 2/2/12 at 3:30 p.m. with the Director of Nurses (DON) revealed that Resident #9 was a two (2) plus person assist for transfers on 5/17/11. The DON stated that a mechanical lift with two (2) persons to assist was to have been used to transfer Resident #9 on 5/17/11. The DON stated that Certified Nurse Aide #6 was issued disciplinary action due to not following proper technique for transferring Resident #9 on 5/17/11. The DON stated that the nurse that was working on 5/17/11 was a Licensed Practical Nurse (LPN) and that she was a contract nurse and not a full time employee of the facility. DON gave a statement on facility letterhead that the (LPN) could not be reached for interview. DON stated that Resident #9 was care planned as "extensive assistance" for all Activities of Daily Living (ADL's). The DON explained that "extensive assistance" meant that Resident #9 was to have had a two (2) plus person assistance for transfers and the use of a mechanical lift. Interview on 2/2/12 at 4:00 p.m. with Registered Nurse (RN#3) confirmed that she conducted that investigation of the fall of Resident #9 on 5/17/11 and that she called the appropriate State agencies on 5/17/11 to verbally report the fall with a fracture of Resident #9. RN#3) stated that she had faxed the paper work for the investigation to the State agencies on 5/20/11. Interview on 2/2/12 at 3:50 p.m. with the Medical Director (MD) revealed that he was not aware of the serious injuries of Resident #9. The MD stated that the cause of Resident #9's injury had not been relayed to him. The MD stated that he was not informed that Resident #9 had a fracture caused by the improper lifting techniques of the staff of the facility. The MD only knew that Resident #9 fell and fractured his hip. The MD stated that he was present at the Quality Assurance (QA) meetings, but had only been given the number of falls and not the names and nature of the injuries. The MD stated that he would make sure that new QA projects were put in to place that would more aggressively address incidents and falls in the facility. Record review revealed that Certified Nurse Aide (CNA) #6 had signed a "Lifting Policy" on 5/19/11 noted: "It is my understanding that this facility, (name of facility) requires that all employees must seek assistance when lifting residents or heavy objects, even if machine devices are used. There should always be at least 2 employees involved in the lifting process. Also, this facility requires that you receive your personal copy of the safety tips to be practiced on a regular basis. Futhermore I understand that any injury claims that are filed as a result of single lifting or improper lifting will be compared by this document with my signature below. My signature signifies that I have received a copy of the policy and safety tips." Record review revealed that Resident #12 moved into the home on 8/30/00 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], noted a Brief Interview for Mental Status score of 00 which indicated that Resident #12's cognitive status was severely impaired. Review of the fall risk assessment, dated 10/17/11, noted Resident #12 was disoriented at all times and was chair bound. Review of a side rail assessment, dated 9/2/10 and updated 4/20/11, noted Resident #12 required side rails x 2 (two) for parameters. Review of the care plan, dated 10/25/11, noted Resident #12 requires assistance with activities of daily living. One approach included total assistance with transfers and bed mobility. Review of the November 2011 Plan of Care Kardex noted Resident #12 required assist of 2 (two) for transfers. Review of a Statement on Accident/Incident report, dated 11/12/11, handwritten by Certified Nurse Aide (CNA) #5 noted "I put the resident in the bed, I turned the resident over to the left. I tucked the lift pad under her, I turned her back toward me. I still could not pull the lift pad from under her so I had to pull her back to the left side and when I pulled the draw sheet to pull her over when she turned over her head hit the chair that was next to the bed. And went to notify the nurse." Review of the "Incident/Accident Report", dated 11/12/11, handwritten by Licensed Practical Nurse (LPN) #2 noted: "CNA stated that she was putting resident to bed and turned resident over hitting her head on the arm of the chair. The report indicated Resident #12 was taken to a local hospital. Review of the "Neurological Assessment Flow Sheet", dated 11/12/11, noted neurological checks were started on Resident #12 following the incident. Review of a handwritten statement by Registered Nurse (RN) #6, dated 11/12/11, revealed "At about 12:45 - 1pm (Name of CNA #5) came to outside the DR (dining room) where I was and ask me to come to (Name of Resident #12) room, that she had something to show me. I went to (Name of Resident #12) room. (Resident #12) was in the bed. I noted a large hematoma on the lt. (left) side of her forehead with a very sm (small) cut in the center of the hematoma with no bleeding ...I asked (Name of CNA #5) what had happen to (Resident #12) head. (Name of CNA#5) stated that she had put (Resident #12) into bed with the lift while turning her to remove the sling from under her, she roll her away from her onto her rt (right) side and the (Resident #12) had hit her head on the arm of a chair that was on the rt. Side of her bed causing the hematoma. Siderails was down on her bed. I talked with (CNA #5) and instructed her to always have someone to assist her when using a lift to put resident's in bed and to also always have the side rails up on Resident bed when moving Residents to the opposite side of the bed away from you." Review of nurse's notes, dated 11/12/11 at 12:50 p.m., noted "CNA (Certified Nurse Aide) reported to writer (LPN#2) that she was putting resident to bed and while changing resident she turned resident to side bumping resident's head on chair at resident's bedside. Resident noted to have hematoma to left side of forehead." Review of a handwritten physician's telephone order, dated 11/12/11 at 1:10 p.m., noted: "Transfer to (Name of Hospital) ER (emergency room ) for evaluation." Review of the local hospital emergency department form, dated 11/12/11, noted Resident #12 [DIAGNOSES REDACTED]. Review of a CT (Computed Axial Tomography) Scan of the cervical spine, dated 11/12/11, noted: "Impression: 1. Nondisplaced odontoid fracture. 2. Fracture of the posterior arch of C1 (cervical disk 1)." Review of the emergency department form, dated 11/12/11, noted: "Pt (patient) has a fractured spine and is to be admitted ." Review of Certified Nurse Aide (CNA) #5's time card and the November 2011 ADL (Activities of Daily Living) Record revealed CNA #5 was working on the day of the incident. Review of the shift assignments revealed Certified Nurse Aide #5 was assigned to the hall where Resident #12 lived. Review of the Activities of Daily Living record for November 2011 revealed documented evidence that Certified Nurse Aide #5 initialed that she had taken care of Resident #12 on 11/12/11. Review of the home's "Lifting" policy, dated 3/18/05, signed by Certified Nurse Aide #5 noted: "It is my understanding that this facility, (Name of Facility), requires that all employees must seek assistance when lifting residents or heavy objects, even if machine devices are used. There should always be at least 2 employees involved in the lifting process." Review of a statement, dated 11/14/11, signed by Registered Nurse #3 noted: "Interviewed (Name of Certified Nurse Aide {CNA}#5) regarding incident with (Name of Resident #12) hitting her head on the arm of chair next to bed past transfer, trying to remove sling of Hoyer lift. (Name of CNA #5) reported she was trying to remove sling by turning patient away from her and failed to raise bed rail." Review of an in-service, dated 11/14/11, noted Certified Nurse Aide #5 had been in-serviced on "Safe turning and re-positioning of a dependant Resident." Review of a "Disciplinary Warning Notice", dated 11/14/11, signed by RN#3 revealed Certified Nurse Aide #5 was disciplined for "Defective work" and "Failure to obey safety rules and was placed on one (1) month probation. " Review of the "Investigative Findings of (Name of Resident #12) Incident", dated 11/17/11, noted: "On 11/14/11, received report that (Name of Resident #12) was being transferred to her by from chair by CNA using a Hoyer lift on 11/12/11. Resident hit her head on a chair positioned next to the bed. Resident was assessed by RN Supervisor, resident sustained [REDACTED].#12) was admitted to the hospital and returned on 11/16/11." Review of the local hospital "Patient Transfer Form (Inter-Agency) revealed Resident #12 returned to the home with a soft collar. Review of the admission nursing assessment, dated 11/16/11, revealed a [DIAGNOSES REDACTED]. Interview on 2/2/11 at 10:20 a.m. with Registered Nurse #5 revealed Certified Nurse Aide (CNA) #5 was trained at this facility. CNA #5 stated that the side rails should be up during transfer. Interview on 2/2/11 at 2:15 p.m. Certified Nurse Aide #5 confirmed the incident on 11/12/11 with Resident #12 as aforementioned in her written statement. Interview on 2/2/11 at 2:25 p.m. Registered Nurse #3 confirmed the incident on 11/12/11 with Resident #12 as aforementioned. Interview on 2/2/11 at 3:35 p.m. the Director of Nurses (DON) confirmed the incident on 11/12/11 with Resident #12 as aforementioned. The DON stated that side rails should be up with a one person lift and that a 2 person transfer (as listed on Resident #12's Kardex) includes 2 (two) people including getting the sling from under the resident. The DON stated that at this point she was unable to find where anybody has been in-serviced on the Hoyer lift. The DON stated that Registered Nurse #3 did a return demonstration, but, we can't find any sign in sheets at this point. Interview on 2/2/11 at 4:00 p.m. with the Medical Director about the 11/12/11 incident with Resident #12 revealed the Medical Director stated "Oh my. This is the first I'm hearing about it." The Medical Director stated that during Quality Assurance meetings that incidents are discussed but numbers rather than names are used. Interview on 2/2/11 at 4:35 p.m. with Resident #12's attending hospital physician revealed that he had taken care of Resident #12 while she was in the hospital following the 11/12/11 incident. Resident #12's attending physician stated "A system needs to be in place to ensure it (accidents like this) doesn't happen again." Interview on 2/2/11 at 5:35 p.m. with Registered Nurse #6 confirmed the incident on 11/12/11 with Resident #12 as aforementioned. Review of an in-service on Proper Lift Procedures/Transfers, dated 5/19/11; and a Monthly CNA Meeting, dated July 28, 2011, included an In-service on Accident Prevention/Causes and Turning and Repositioning Patients" was on the agenda; however, there were no sign in sheets for the in-services. Review of the home's "Two Person Assist" policy, not dated, noted: "It is the policy of this facility that residents requiring two person assist will be handled as follows: Care rendered will be performed by two CNAs (Certified Nurse Aides) and Any CNA not following the ADL (Activities of Daily Living) Care Plan will be reprimanded as deemed necessary by the administrative staff." Review of the home's "Turning" policy, not dated, noted: "Lift in order to turn the resident, do not pull or side the resident across the bed." Review of the home's "Hoyer Lift" policy, revised 11/6/09, did not address how to remove the Hoyer lift sling from under a resident once in bed. Review of the home's "Side Rail Policy", not dated, did not address the use of side rails during transfer and positioning.Review of the home's "Sabina Sit to Stand Lift" policy, date 9/8/05, noted: " Purpose: To enable one individual to assist resident from a sitting position to standing safely. The sit to stand lift should be used on weight bearing residents. Equipment 1. Sabina sit to stand lift 2. Liko safety vest (Fit very thin to large residents) Procedure 1. Explain procedure to resident 2. Slide safety vest down behind the residents to waist level with residents arm outside of the vest..." Review of the home's "Policy: Falls", dated 10/30/09, noted: "To determine the resident's risk of future falls or injuries. Falls are a common because of morbidity and mortality among elderly nursing facility residents. Residents who have sustained at least one fall are at risk of future falls. Resident with a fall will be assessed for injury, then doctor and responsible party would be notified. A post fall assessment will be completed for monitoring." The facility failed to transfer Resident #9 properly and caused the fractured hip and need for hip replacement for Resident #9. The facility did not follow its policy and procedure for the use of the mechanical lift and did not follow its policy and procedure for assessments after a fall. The facility did not follow its two (2) plus person policy and procedures for transferring Residents. The facility's failure to follow its policies and procedures caused the serious injuries and pain to Residents #9 and #12. The facility also did not have effective QA programs in place to appropriately monitor all incidents/accidents/falls.

CI MS #8961 Based on observation, interview, record review and policy review, the facility failed to provide adequate supervision to ensure that one (1) of four (4) residents did not leave the facility unsupervised and without staff knowledge (Resident #1). Resident #1 left the facility without staff knowledge on 01/10/11 between 5:38 a.m. and 5:50 a.m. in inclement weather. Resident #1 was wearing pajamas and socks at the time. Certified Nursing Assistant (CNA) #1 began the search for Resident #1 on 01/10/11 at 5:50 a.m. when she did not find Resident #1 in his room. An unidentified person called the facility on 01/10/11 around 6:33 a.m. and asked if the facility had a missing person and described a male wearing pajamas walking on Forest Avenue. Resident #1 was located approximately 1.3 miles from the facility on Forest Avenue wearing pajamas and wet socks. The street was a two (2) lane road with several ditches on both sides of the road. There were different degrees of gradient to the road and a lake on one (1) side of the road. Resident #1 was returned to the facility at approximately 7:05 a.m. and was assessed later in the morning by the Physician. Resident #1 had contusions to his feet possibly due to cold exposure. There was ice on the roads. The temperature was approximately 32 degrees Fahrenheit (F) on 01/10/11 at that time. The facility investigation revealed that an exit door alarm was not activated on the 200 hall. The facility administration and maintenance were the only people with a key to deactivate the alarm. The facility was not sure when the alarm was deactivated. The facility's failure to ensure that Resident #1 received adequate supervision, and to ensure that the alarm was activated on the 200 hallway to prevent him from leaving the facility without staff knowledge was deemed as Substandard Quality of Care and an Immediate Jeopardy (IJ) on 01/12/11 at 3:45 p.m. The Administrator and Director of Nursing (DON) were notified at that time. The Immediate Jeopardy (IJ) was identified to begin on 01/10/11 through 01/13/11. The facility provided a an acceptable credible Allegation of Compliance (AoC) on 01/13/11 at 1:10 p.m. Based on the facility's implementation of corrective actions the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 01/14/11 to a "D" level which constitutes no actual harm with potential for more than minimal harm. Findings Include: On 01/10/11, the State Agency received a verbal self reported incident from the facility which stated that "(Resident #1) had wandered from the facility this morning and was found with no injuries. There was no change in (Resident #1's) status and an investigation was being completed." However, Resident #1 had contusions to his feet possibly due to cold exposure and his temperature would not register when he was returned to the facility. Review of a weather report generated for 01/10/11 for the vicinity where the facility was located revealed that the temperature between 5:31 a.m. and 7:53 a.m. was 32 degrees Fahrenheit (F) with winds ranging from 3.5 miles per hours to 5.8 miles per hour. There was light freezing rain between 3:02 a.m. and 3:53 a.m. Observation and interview with Resident #1 on 01/12/11 at 11:25 a.m. revealed that he was in the dining room in a wheelchair with a pad alarm intact. Resident #1 was alert and oriented only to person. Resident #1 denied mistreatment and did not recall leaving the facility or going outside on 01/10/11. He stated "must have been going to see somebody". Observation of Resident #1 on 01/13/11 at 10:15 a.m. revealed that he was ambulating with CNA #3 to the activity room. Observation on 01/13/11 at 11:25 a.m. revealed that Resident #1 was in a chair in the dining room with an alarm pad in the chair. Resident #1's son was present. Resident #1's son stated that he was notified of his father's trip out into the cold. The son stated that he was glad that his father was okay. The son stated that he had no inkling that Resident #1 had attempted to leave the facility prior or since that time, and was happy with the care that he was receiving. Further observation of Resident #1 on 01/14/11 at 8:40 a.m. revealed that he was in the bed and was wearing two (2) pair of socks. RN #1 removed by Resident #1's socks. There were no cuts, bruises or open areas noted to Resident #1's feet.. Resident #1 stated that his feet felt fine. (When the resident moved in bed, the alarm sounded and when he repositioned the alarm silenced). Review of Resident #1's medical record revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/27/10 revealed that Resident #1 was severely impaired in cognitive skills for daily decision-making. Resident #1 was unable to recall the correct year, month or day of the week and could not recall three (3) items after a brief time had passed. There were no behaviors exhibited for wandering or rejection of care. Resident #1's Activity of Daily Living (ADL) assessment was documented requiring extensive assistance of one (1) person for transfer and ambulation. Balance was coded as being not steady, only able to stabilize with human assistance. There were no assistive devices identified as being used. Resident #1's admission MDS with ARD of 12/20/10 revealed that he was severely impaired in cognitive skills for daily decision making. The MDS also indicated that Resident #1 required extensive assistance of two (2) persons for transfer and ambulation. There was no wandering behavior identified on the MDS. The MDS indicated that Resident #1 had sustained a fall since admission to the facility. Review of a Nurse's Note dated 01/10/11 at 6:22 a.m. revealed that a CNA came to the 100 hall asking if Resident #1 had been seen because he was not in his room. The writer stated that the resident was in his room when she had given his roommate's medication. The Supervisor was notified and a search began. A Nurse's Note dated 01/10/11 at 6:45 a.m. revealed that Resident #1 was not in the building. A call had been received that an elderly man was walking up Forest Avenue with only a pair of socks and red pajamas on. Staff was alerted to search the building room to room; check all doors for alarm functioning; and perform a head count. Resident #1 was not accounted for. Staff members searched the grounds and surrounding area. The Nurse's Note at 7:05 a.m. stated that Resident #1 was found per staff and returned to the facility. An assessment was completed. Skin was cold to the touch, respirations even and unlabored, feet were cold and wet without discoloration. Skin was intact without edema or skin breaks. Resident was alert and talkative and stated that he was headed to meet Jr. because they were going to play cards. Resident was cooperative and laughing with no noted injury. Body temperature was not measurable on the thermometer. Resident denied being cold. At 8:15 a.m. an assessment was completed and Resident #1's temperature (T) was 96.6 axillary, respirations (R) 20, pulse (P) 60 and blood pressure (BP) 150/80. Skin was cool to touch, feet cold, dry and socks in place. The Physician was called. The Medical Director and Responsible Party were notified at 8:20 a.m. and 8:25 a.m. respectfully. At 10:00 a.m. the Nurse's Note documented that the Medical Director and Podiatrist were there to see Resident #1. (This was confirmed by the progress note). Review of the Medical Director's progress note/evaluation dated 01/10/11 at 10:40 a.m. revealed that he was notified by the DON around 7:04 a.m. that Resident #1 had left the facility. Resident was unable to give details of leaving the facility other than leaving out of the back door of the 200 hall. Alarm system did not sound, investigation pending by Administration. Vital signs 97.6 axillary (temp), 140/20 (blood pressure), 84 (pulse) and 20 (respirations). Evaluation determined positive pedal pulses; no skin ulcerations; tender with pressure to feet; and wearing two (2) pair of socks. Muscle contusion secondary to cold exposure with good prognosis considering underlying PVD (peripheral vascular disease). Review of the Podiatry note dated 01/10/11 revealed an unscheduled appointment for possible cold injury to the feet for Resident #1. Assessment revealed contusion of muscles secondary to cold exposure with good prognosis. Review of a "Daily Documentation" record for Resident #1 dated 01/10/11 at 7:00 a.m. revealed that the resident was returned to the facility around 6:50 a.m. and he was aware, alert, and oriented to person. No complaints voiced at 0:700 a.m.. No signs of distress noted at this time. Vital signs were documented at 10:00 a.m. as BP= 150/82, T=96.2; P=84 and R=18. Review of "Social Progress Notes" dated 01/10/11 at 9:00 a.m. revealed that the Social Worker (SW) was informed of Resident #1's elopement situation that had occurred earlier that morning. Resident #1 denied anyone letting him out of the building. Resident #1 stated that he'd left of his own free will, and had friends in the neighborhood that he was going to see. Review of a "Wandering/Elopement Risk Assessment" dated 12/06/10 revealed that Resident #1 was not deemed an elopement risk at that time. Review of a "Wandering/Elopement Risk Assessment" dated 01/10/11 revealed that Resident #1 was deemed an elopement risk. A care plan was initiated for the potential and actual elopement. The interventions included; visual monitoring at least every hour and document; sensory chair/bed alarm; exit door alarms checked every shift and two (2) to three (3) pairs of socks at all times for one (1) to two (2) weeks; extra blankets to foot area; and don't elevate legs/feet-keep below heart level. Review of a "Fall Risk Assessment" for Resident #1 revealed that he was assessed on 12/04/10 with a score of "13". Any score above "10" represented a high risk for falls. Further assessment for the fall risk documented on 12/06/10, 12/07/10, 12/09/10, 12/10/10, 12/13/10, 12/14/10 and 12/15/10 post falls had a final score of "17" on 12/15/10. Resident #1 had no falls documented and was care planned for the being at risk for falls. There was a care plan for bed/chair alarm to be checked to ensure that the alarm box was activated and the sensor pad was in the correct position in the bed. There was also a statement to keep in view during the p.m. hours. Review of a "Plan of Care Kardex" for December 2010 revealed that Resident #1 was supposed to be kept in view during the p.m. hours and to ensure that the alarm box was activated. Documentation included that Resident #1 required assistance of two (2) persons for transferring and ambulation. Review of the January 2011 "Plan of Care Kardex" included the same information with the addition of hourly visual checks and ID bracelet. Review of the facility's investigation for Resident #1's leaving the building on 01/10/11 revealed a hand written timeline that documented Resident #1 was observed in the building between 5:30 a.m. and 5:40 a.m. The note indicated that shortly before 6:00 a.m. Resident #1 was noticed missing. Between 6:20 and 6:22 a.m. CNA #1 notified LPN #2 that Resident #1 was missing. At 6:33 a.m. LPN #1 took a call from a lady about someone walking down the road. At 6:30 a.m. it was documented that the 200 hall alarm was off. The timeline documented that Resident #1 was found 1.3 miles distance from the facility. Review of the facility's final investigation for Resident #1's elopement dated 01/13/11 revealed that it was reported by the CNA taking care of Resident #1, to a staff nurse on 01/10/11 at 6:20 a.m., that Resident #1 was not in his room and that she was unable to locate him. The Resident was last seen around 5:40 a.m. by the Nurse. A search was initiated in and outside the facility. A phone call was received that an elderly gentleman was seen walking on Forest Avenue and staff went to investigate and recovered Resident #1. Initial assessments were done with no injury noted to Resident #1. All 11-7 staff were interviewed along with Maintenance Staff and it was discovered that the alarm switch was not reactivated after maintenance had worked in that area. There were documented and signed interviews from the staff, and implementations of hourly visual monitoring for Resident #1. The facility conducted inservices on 01/12/11 for the "Wandering/Elopement" and "Door Alarm" policy to include checking of the door alarms. Nurses are to check door alarms every shift and maintenance to check every morning and evening. An estimate for Mag lock and Keypad/switch with an estimated date of installation of 01/17/11(This is a keypad lock). Interview with the Director of Nursing (DON) on 01/12/11 at 10:45 a.m. revealed that an event was called in to the State for Resident #1. She stated that Resident #1 was very weak when he was first admitted and therapy had worked with him and gotten him stronger. The DON stated that Resident #1 had never shown any signs of wanting to leave the facility. She stated that and Resident #1 said that he was on his way to a card game. The DON stated that a Nurse was in his room on 01/10/11 about 5:38 a.m. giving medication to his roommate. When the CNA went to the room about 5:50 a.m., Resident #1 was not there. She stated that they begin to search inside and outside the facility. She stated that Resident #1 was found down Forest Avenue about a mile from the facility. She stated that Resident #1 had on pajamas and gripper socks and a flannel jacket. He was brought back to the facility in the CNA's car. She stated that the temperature was cold, probably below 32 degrees F, and there was ice. The DON stated that Resident #1 had no injury and the Medical Director came and looked at him. She stated that Resident #1 was re-assessed as a wander risk. The DON stated that RN #1 found that the key switch on the 200 hall was engaged which makes the door lock/alarm. She stated that Maintenance was the only person with a key to the door switch. She stated that all of the other doors were checked and were engaged and working properly. An observation on 01/12/11 at 11:20 .a.m.. with the DON revealed that the exit door to the 200 hall had a key switch light that was illuminated as a red color. The door was opened and the alarm sounded. The DON stated that the red light was not on when they had checked the morning that Resident #1 left the building. The DON stated that the alarm didn't sound because it was not set. The DON stated that Resident #1 was out of the building for approximately one (1) hour all together. Interview with Registered Nurse (RN) #1 on 01/12/11 at 11:40 a.m. revealed that she had gotten to the facility 01/10/11 around 6:42-6:43 a.m. because the weather had been so bad. RN #1 stated that it was below freezing and that there was ice on some of the bridges. RN #1 stated that she was informed, upon entering the facility, that Resident #1 was missing. She stated that a head count was done and Resident #1 was the only missing person. She stated that the doors were checked and it was discovered that the alarm to the 200 hall door did not alarm. RN #1 stated that she had maintenance to come and check the door and found that the keypad was not engaged. The keypad makes the alarm sound. RN #1 stated that the light was not on that indicated that the door alarm was activated. She stated that there was a key at the desk that turned the front door alarm off. She stated that they discovered that it also turned off the alarm on the 200 hall door. RN #1 stated that staff denied turning off the alarm and maintenance said they had been working in that area however, had turned the alarm back on. RN #1 stated that someone who worked at the hospital called the facility and asked if there was a resident missing. The person stated that there was a man, with red and gray pajamas, walking on the road. CNA #2 got in her car and and brought Resident #1 back to the facility. RN #1 stated that when Resident #1 returned to the facility his socks were wet and those were changed. She stated that Resident's clothes were also changed. RN #1 stated that that she put two (2) pair of socks and blankets on him. RN #1 stated that Resident #1's temperature would not register on the first attempt and later registered 96.6 degrees F. She stated that the Physician and Podiatrist were notified and they came to the facility and examined Resident #1. She stated that they thought that Resident #1 might have some muscle contusion to the lower extremity because he was walking in such cold temperatures. RN #1 stated that they monitored Resident #1 every 30 minutes to one (1) hour and made sure that his sensory pad was working properly. RN #1 stated that she changed out the battery on the sensory pad just to be on the safe side. RN #1 stated that a sign was placed on the back door to ensure that the double doors were closed at all times. RN #1 stated that Resident #1 had not attempted prior or since that time to exit the building. RN #1 stated that Resident #1 was placed on the wander list with visual monitoring every hour documented on the log. RN #1 stated that the nurses are now supposed to check the door alarms every shift. RN #1 stated that prior to the incident that only maintenance had checked them either daily or weekly. Interview with Maintenance Person #1 on 1/12/11 at 1:15 p.m. revealed that he had gotten to the facility on [DATE] at approximately 6:10 a.m. and was told that Resident #1 was missing. Maintenance Person #1 stated that he assisted with looking for Resident #1. He stated that RN #1 arrived at the facility and was told about the missing resident. Maintenance Person #1 stated that he was made aware that Resident #1 had been found and was being brought back to the facility by one (1) of the CNAs. Maintenance Person #1 stated that he saw Resident #1 when he returned. He stated that Resident #1 had on pajamas and wet socks. He stated that the resident wasn't shivering and didn't complain of being cold. He stated that the temperature outside was about freezing and the weather had been rough during the night with freezing rain. Maintenance Person #1 stated that he checked the doors and discovered that the door on the 200 hall was not secured. He stated that there was a key that was used to engage the lock for the alarm to sound. He stated that the light should have been red, indicating that the alarm was armed, but that it was not on. He stated that the door opened but the alarm did not sound. He stated that someone would have to physically turned the alarm off with a key. Maintenance Person #1 stated that he and Maintenance Person #2 had keys to the system. He was not sure who else had them. He stated that he had worked on the 200 hall door about a week ago and had turned the alarm off at that time. Maintenance Person #2 stated that he thought he had re-armed the alarm after he had completed his work. He stated that maintenance personnel checked the doors weekly, usually every Monday, to ensure that they are functioning properly and document it on a weekly check sheet. Interview with the Assistant Administrator (AA) on 01/12/11 at 1:30 p.m. revealed that she was notified by the Human Resource Director (HRD) that Resident #1 had left the building on 01/10/11. The AA stated that they held the staff over during the shift to take individual statements. She stated that Administration and Maintenance had a key that disarmed the 200 hall exit door. The AA stated that no one admitted to turning the alarm off, and no one could pin point a time when they had gone out the door. No one admitted to turning the alarm off without turning it back on when they returned. She stated that the alarm had to be manually turned off. They were unable to identify who had turned the alarm off or when it was turned off. She stated that no one recalled hearing Resident #1's bed alarm sounding after he'd been assisted back to bed around 2:00 a.m. Interview with Maintenance Person #2 on 01/12/11 at 1:50 p.m. revealed that all of the doors have key pad locks except the 200 hall exit door. He stated that there were double doors before you get to the exit door. Maintenance Person #2 stated that he had never seen residents go down that hallway. He stated that the door had a turn key alarm so that when the door opens the alarm was supposed to go off. He stated that he was told that the door alarm was off the morning that Resident #1 left the building. He stated that Maintenance and Administration had keys to the alarm. He could not recall going out that door recently. He stated that the alarm had to be turned off with a key, that it could not automatically flip off. Maintenance Person #2 stated that the door and window alarms were checked every Monday to ensure that they were functioning. He stated that they had not experienced a problem with the alarms prior to that day. He stated that they were in the process of having someone come Monday to install a key pad lock to the 200 hall exit door. Interview with Certified Nursing Assistant (CNA) #1 on 1/12/11 at 2:00 p.m. revealed that she had worked 11-7 and was here the morning that Resident #1 left the building. She stated that Resident #1's bed alarm went off around 1:30 a.m. or 2:00 a.m. She stated that Resident #1 was up in the hall and she took him to the bathroom. CNA #1 stated that she checked around 3:00 a.m. and again just before 5:00 a.m. and he was in the bed. CNA #1 stated that she did not recall any alarms going off after that time. CNA #1 stated that she went to get Resident #1 up just before 6:00 a.m. and he was not in his bed or in the bathroom. She said that no alarm was sounding. CNA #1 stated that Resident #1 was known to go to other resident's rooms/bathrooms so, she searched for him, then notified other staff to help search for him. CNA #1 stated that Resident #1 was wearing red pajama bottoms, a long sleeve gray shirt and socks. She stated that LPN #3 went outside the door on the 200 hall and the door alarm did not sound. CNA #1 stated that she had never opened that door before and had thought that it was locked. She stated that they had received a call from someone who stated that they had seen a gentleman with pajamas on down the street. CNA #1 stated that it was after 6:00 a.m. and the CNA who had stayed over from 3-11 went and got him. CNA #1 stated that she had been inserviced and had participated in drills to look for missing persons. Interview with Licensed Practical Nurse (LPN) #2 on 1/12/11 at 3:25 p.m. revealed that she had worked the 11-7 shift on 1/9/11 and stated that Resident #1 was in the bed asleep when she gave his roommate medication at 5:30-5:40 a.m. She stated that around 6:20 a.m. CNA #1 asked if she had seen Resident #1 because he was wasn't in his room. She stated that a search began for Resident #1, and she reported that he was missing to the supervisor (LPN #3). LPN #2 stated that LPN #1 came in for the 7-3 shift and taken a call from someone who had seen Resident #3 down the street. CNA #1 stated that CNA #2 went to get Resident #1 and brought him back to the building around 7:00 a.m. LPN #2 stated that Resident #1 walked back in the building and that his temperature did not register the first time it was taken. She stated that Resident #1 was wearing pajamas and socks and his socks were wet but, the resident did not have any complaints. LPN #2 stated that she heard no alarms going off after Resident #1 had been assisted back to bed around 2:00 a.m. She stated that Resident #1 could have possibly turned his bed alarm off, so it was changed out after he returned. LPN #2 stated that they did a head count and all doors were checked to see if they were locked. She stated that Resident #1 had to go out the 200 hall door because he would have been sees if he'd come down the 100 or 300 hall. LPN #2 stated that afterwards they found out that the alarm to the 200 hall door was not engaged. Interview with CNA #2 on 01/12/11 at 3:50 p.m. revealed that she had worked the 11-7 shift and was told that Resident #1 was missing after 6:00 a.m. She stated that a search was conducted and a head count was completed. She stated that someone called and said that someone was up the road on (Name of Street). CNA #2 stated that she got in her car and started up the road. CNA #2 took the Surveyor along the route she took to locate Resident #1. CNA #2 stated that she had looked on the sides of the road to make sure Resident #2 had not fallen into the ditches. CNA #2 stated that there was only one (1) other car on the road during the time she was looking for Resident #1. CNA #2 stated that she had ridden approximately 1.3 miles from the facility when she found Resident #1 on the right side of the road next to a road sign. CNA #2 stated that she assisted Resident #1 in her car and turned the heater on. CNA #2 stated Resident #1 said that the heat felt good. CNA #2 stated that Resident #1 was dressed in pajama pants and shirt and had socks on. She stated that she did not see any indications that the resident had fallen. CNA #2 stated that he had a very unsteady gait and was surprised that he had walked that far without falling. She stated that it was cold and the road was icy. She stated that she took Resident #1 back to the facility and was informed that the 200 hall door alarm was not working. Observation of the route taken on Forest Avenue revealed ditches on both sides of the road; a lake to the south side of the road that was enclosed by fencing; and different degrees of gradient to the two (2) lane road causing hazardous conditions for Resident #1. Interview with LPN #3 on 01/12/11 at 6:00 p.m. revealed that she was notified around 6:00 a.m. that Resident #1 was missing and that they had searched inside and outside the building. LPN #3 stated that she had CNA #1 hold the door open on the 200 hall while she went outside to search. LPN #3 did not recall the alarm sounding. LPN #3 stated that LPN #1 had taken a call that Resident #1 was found and someone went and got him. Interview with LPN #1 on 01/13/11 at 8:50 a.m. revealed that she came to work on 01/10/11 about 6:31 a.m. LPN #1 stated that she answered a phone call from a female who stated that she saw an elderly gentleman with red and blue pajamas and no shoes walking down Forest Avenue and wanted to know if he could be one of our residents. LPN #1 stated that after hanging the phone up, she was told that Resident #1 was missing. LPN #1 stated that CNA #2 got in her car and went west on Forest Avenue and returned about 6:50 a.m. with Resident #1. She stated that Resident #1 was assessed and vital signs taken. LPN #1 stated that she was unaware of a key to unlock the 200 hall door, but was told that the door alarm was turned off. She stated that Resident #1's temperature shortly after his return was 96 degrees (F). Interview with the Medical Director on 01/13/11 at 12:15 p.m. revealed that he came to the facility for a Quality Assurance meeting. The Medical Director stated that he was notified by the DON about Resident #1 leaving the building. He stated that he and the Podiatrist both came and evaluated Resident #1. He stated that there were possible contusions due to cold exposure, but no lasting damage. He stated that it was unacceptable for the alarm to be off and the resident leaving like that. He stated that it was hard to believe that Resident #1 had gotten a mile without falling in that length of time. Review of an "Elopement Policy" provided by the facility on 01/13/11 at 8:30 a.m. revealed that an elopement is considered to be when a resident (confused or oriented) attempts to leave the facility and is successful in his/her attempt. Under the section: "Facts to Consider", documentation includes that an injury may or may not occur with an elopement; any time the resident is successful in getting off the facility premises, this is considered to be an elopement...." The facility provided a Credible Allegation of Compliance (AoC) on 01/13/11 at 1:10 p.m. The AoC is as follows: "Resident #1 left the facility unattended on January 10, 2011 between 5:38 a.m. and 5:50 a.m. CNA #1 realized that the Resident was not in his room at approximately 5:50 a.m. A facility search was initiated by nursing staff on duty by searching all the rooms and bathrooms. The outside perimeters were searched by staff who were present at that time. The search continued in the facility until all residents had been accounted for except Resident #1. LPN #1 received a call from an unidentified female at approximately 6:33 a.m. on January 10, 2011, reporting an elderly gentleman walking down Forest Avenue in pajamas. CNA #2 immediately drove her car down Forest Avenue and discovered that the gentleman was Resident #1. CNA #2 helped Resident #1 into her car and returned the Resident to the facility on [DATE] at approximately 7:05 a.m. The Resident #1 was assessed head to toe for injury by RN #1 upon return to facility with no injury noted. Vitals signs taken. Temperature would not register on immediate return. Later temperature at 8:05 a.m. was 96.6 ax. Resident #1's wet clothes were removed and dry clothes applied. Two pair of socks were put on his feet and he was wrapped in blankets. Resident #1 was placed on visual monitoring for this elopement risk every hour beginning January 10, 2011 at 7:05 a.m. and documented by the nursing staff. The attending physician was notified by LPN #2 on January 10, 2011 at approximately 7:05 a.m. when Resident #1 was returned to the facility. The Responsible Party was notified by LPN #2 at approximately on January 10, 2011 at approximately 7:05 a.m. The Medical Director was notified by the Director of Nursing on January 10, 2011 at approximately 7:15 a.m. The Medical Director and the Podiatrist came to the facility to see the resident at approximately 10:40 a.m. The findings by the Medical Director and the Podiatrist on January 10, 2011 were as follows: Resident #1 had sustained muscle contusion that possibly could have been the result of the cold but could have possibly been from previous [DIAGNOSES REDACTED]. Pedal pulses were palpable. Investigation revealed that the alarm was not responding when the 200 Hall exit door was opened. The alarm was reactivated by maintenance and was working appropriately on January 10, 2011 at approximately 7:10 a.m. All residents were reassessed for the potential for elopement on January 12, 2011. The re-assessments were done by RN #1, RN #2 and RN #3. There were no residents identified at risk for elopement that had not been previously identified. Currently there are six residents that have been identified at risk for elopement in the facility. For residents who were assessed at risk for elopements, the interventions were reviewed by those staff members listed above for effectiveness and revised if applicable. A new Care Plan was put into place on the six residents who were assessed to be at risk for elopement that includes diversional activities as an intervention. The facility initiated a door alarm check policy and form on January 10, 2011. The door alarm is checked for proper functioning by the Unit Managers and Supervisors on each shift and documented on the Door Alarm Log. Maintenance checks the alarms twice a day a.m. and p.m. and documents the checks on the Maintenance Log. In-service addressing Elopement/Missing Persons and checking door alarms was initiated for all staff members beginning January 12, 2011. Staff in attendance included Nursing staff, Dietary staff, Maintenance staff, Laundry staff, housekeeping staff, Therapy, and office personnel. This in-service was conducted by the RN Nurse Consultant. No staff member will be allowed to work until the in-service has been done. Visual Monitoring every hour is done by the nursing staff on all residents who have been assessed at risk for elopement. A formal Quality Assurance Committee meeting will be held on January 13, 2011 at 12:15 p.m. to determine if further action is necessary. A representative from (Name of Security Agency) has been contacted on January 13, 2011 by the Assistant Administrator concerning a coded lock panel on the 200 Hall ex