Every finding on record at Pruitthealth - Brookhaven

Based on record review, staff interviews, and review of the facility's policy titled MDS Assessment Accuracy, the facility failed to ensure Minimum Data Set (MDS) assessments were coded accurately for 4 of 47 sampled residents (R) (R100, R12, R88, and R66). This deficient practice had the potential to place R100, R12, R88, and R66 at increased risk of not receiving care and services according to their needs. Findings include: Review of the facility's policy titled MDS Assessment Accuracy, dated 5/1/2006, revealed the Policy Statement included, It is the policy of this healthcare center that each Minimum Data Set (MDS) reflect the acuity and the medical status of each patient/resident in accordance with acceptable professional standards and practices. 1. Review of the Face Sheet for R100 revealed the resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, bipolar disorder. Review of the Annual MDS for R100, dated 8/27/2025, revealed that Section A (Identification Information) documented the resident was not currently considered by the state-level II Preadmission Screening and Resident Review (PASRR) process to have serious mental illness and/or intellectual disability or a related condition. Review of the care plan for R100 revealed a care plan area of the resident has a PASRR Level II related to a bipolar diagnosis. In an interview on 1/18/2026 at 8:45 am, the MDS Coordinator confirmed the resident had a PASRR Level II dated 3/25/2024, and the Annual MDS dated [DATE] indicated the resident did not have a PASRR Level II. She stated the MDS should be coded according to the resident's status. Review of the Quarterly MDS assessment for R12, dated 12/10/2025, revealed that Section P (Restraints) documented that 'other' restraints were used less than daily. Review of the care plan for R12 revealed no care plan area for the use of restraints. Review of the physician's orders for R12 revealed no restraints orders. Review of the progress notes for R12 revealed no notes of restraints in use. In an interview on 1/17/2025 at 1:15 pm, the MDS Coordinator confirmed that the Quarterly MDS assessment dated [DATE] for R12 documented the use of restraints. She stated that restraints were not used for R12, and this was an error in coding. She further stated that she would submit a revised submission. In an interview on 1/18/2026 at 12:00 pm, the Director of Health Services (DHS) stated the MDS Coordinator was responsible for ensuring the MDS assessments were coded accurately. She further stated she expected the MDS assessments to be coded accurately to reflect the resident's status at the time of the assessment. She stated that an inaccurate assessment could adversely affect the resident's care. 2. Review of the Face Sheet revealed R88 was admitted to the facility with diagnoses of but not limited to dementia, unspecified depression, and unspecified altered mental status. Review of R88's Annual MDS assessment dated [DATE] revealed a BIMS score of 4, indicating severe cognitive impairment. Further review of Section P (Restraints and Alarms) documented a code of 0, denoting no wandering or elopement alarms in use. Review of R88's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 6, also indicating severe cognitive impairment. Further review of Section P (Restraints and Alarms) again documented a code of 0, indicating no wandering or elopement alarms in use. Review of R88's comprehensive care plan identified the following problem statement: Presence of behavior — wanders unsafely; wander guard in place. Review of physician's orders for R88 revealed an order from 6/17/2024 to check the function of the wander guard to the left ankle every shift, During an interview conducted on 1/17/2026 at 3:38 pm, the MDS Coordinator confirmed that R88 was not coded correctly on both the Annual MDS dated [DATE] and the Quarterly MDS dated [DATE]. The MDS Coordinator stated that accurate coding was essential because it directly supported the development and implementation of an appropriate resident care plan. 3. Review of the Face Sheet revealed R66 was admitted to the facility with diagnoses of but not limited to unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of R66's quarterly MDS assessment dated [DATE] revealed BIMS score of 14, indicating little to no cognitive impairment. Further review in Section P (Restraints and Alarms) revealed R66 was documented as 0 for no wandering/elopement alarms in use. Review of the care plan revealed R66 is at risk for elopement for exit seeking behaviors with interventions to apply wander guard alarm system. Review of Physician's Orders for R66 revealed an order dated 5/30/2025 to check the function of wander guard to right wrist every shift. Interview on 1/17/2026 at 3:38 pm with the MDS Coordinator stated when completing a resident assessment, she looked through the electronic medical record (EMR) to assist with her coding. The MDS Coordinator confirmed that R66 was not coded correctly on the MDS and it was missed moving and clicking too quickly. Interview on 1/17/2026 at 3:55 pm with the Director of Health Services (DHS) stated she expected the MDS to be updated to close time for accuracy and the MDS was responsible for conducting audits to ensure the assessment was current.

Based on record review and staff interviews, the facility failed to submit a Preadmission Screening and Resident Review (PASRR) Level II for one of one resident (R) (R1) reviewed from a sample of 47 residents. This deficient practice had the potential to place R1 at increased risk for not receiving the necessary behavioral health services and support needed to meet R1's needs.Findings include: Review of the electronic medical record (EMR) revealed R1 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Post Traumatic Stress Disorder (PTSD), major depressive disorder, and anxiety disorder. Review of the admission Minimum Data Set (MDS) assessment for R1, dated 11/6/2025, revealed Section A (Identification Information) documented the resident was not currently considered by the State Level PASRR process to have a serious mental illness and/or intellectual disability or a related condition. Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 13 (indicating little to no cognitive impairment). Section I (Active Diagnoses) documented anxiety, depression, and PTSD. There were no neurological diagnoses marked. Review of the care plan for R1 revealed a Problem area dated 12/30/2025, of psychotropic drug use, and the resident received antidepressant medication related to depression. Review of the physician orders for R1 revealed an order dated 1/12/2026 for trazodone 50 milligrams (mg) for depression, unspecified. An order dated 11/3/2025 for bupropion HCl sustained release 12-hour tablet, 150 mg, one tablet via gastric tube twice daily at 9:00 am and 5:00 pm for depression, unspecified. Review of the EMR for R1 revealed no PASRR Level II. During an interview on 1/17/2026 at 1:38 pm, the Social Service Coordinator (SSC) stated her responsibilities included the oversight of the PASRR processes. She was unable to confirm whether R1 had a PASRR Level II but stated she would review her records and follow up with the surveyor. She acknowledged that submitting PASRR documentation was part of her responsibilities. During a follow-up interview on 1/18/2026 at 9:03 am, the SSC confirmed that R1 did not have a PASRR Level II submitted. She stated this was an oversight.

Based on observations, record review, resident and staff interviews, and review of the facility policy titled, Care plan, the facility failed to follow approaches described in the care plan for one of 16 residents (R) (R69) receiving Restorative Nursing care. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life.Findings include:Review of the facility policy titled Care Plans revised on 10/21/2025 revealed a policy statement of it is the policy of the health care center for each patient/resident to have a person centered baseline care plan followed by a comprehensive care plan developed following completion of the minimum data set (MDS) and Care area assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the patient/resident choice. The care plan approach serves as instructions for the patient/resident's care and provides continuity of care by all partners. short and concise instructions, which can be understood by all partners. Review of the care plan for R69 revealed Problems listed as but not limited to resident requires training and skill practice in transfer, resident require PROM (passive range of motion) to left hand to prevent further contractures six days a week, and resident requires splint/brace assistance to left hand six days a week. Further review revealed approaches documented as but not limited to resident will transfer to and from bed to chair and sit to stand, place resident in restorative nursing program for PROM and splinting as tolerated to left hand.During an interview on 1/17/2026 at 2:23 pm with the Director of Nursing (DON) and Regional Nurse Consultant, the DON revealed that restorative care was care planned. She stated she expected the restorative nursing staff to provide restorative care as described in the care plan. She confirmed that the care plan for R69 had a problem area of Resident requires training and skill practice in transfer with an approach of resident will safely transfer to and from bed to chair as sit to stand in rw (rolling walker). start date 10/24/2025 and a problem of Resident requires splint/brace assistance to left hand x 6 days per week with an approach of Place resident in restorative program for splinting as tolerated to left hand. Once a day dated 7/1/2025 and a problem Resident requires PROM to left hand to prevent further contractures x 6 days a week with an approach Place resident in restorative nursing program for PROM to left hand dated 7/3/2025.

Based on observations, staff and resident interviews, record review, and review of the policy titled, Restorative Nursing Program, the facility failed to provide services to maintain and or prevent further decrease in range of motion or mobility for one of 16 Residents (R) (R69) receiving Restorative Nursing care. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life.Findings include:Review of the policy titled Restorative Nursing Program revised 11/4/2021 revealed a Policy Statement: it is the policy of this healthcare center to provide restorative nursing which actively focuses on achieving and maintain optimal physical mental and psychological functioning and wellbeing of the patient/resident. Restorative Nursing program is under the supervision of a Registered Nurse (RN) or a License Practical Nurse (LPN) and restorative nursing services are provided by Restorative Nursing Assistants (RNAs), Certified Nursing Assistants (CNAs) and other qualified staff. Nursing assistants/aides must be trained in techniques that promote resident involvement in the activity.Review of the electronic medical record (EMR) revealed R69 was admitted to the facility with pertinent diagnoses including but was not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Cerebral infarction, and difficulty in walking.Review of R69's annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/26/2025 revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicates R69 was cognitively intact. Section G, functional status, revealed R69 required partial to moderate assistance with showers/bathing, upper body dressing and substantial maximal assistance with toileting, lower body dressing, putting on and taking off footwear, sit to stand, and chair / bed-to-chair transfer. Review of Progress Notes revealed a nursing note was entered on 7/3/2025, 7/10/2025, 8/7/2025, 9/12/2025, 10/16/2025, 11/20/2025 and 12/18/2025 indicating R69 was on restorative nursing and staff applied splint and perform exercises. The note dated 12/18/2025 indicated R69 was assisted with transfer from bed to chair and from chair to bed with one staff assist.Review of Restorative Nursing Notes for minutes for transferring revealed:December of 2025 five entries total were made: Three were documented as not observed and two were documented as no information.January 2026 two entries were noted: One was documented as not observed and one was documented as no information. Review of Restorative Nursing Notes for minutes for splint or brace assistance revealed:October of 2025, 22 entries were made: Seven entries were documented as Minutes - 15, tolerance: fair, Progress improved. Eight entries were documented as minutes 15, tolerance fair, progress no change. Five entries were documented as no information. Two entries were documented as refused. November of 2025 the notes revealed 18 entries: Seven were documented as 15 minutes, tolerance fair and progress no change. One entry was documented 15 minutes, tolerance fair, and progress improved. One entry was documented as refused. Three entries were documented as not observed. Six entries were documented as no information.December of 2025 the notes revealed 12 entries: Five entries were marked as no information. Seven were marked not observed.January of 2026 the notes revealed six entries: Five were marked no information. One was marked not observed.Review of Restorative Nursing Notes for minutes for passive range of motion (PROM)November 2025 the notes revealed 18 entries: Seven entries were documented as 15 minutes, tolerance fair, and progress no change. One entry was documented as 15 minutes, tolerance fair, and progress improved. One entry was documented as refused. Six entries were documented as no information. Three entries were documented as not observed.December 2025 the notes revealed 12 entries: Seven entries were documented as not observed. Five entries were documented as no information.January 2026 the notes revealed six entries: One entry was documented as not observed. Five entries were documented as no information.Review of the EMR revealed Physician's Orders for R69 included but not limited to splint to left hand 4 - 7 hours per day as tolerated with monitoring of edema, skin integrity and pain and was dated 6/17/2025.Observations and interview with R69 on 1/16/2026 at 10:10 am revealed R69 was in bed and he stated he wanted to get up but staff do not get him up into a wheelchair at all. He revealed he received physical therapy but since the discharge from therapy services he has not been gotten up to a chair or wheelchair on a regular basis. He stated he felt as though he would lose the abilities he had obtained during therapy. Observed that R69 did not have a splint/brace on his left hand.Observations and interview with R69 on 1/17/2026 at 12:35 pm revealed R69 was in bed in his room. He reported staff did not offer to assist him to a chair the morning of 1/17/2026 nor did he ask to be assisted to a chair. He stated he did have a splint for his left hand but the last time he used it was several weeks ago and now he was unsure where it was. He stated he did want to get up into a chair. No splint/brace was noted to be on his left hand/extremity.Interview with CNA BB on 1/17/2026 at 1:45 pm, CNA BB stated she could find residents who needed restorative care by looking at their care plan she also revealed that when she documented in the EMR under the Activity of Daily Living (ADL) tab she could see restorative nursing that needed to be completed so she would only document no information because she was not the Restorative Aide. She stated only the Restorative Aide documented the actual restorative care given.interview with CNA CC on 1/17/2026 at 2:03 pm revealed that after residents finished rehab, some residents were transferred to the long-term care unit, and they assisted them with ambulation, range of motion, and placement of splints. She stated she could find which residents needed restorative nursing care in the EMR. She revealed that she documented restorative care in the EMR. She stated she documented the time spent with the residents and the activity performed. She stated when a resident refused twice, they reported this to the Restorative Nursing Supervisor who refers them back to rehab. An interview on 1/17/2026 at 2:23 pm with the Director of Nursing (DON) and the Regional Nurse Consultant, the DON revealed the process for a resident to be placed on restorative nursing care. A therapist from the therapy department evaluated the resident based on their needs and documented orders for restorative nursing, then the next step was the resident was placed on restorative nursing. She stated the Restorative Aide could print a list of residents from the EMR who were on restorative care and it would list the activities that the CNA needed to assist each resident with. She stated the Restorative Aide and CNAs could go to the point of care section of the EMR and it would show the restorative nursing activity that needed to be documented on. She stated only restorative aides documented restorative care and other CNA's who had been trained in restorative nursing could document the restorative care provided, but not all CNAs were trained in restorative care. She reported there was a Restorative Aide working six days a week. She stated that restorative nursing care should be documented when performed and the Restorative Nurse documented once a month. She confirmed and verified documentation of the restorative nurse documented a note on 7/3/2025, 7/10/2025, 8/7/2025, 9/12/2025, 10/16/2025, 11/20/2025 revealing the resident was receiving restorative nursing care and staff were applying a splint and performing exercises and in December 2025, the note revealed the resident was assisted with transfer from bed to chair and from chair to bed with one staff assist. She confirmed and verified the restorative aide documentation revealed in December of 2025 and January of 2026 the transfer assistance was not documented as completed.Review of the notes related to splint or brace assistance: The DON verified and confirmed for October of 2025 of the 22 entries made, only 15 documented the care was given and two entries documented the resident refused; the other five entries were documented and no information. She verified and confirmed in November of 2025, of the 18 entries made eight were documented as care was completed and one entry documented the resident refused, the other nine entries were documented as not observed or no information. She verified and confirmed that in December of 2025 there were 12 entries, five were documented as no information and seven were documented as not observed. She verified and confirmed that in January of 2026 only six entries had been made and five were documented as no information, and one as not observed. In review of the notes related to PROM she verified and confirmed in November of 2025 the documentation supported eight entries indicated the care was completed, six entries were documented as on information and three were documented as not observed. In December of 2025 she verified and confirmed the PROM was documented seven times as not observed and five times as no information. She verified and confirmed that the PROM was documented in January of 2026 one time as not observed and five times as no information. She stated her expectation was that staff document effectively and efficiently the care the Restorative Aide/Nurse provided, and if the resident refused care, the restorative aide should document the refusal and notify the nurse. She revealed R69 should receive restorative care 15 minutes a day, six days a week for each area noted under restorative care.

Based on observations, resident and staff interviews, and record review, the facility failed to ensure one of 47 sample resident's (R) (R41) food preferences/needs were being accommodated, specifically for food allergies.Findings include:Review of R41's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating little to no cognitive impairment.Review of R41's banner on the electronic medical record (EMR) revealed caffeine was listed as an allergy.Review of the care plan for R41 revealed caffeine was listed as an allergy.Review of the meal ticket for R41 revealed caffeine was listed as an allergy.During an observation and interview on 1/16/2026 at 12:00 pm with R41 stated the dietary department consistently gave her coffee and she was allergic to caffeine. She further stated she did not touch it and unclear why it was overlooked when it was printed on the meal ticket.An observation on 1/17/2026 at 9:14 am of R41 with her meal tray confirmed there was a cup of coffee on her meal tray.During an interview on 1/17/2026 at 2:20 pm with the Dietary Manager (DM), he stated himself and the dietary aides were responsible for ensuring the meal tickets and meal trays were accurate. The DM further confirmed that coffee was a caffeinated beverage they give to residents on their breakfast tray. The DM was unsure of R41's allergies and if she was receiving caffeinated or decaffeinated beverage on her tray. However, he stated the nursing staff on the units should also be checking the meal tickets to ensure the tray was accurate before delivering it to the resident.During an interview on 1/17/2026 at 2:30 pm with R41, she stated when her meal tray was delivered, the staff did not verbalize if her coffee beverage was caffeinated or decaffeinated. An interview on 1/18/2026 at 12:58 pm with the Director of Health Services (DHS) stated upon admission they reviewed the residents' allergies on the hospital records and from there it would be stated throughout the EMR. The DHS continued to state the dietary staff were expected to verify the meal ticket with the meal tray and the nursing staff delivering the trays were to also confirm the meal ticket with the meal trays.

Based on resident and staff interviews, record review and review of the facility's policy titled Resident Trust Fund Policy, the facility failed to provide a quarterly statement to seven residents (R) (R89, R50, R46, R108, R92, R20, R7) and the facility failed to employ proper bookkeeping techniques for two residents (R89 and R46) out of 65 sampled residents. This had the potential to affect residents with trust fund accounts managed by the facility, affect the residents' financial records and overall transparency, potentially leading to confusion or errors in their account balances. Findings Include: Review of the facility's policy titled, Resident Trust Fund Policy, revised on 6/4/2024 under the Policy Statement revealed, It is the policy of [Name of Organization] and its affiliated Healthcare Centers (collectively, the Organization to protect patients' funds in accordance with applicable regulatory guidelines, as addressed in the Omnibus Budget Reconciliation Act of 1990 (OBRA) and relevant state policies. Under the section titled Scope revealed, This policy applies to all [Name of Facility] Healthcare Centers (HCCs or facilities). The Administrator of each HCC should ensure compliance with the procedures described below, as well as any additional state-specific policies that may apply. 1.Review of R89's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated the resident was cognitively intact. An interview conducted on 11/6/2024 at 9:28 am with R89 revealed he had never received a quarterly statement since he had been in the facility and stated he had concerns regarding the amount of money he had in his account. R89 stated sometimes when he asked the facility for money, they don't always give him all the money he requests. Review of R46's Annual MDS assessment dated [DATE] which revealed, a BIMS summary score of 15, which indicated little to no cognitive impairment. An interview conducted on 11/6/2024 at 11:55 am with R46 revealed she had received her resident statement for the first time on 11/6/2024 but was unable to read her statement and asked for assistance by the facility. Review of R50's Quarterly MDS assessment dated [DATE] which revealed, a BIMS summary score of 13, which indicated little to no cognitive impairment. An interview conducted on 11/6/2024 at 1:13 pm with R50 revealed she had never received a quarterly statement from the facility. Review of R108's Quarterly MDS assessment dated [DATE] which revealed, a BIMS summary score of 15, which indicated little to no cognitive impairment. An interview conducted on 11/6/2024 at 9:22 am with R108 revealed he did not know how much money he had because the facility does not provide a statement. R108 stated when he would ask questions to the Financial Counselor, she would state she would come back to address his questions and would never come back. Review of R92's revealed Quarterly MDS assessment dated [DATE] revealed, a BIMS summary score of 15, which indicated little to no cognitive impairment. An interview conducted on 11/6/2024 with R92 revealed the facility did not give him a statement or anything. R46 confirmed no one had come to talk with him about anything financially related. Review of R20's Quarterly MDS assessment dated [DATE] revealed, a BIMS summary score of 12, which indicated little to no cognitive impairment. An interview conducted on 11/6/2024 at 11:45 am with R20 revealed he was unaware of a resident statement and denied receiving any information. Review of R7's Annual MDS assessment dated [DATE] revealed, a BIMS summary score of 15, which indicated little to no cognitive impairment. An interview conducted on 11/5/2024 at 1:22 pm with R7 revealed she had never received a quarterly statement since she had been at the facility. R7 stated she requested one from the Financial Counselor, but she never brought her one. An interview conducted on 11/6/2024 at 2:00 pm with the Financial Counselor revealed she was supposed to send out resident's quarterly statements every three months. She stated the last statement she sent out was in September 2024. The Financial Counselor further stated she had never given out a printed copy of the resident's statements, but if they ask for one, she will provide one for them. The Financial Counselor further stated she was aware she was supposed to provide a copy to the residents of their quarterly statement, but she doesn't necessarily provide it to everyone because it's a lot of residents. She further stated she doesn't review the quarterly statement with everybody, but with the residents that like to be on top of it An interview conducted on 11/7/2024 at 2:19 pm with the Administrator revealed her expectations that the facility follows the Center for Medicaid and Medicare Services (CMS) guidelines for residents and their representatives to be provided with a quarterly statement. The Administrator further revealed that she has provided in-service education for the financial counselor of CMS guidelines. 2.Review of R89's Quarterly MDS assessment dated [DATE] revealed, a BIMS summary score of 15, which indicated little to no cognitive impairment. An interview conducted on 11/6/2024 at 9:28 am with R89 revealed he has never received a quarterly statement since he has been in the facility and stated he has concerns regarding the amount of money he has in his account. R89 stated sometimes when he asks the facility for money, they don't always give him all the money he requests. Review of R46's Annual MDS assessment dated [DATE] revealed, a BIMS summary score of 15, which indicated little to no cognitive impairment. An interview conducted on 11/6/2024 at 11:55 am with R46 revealed she had received her resident statement for the first time on 11/6/2024 but was unable to read her statement and asked for assistance by the facility. Record review on 11/7/2024 with the Administrator, [NAME] President of Regional Area, Financial Counselor and Administrative Assistant in Training of R89's Resident Statement Landscape from RFMS revealed the following discrepancies on his statement landscape: - On 1/24/2024, an entry was made for a debit of $3.50 to Petty Cash for the Snack Bar, but no entry was found on the snack sheet for the service date of 1/19/2024. - On 7/25/2024, an entry was made for a debit of $12.00, paid to [Name of Facility] Snacks for the Snack Bar, but no entry was found on the snack sheet for the service date of 7/19/2024. - On 7/22/2024, an entry was made for a debit of $4.36, paid to [Name of Facility] Snacks for the Snack Bar, but a duplicate entry was found for the service date of 7/15/2024. - On 10/17/24, an entry was made for a debit of $22.00 to Petty Cash for a Resident Advance Check, but no cash receipt was found for the service date of 10/8/2024. Record review on 11/7/2024 with the Administrator, [NAME] President of Regional Area, Financial Counselor and Administrative Assistant in Training of R46's Resident Statement Landscape from RFMS revealed the following discrepancies on his statement landscape. - On 8/15/2024, an entry was made for a debit of $25.00 for Personal Needs Items, but the cash receipt recorded that $20.00 was given on the service date of 8/10/2024. - On 8/6/2024, an entry was made for a debit of $15.00, paid to [Name of Facility] Snacks for the Snack Bar, but no entry was found on the snack sheet for the service date of 7/30/2024. -On 9/4/2024, an entry was made for a debit of $20.00 to Petty Cash for a Resident Advance Check, but no cash receipt was found for the service date of 8/28/2024. - On 10/1/2024, an entry was made for a debit of $15.00, paid to [Name of Facility] Snacks for Personal, but the name was not found on the snack sheet for the service date of 9/30/2024. An interview conducted on 11/7/2024 at 5:14 pm with the Administrator revealed a reconciliation will be reviewed and reimbursements will be made as appropriate. The Administrator revealed a facility wide audit will be conducted in the month of November 2024. Furthermore, the Administrator revealed the Financial Counselor had been put on a Performance Improvement Plan since 10/18/2024. The Administrator revealed the expectations were that the facility follow basic accounting standards.

Based on staff interviews, record review, and review of the facility's policy titled Advance Beneficiary Notice of Noncoverage, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) to one of three residents (R) (R31) reviewed for Beneficiary Notification who remained in the facility and was discharged from Medicare Part A services. Findings include: Review of the facility's undated policy titled,Form Instructions Advance Beneficiary Notice of Noncoverage, under the section titled Overview revealed, they must complete the ABN as described below and deliver the notice to affected beneficiaries or their representative before providing the items or services that are the subject of the notice. The ABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice. Review of clinical records under Resident Census tab for R31 revealed on 5/2/2024 R31 was skilled Medicare part A and on 5/10/2024 a payer change was indicated. Review of clinical records for R31 revealed no evidence that a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form or a Notice of Medicare Non-Coverage (NOMNC) was provided. Interview on 11/5/2024 at 3:26 pm with the Social Service Coordinator verified R31 was discharged from Part A services with days remaining on 5/10/2024 according to the census. She stated in her professional opinion he should have received both an ABN and a NOMNC prior to discharge on 5/10/2024. She stated she was not sure why he was discharged from part A services. She revealed that she thought maybe he had been admitted to the hospital but after review of the records she discovered he was not admitted to the hospital at the time of this discharge from part A services on 5/10/2024. She stated he should have received an ABN and NOMNC at least 48 hours prior to last covered date. She stated the outcome of not providing the ABN & NOMNC could cause a disadvantage to patient resulting in them not being able to file an appeal or be skilled when they could have been and to receive the services they need. Interview on 11/5/2024 at 3:47 pm with the Administrator confirmed and verified that R31 was discharged from Part A Services on 5/10/2024 and she was not sure why he was discharged from Part A services. She stated her expectation was that the facility follows CMS guidelines to ensure ABNs and NOMNC were issued timely. She revealed the possible outcome of not providing notification to residents could negatively impact care and services the resident was entitled to.

Based on observations, resident and staff interviews, the facility failed to provide a safe environment as evidenced by loose wires were exposed unsecured in the room of one of 65 sampled residents (R) R50. The deficient practice had the potential to increase the risks of an accident. Findings include: Review of Electronic Medical Records (EMR) revealed, R50 was admitted with diagnoses that included but were not limited to muscle weakness, cognitive communication deficit, lack of coordination, ataxic gait, lack of physical exercise, dementia, repeated falls, and altered mental status. Review of R50's care plan dated 10/10/2024 revealed, a Problem Category: Falls, Patient/ resident at risk for falls related to fall on 5/9/2024 with Goal that patient/ resident will not sustain injury related to falling through next review; Approaches included but not limited to: assist with toileting and transfers prn, cue for safety awareness, keep environment safe, place call light within reach. Observation on 11/4/2024 at 1:45 pm revealed R50 sitting in wheelchair beside her bed. There were loose wires in the corner of R50's room hanging from the wall on the right side of her room near her rolling walker. One of the wires was noted to have an uncovered end. Observation on 11/5/2024 at 3:22 pm revealed R50 sitting up in bed. There were loose wires in the corner of R50's room hanging from the wall on the right side of her room near her rolling walker. One of the wires was noted to have an uncovered end. Observation on 11/6/2024 at 1:05 pm revealed R50 lying in bed. There were loose wires in the corner of R50's room hanging from the wall on the right side of her room near her rolling walker. One of the wires was noted to have an uncovered end. Observation and interview on 11/7/2024 at 10:10 am revealed R50 sitting in chair at the foot of her bed. There were loose wires in the corner of R50's room hanging from the wall on the right side of her room near her rolling walker. One of the wires was noted to have an uncovered end. R50 revealed that she uses her walker for ambulation which was located near the loose wires. She revealed, the loose wires had been there for a while, and no one had moved them. Interview on 11/7/2024 at 10:13 am with the Maintenance Assistant confirmed the loose wires were present in the corner of R50's room and the wires should not be there. He stated the lose wires were a cable wire, telephone cord and was unsure what the third wire was which had an uncovered end. He further stated the loose wires could cause the resident to trip and fall and get hurt. He also stated the resident could be electrocuted if the loose wires came in contact with water. Interview on 11/7/2024 at 10:19 am with Licensed Practical Nurse (LPN) UU revealed, confirmed the loose wires in the resident's room were not to be there. She stated the wires were an accident hazard. Interview on 11/7/2024 at 10:25 am with Certified Nursing Assistant (CNA) confirmed the loose wires were in R50's room and stated the wires should not be there. She stated R50 could get hurt by the loose cords being in her room. Interview on 11/7/2024 at 11:14 am with Maintenance Director revealed, his expectations were for a safe environment to be maintained for the residents and that no loose wires should be present in R50's room. He stated the outcome would be R50 could trip on the wires and hurt herself.

Based on staff interviews and record review, the facility failed to ensure comprehensive Minimum Data Set (MDS) assessments were completed and submitted for one of three Residents (R) (R31) reviewed for Beneficiary Notification. Specifically, the facility failed to complete and submit a Part A Prospective Payment System (PPS) Discharge MDS assessment for R31. Findings include: Review of the Electronic Medical Record (EMR) for R31 revealed the resident was admitted on [DATE] and discharged from Medicare Part A Services on 5/10/2024. Review of MDS 3.0 Resident assessments for R31 dated 5/2/2024 revealed an entry assessment was completed and accepted. Further review revealed on 5/9/2024 an assessment coded as NPE (Nursing Home Part A PPS Discharge) was deleted. Interview on 11/6/2024 at 4:48 pm with the Registered Nurse (RN) Clinical Reimbursement Consultant CC verified and confirmed that there was not a Part A PPS Discharge Assessment completed for the last covered day of part A services on 5/10/2024. She verified and confirmed the Census revealed, R31 was discharged from Medicare part A services on 5/10/2024. She revealed that a discharge MDS assessment was started on 5/9/2024 but was deleted and not submitted. She stated she was not sure if there should have been a Part A PPS Discharge Assessment completed for the end of part A services dated 5/10/2024. She stated the process was that they follow the MDS Manual for completing Medicare discharge assessments. Interview on 11/7/2024 at 9:38 am with the Administrator confirmed and verified the MDS discharge assessment was started but deleted on 5/9/2024. She confirmed it was not submitted. She stated her expectation was for the MDS coordinator to follow CMS and resident assessment instrument (RAI) guidelines assessment for competition of assessments in a timely manner. She stated if this was not done in a timely manner it had the potential for negative outcome for assessments not to be completed timely which could affect care, services and finances.

Based on record reviews and staff interviews the facility failed to screen one of two residents (R) R119 reviewed for Pre-Admission Screening and Record Review (PASARR). This deficient practice had the potential to cause R119 to not receive care and services in the most integrated setting appropriate to his needs and have diminished quality of life. Findings include: Review of Electronic Medical Records (EMR) for R119 revealed, he was admitted on [DATE] with diagnoses that included but not limited to Autistic Disorder (AD). Review of R119's quarterly Minimum Data Set (MDS) dated [DATE] for Section C (Cognitive Pattern) revealed, a Brief Interview of Mental Status (BIMS) of three which indicated severe cognitive impairment, Section I (Active Diagnosis) revealed, Non-Traumatic Brain Dysfunction. Review of R119's admission Minimum Data Set (MDS) dated [DATE] for Section C (Cognitive Pattern) revealed, a Brief Interview of Mental Status (BIMS) of three which indicated severe cognitive impairment, Section I (Active Diagnosis) revealed, Depression. Review of R119's admission referral dated 6/15/2024 revealed, R119 had a past medical history of Autism. Review of R119's PASRR Level I Assessment form dated 6/18/2024 revealed, he did not have a Primary Diagnosis of Serious Mental Illness, developmental disability or related condition. Interview on 11/5/2024 at 2:00 pm with Social Services Coordinator QQ revealed, that residents were admitted with a PASARR Level I and if they have behaviors, they are referred for a psychiatric evaluation. Interview on 11/6/2024 at 10:09 am with Social Services Coordinator QQ revealed, she had not submitted a referral for PASARR Level II assessment for R119. She confirmed R119 had been in the facility for almost four months and had not been referred for a PASARR Level II assessment. Interview on 11/7/2024 at 10:07 am with Social Services Coordinator QQ revealed, a review of the residents' diagnoses and medications were to be done on admission. She stated that if a resident had a diagnosis, that would prompt submission for a PASARR level II referral, then it should be done as soon as possible. She stated if a PASARR level II referral was not done as close to admission as possible, R119 would be missing extra services he would have benefited from and missing out on treatment which would help him. Interview on 11/7/2024 at 11:36 am with the Administrator revealed, PASARR Level II referrals were to be completed at the time of admission. She also stated that based on the Level I assessment results, if a Level II was triggered, it should be completed timely. She confirmed that R119 was admitted [DATE] and should have had a PASARR Level II referral done as close to admission as possible. The Administrator also confirmed that the PASARR Level II referral had not yet been done for R119. She stated the outcome for R119 not having a PASARR Level II referral and assessment done could cause a potential negative outcome for R119.

Based on staff interviews, record reviews, and review of the facility's policy titled Care Plans, the facility failed to develop a baseline care plan that addressed care and management for a PICC (peripherally inserted central catheter) line within 48 hours of admission for one of four residents (R) R542 reviewed with PICC lines. This deficient practice had the potential to increase the resident's risk of adverse health outcomes related to PICC lines. Findings include: Review of the facility's policy titled Care Plan dated 12/31/1996 under the section titled, Procedure revealed, New Admission Baseline Plan of Care 1. Upon a new admission, a baseline care plan will be developed by the attending nurse/nurses in conjunction with other Inter- Disciplinary Team (IDT), the patient, resident and or patient /resident representative. The baseline care plan should be initiated in 24 hours and will be completed and implemented within 48 hours of admission. 2. The Baseline Care Plan will be updated to reflect changes to approaches as necessary that result from significant changes in condition or needs, occurring prior to the development of a comprehensive care plan. 3. Within the first few days of admission, a post admission care conference will be held for updates and review of the baseline care plan. The baseline care plan should be updated to reflect changes since baseline care plan implementation . Review of Electronic Medical Records (EMR) revealed, R542 was admitted to the facility on [DATE] with a right upper arm PICC line for the administration of antibiotics. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed, it had not been completed related to R549 was recently admitted on [DATE]. Review of Care Plan dated 11/6/2024 revealed, no evidence of PICC line care and management. Review of Physician orders dated 11/5/2024 documented orders included but not limited to CENTRAL Access Device MAINTENANCE: Change dressing every (Q) week. Change injection caps with or without extension tubing Q week, after blood draws. Once A Day on Mon Days 07:00 AM - 07:00 PM 11/5/2024 CENTRAL Access Device MAINTENANCE: Change dressing Q week. Change injection caps with or without extension tubing Q week, after blood draws. Once A Day on Mon Days 07:00 AM - 07:00 PM 11/05/2024 Review of Nursing Progress Notes dated 10/31/2024 revealed, R549 was admitted to PH with a right upper arm picc [sic] line for the administration of antibiotics (ceftriaxone and metronidazole). Per PH SOP and the CDC's recommendations, Enhanced Barrier Precautions have been implemented. Interview on 11/5/2024 at 1:14 pm with MDS Coordinator revealed, nursing staff implemented care plans and MDS checked would check the entire care plan afterwards. Interview on 11/5/2024 at 2:19 pm with Assistant Director of Health Services (ADHS) revealed care plans were initiated by the ADHS, the Director of Health Services (DHS), the Nurse Navigator and the Unit Manager. The ADHSfurther stated whenever a resident was admitted , a baseline care plan was to be done within 48 hours. The ADHS stated, If a resident had specialized care, it was important for it to be care planned. She stated if specialized care was not care-planned for a resident, the outcome would be missed care and serious outcomes for the resident. Interview on 11/7/2024 at 9:45 am with Clinical Re-imbursement Coordinator (CRC)/ Consultant revealed nursing staff initiates care plan and follow up was done by MDS staff to ensure the resident received care. She stated the IDT team also check and ensure care plans were done. The CRC/Consultant confirmed that no care plan was done for R549's PICC line care and management since his admission on 10/30/2024 until 11/7/2024. She stated her expectation was for R549's PICC line care and management should have been care planned within 48 hours of admission.

Based on staff and resident interviews, record reviews, and review of the facility's policy titled Care Plans, the facility failed to develop a resident centered care plan for one of five residents (R) R68 reviewed for unnecessary medication use, that included problem, goals or interventions related to diuretic use, and one of six residents (R101) for enteral feedings received through a gastrostomy tube (G-tube). In addition, the facility failed to develop a comprehensive care plan for one of four residents (R6) with a seizure disorder that included necessary seizure precautions, to ensure the resident's optimal physical, mental, and psychosocial well-being. Findings include: Review of the policy titled Care Plans, with an effective date of 12/31/1996, under the Policy Statement revealed, It is the policy of the health care center for each resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following the completion of the [NAME] Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the patient/resident choice. Under the section titled Person -Centered Care revealed, Focus is on the resident as the center of control. Supports each resident in making his or her own choices. Includes trying to understand what each resident is communicating, verbally and nonverbally, to identify what is important to each resident regarding daily routines and preferred activities and having and understanding of the resident's life before coming to reside in the health care center. 1. Review of the Electronic Medical Record (EMR) for R68, revealed that he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to cerebral infarction, hemiplegia and hemiparesis of right dominant side, dementia, psychosis, major depressive disorder, hereditary and idiopathic neuropathy, chronic diastolic (congestive) heart failure, pain and chronic atrial fibrillation. Review of the physician medication orders for R68 revealed that he received Eliquis (anticoagulant) dated 11/2/2024, furosemide (diuretic) dated 3/25/2024, Jardiance (diabetic medication) dated 11/2/2024, tramadol (pain medication) dated 9/13/2024, trazodone (anti-depressant) dated 3/25/2024, Zoloft (anti-depressant) and Zyprexa (antipsychotic) dated 3/25/2024. Further review revealed, non-medication orders that included, monitor resident for signs and symptoms of bleeding/bruising every shift, monitor for signs and symptoms of hypo/hyperglycemia every shift, Pain evaluation every shift and monitor for medication side effects: Behavior Monitoring Review of the quarterly minimum data set (MDS) for R68, dated 9/20/2024, for Section N (Medications) revealed that he was receiving antipsychotic, antidepressant, anticoagulant, diuretic, opioid, and hypoglycemic as a resident. Review of the care plan last reviewed/revised date of 9/15/2024 revealed that R68 had risk for abnormal bleeding or hemorrhage because of anticoagulation usage, psychotropic drug use (trazodone, Zoloft, Zyprexa), resident has pain, resident at risk for falls related to hypertension, psychotropic medication use. 2. Review of the EMR for R101, revealed that he was admitted to the facility on [DATE], with diagnoses that included but were not limited to cerebral infarction, enterocolitis due to clostridium difficile, contractures of right upper arm, dysphagia, depression, pneumonitis due to inhalation of food and gastrostomy status. Review of the physician orders for R101, revealed orders for enhanced barrier precautions due to having a g-tube dated 9/18/2024, G-tube to be checked for residual before feeding and G-Tube placement to be checked prior to medication administration dated 8/1/2024; and Jevity 1.5 (feeding formula) to be administered through the G-tube at 55 milliliters (mL) an hour for 22 hours a day with feeding to be turned on at 10 am and then turned off at 8 am dated 10/7/2024. Review of the admission MDS dated [DATE], for R101 for Section K (Swallowing/Nutritional status) revealed, that the resident had a gastrostomy tube, and received feedings as a resident and before becoming a resident. Review of the care plan for R101 revealed, he was at risk for dehydration/malnutrition, related to C-difficile, pressure ulcers, and G-tube dated 8/1/2024. The resident received mechanically altered, pureed diet and enteral nutrition support related to a history of cardiovascular accident (CVA), dysphagia, and difficulty with self-feeding dated 8/5/2024. There were no interventions in place related to G-tube or enteral nutrition except for enteral nutrition as ordered and encourage oral meal and fluid intake. There were no interventions in place for G-tube care. Interview with the Registered Nurse (RN)/Clinical Reimbursement Coordinator (CRC) CC on 11/7/2024 at 12:33 pm revealed that if the clinical team felt that something was an issue, then it would be care planned. She continued by stating that at some point after something was discontinued, it will be discontinued on the care plan. She then stated that typically, the MDS coordinator would look at care plans quarterly, changes are reconciled with the completion of assessments. 50940 3. Review of EMR for R6 revealed he was admitted to the facility with diagnoses that included but not limited to seizures and cerebral infarction. Review of the most recent quarterly minimal data set (MDS) assessment dated [DATE] revealed for Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) score is 5, indicating significant cognitive impairment; Section N (Medications) revealed, he received insulin, hypoglycemic, antidepressant, antianxiety, hypnotic, anticoagulant, antibiotic, diuretic, opioid, antiplatelet, and anticonvulsant medications. Review of Nurse Practitioner (NP) encounter note, dated 9/16/2024, revealed, Plan of care includes continue Phenobarbital. Monitor phenobarbital levels every 6 months and as needed. Review of the Physician Orders dated 9/26/2023 revealed, .Order to check phenobarbital levels every six months on the fourth Tuesday. Review of the resident's medication include, but not limited to Phenobarbital (anti-seizure medication) 32.4 mg 1 (one) tab daily at 9 am and Phenobarbital 32.4 mg 2 (two) tab daily at 5 pm. Review of the Medication Administration Record (MAR) revealed that the resident is monitored daily for behaviors, but nowhere in the MAR it was found that the resident was monitored for seizure precautions. Review of the most recent care plan, dated 10/31/2024, revealed that R6 was not care-planned for seizure precautions, and there was no mention of the resident's seizure diagnosis in the plan. Interview on 11/6/2024 at 10:30 am with the Unit Manager Licensed Practical Nurse LPN JJ revealed that residents with a diagnosis of seizures must have seizure precautions included in their care plan. Upon reviewing the chart, the Unit Manager LPN, JJ confirmed there was no documentation regarding seizures or seizure precautions in the care plan. Interview on 11/6/2024 at 3:15 pm with the MDS coordinator, Registered Nurse RN RR and Corporate Clinical Reimbursement Registered Nurse RN SS revealed it was not always necessary to include seizure precautions in the care plan if the resident was stable and not experiencing seizures. However, they admit that a resident should be care planned if blood work monitoring is required, such as for those on phenobarbital. Interview on 11/7/2024 at 10:23 am with the Director of Health Services (DHS) revealed that if a resident had a medical diagnosis (i.e. seizure disorder) when they complete the Minimum Data Set (MDS) it would trigger the areas that need to be care planned.

Based on observations, staff interviews and record reviews, the facility failed to provide nail care for one of four residents (R) R101 reviewed for Activities of Daily Living (ADLs). Specifically, the facility failed to and trim R101's long fingernails on both hands and clean fingernails on his left hand. The deficient practice had to the potential to cause skin breakdown and infection to the palm of hands with contractures. Findings include: Review of the Electronic Medical Record (EMR) for R101, revealed that he was with diagnoses that included but were not limited to cerebral infarction and contractures of right upper arm. Review of the care plans for resident R101 revealed that he has Activities of Daily Living (ADL) decline related to cardiovascular accident (CNA) with right sided hemiplegia, right arm contracture, sepsis, protein calorie malnutrition. Review of the admission Minimum Data Set (MDS) dated [DATE] for R101, Section GG (Functional Abilities and Goals) revealed, he was dependent for personal hygiene. Section I (Active Diagnoses) revealed that he had hemiplegia or Hemiparesis. Review of physician orders for R101 dated 9/26/2024 revealed, that he was to have a splint to right resting hand 5 (five) to 7 (seven) hours per day daily as tolerated with monitoring of edema, skin integrity and pain. An observation of R101 on 11/3/2024 at 2:47 pm, revealed fingernails on his right contracted hand were long and turned inward towards the palm of his hand and fingernails on his left hand were noted to be long and dirty. An observation of R101 on 11/4/2024 at 12:54 pm, revealed fingernails on his right contracted hand were long and turned inward towards the palm of his hand and fingernails on his left hand were noted to be long and dirty. An interview on 11/5/2024 at 12:36 pm with Certified Nursing Assistant (CNA) II revealed, that fingernails should be completed during showers or anytime they were long and dirty. She revealed that she would inform the unit manager regarding nail care for the hand that was contracted. An interview JJ on 11/5/2024 at 12:43 pm with Licensed Practical Nurse (LPN)/Unit Manager (UM) revealed, that if a resident hand was contracted and the CNA and nurse could perform nail care safely, they should do it. She then stated that if it could not be done safely, then they would ask podiatry to perform nail care or ask therapy if they had something to place in the resident's palm to protect it. An interview on 11/6/2024 at 4:00 pm with CNA EE revealed, that when R101 moved to the hall in which she had been assigned a week ago, he had long nails. She then stated that for as long as she has had him, he has not refused care. An interview on 11/7/2024 at 10:24 am with Director of Health Services revealed, that she expects that fingernails of residents should be cleaned and trimmed. She stated that some residents want them longer than others. She then stated that if a CNA felt comfortable about trimming the nails on a contracted hand, then I expect them to do it, and if not then they need to inform the nurse and let them handle it.

Based on observations, staff and resident interviews, record review and review of the facility's policy titled Activities Program, the facility failed to provide an ongoing program of activities based on person-center activities for three of nine residents (R) (R92, R121, and R540) reviewed for activities whose primary language was non-English. Findings Include: Review of the facility's policy titled Activities Program, dated 9/28/2023 under the section titled Procedure revealed, 5. The programming should reflect cultural and ethnic interests of the resident. Review of records revealed the facility had nine residents whose primary language was non-English. 1. Review of the clinical records for R92 revealed she was admitted to the facility with diagnoses that included but not limited to cerebral infarction, emphysema, unspecified, unspecified asthma, uncomplicated, pneumothorax, unspecified, muscle weakness, acute respiratory failure with hypoxia, shortness of breath, chest pain, chronic obstructive pulmonary disease, and pain in unspecified shoulder. Review of R92's Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Pattern) revealed, a Brief Interview for Mental Status (BIMS) score of 15 which indicated little to no cognitive impairment; Section F (Preferences for Routine and Activities) revealed, the primary respondent for the questions was the resident, and indicated it was very important for her to listen to music she likes, keep up with the news, do things with groups of people, do favorite activities and go outside for fresh air. Review of R92's care plan dated 10/31/2024 revealed, R92 enjoys watching TV (television) and visits from friends and family with start date of 8/8/2024; Goal(s) Patient/ Resident will choose and participate in activities of choice, Independent Activities, 1:1 Visitation with Approaches that included but not limited to, check with patient/ resident regularly to assess satisfaction with activities offered, introduce to other patient/ residents with similar interests, give calendar of scheduled activities, describe activities available and assist patient/ resident to choose activities to match interests and abilities, give patient/ resident tour of activity areas and equipment, interview patient/ resident about preferences, past roles, customary routines, and interests, and welcome resident/ patient to the facility and introduce activities staff members. Review of the Activity Interest and Attendance Records for the past three (3) months from August 2024 through October 2024 revealed, R92 had four one-on-one in August that consisted of being brought water, going over activities for the day, conversation, and one refusal. September and October revealed no data of actively participating in 1:1 activity. Observation and Interview on 11/4/2024 at 1:39 pm with R92 revealed he was sitting in bed with the light off. R92 revealed, he had no activities because he could not read activities monthly schedule nor was the TV channels understandable. R92 shared that it was too boring at the facility and that only eat and sleep. He stated, he did not want to participate in any of today's activities because they don't hold his interest. Interview on 11/6/2024 at 12:37 pm with R92 revealed he just eat, sleep, and shower. R92 revealed, they could not go outside because they lock the doors. 2. Review of the clinical records for R121 revealed she was admitted to the facility with diagnoses that included but were not limited to encephalopathy, unspecified injury of head, muscle weakness, difficulty in walking, unsteadiness on feet, repeated falls, and unspecified dementia, Review of R121's MDS assessment dated [DATE] for Section C (Cognitive Pattern) revealed, a BIMS score of 5 (five), which indicated severe cognitive impairment; Section F (Preferences for Routine and Activities) revealed, the primary respondent for the questions was the resident, which revealed the following: it was somewhat important to participate in religious service, keep up with the news, do things with groups of people, do favorite activities and go outside for fresh air. Review of R121's care plan dated 11/7/2024 revealed resident primary language was not English and that of Chinese with Goals to Increase ability to communicate with patient, through the review and Approaches that included to provide cultural appropriate activities as able. Review of the Activity Interest and Attendance Records for the past three (3) months from August 2024 through October 2024 revealed, R121 had no data of actively participating in 1:1 activity. 3. Review of the clinical records for R540 revealed she was admitted to the with diagnoses that included but were not limited to muscle weakness, chronic osteomyelitis, benign prostatic hyperplasia without lower urinary tract symptoms, chronic venous hypertension (idiopathic) with ulcer of unspecified lower extremity, and pain. Review of R540's MDS assessment dated [DATE] for Section C (Cognitive Pattern) revealed a BIMS score of 13, which indicated little to no cognitive impairment. Section F (Preferences for Routine and Activities) revealed, the primary respondent for the questions was the resident, it was very important to participate in religious service, be around animals, keep up with the news, do things with groups of people, do favorite activities and go outside for fresh air. Review of R540's care plan dated 11/7/2024 revealed, Resident primary language was not English and that of Kannada with Goals to increase ability to communicate with resident, through the next review and Approaches that included, provide cultural appropriate activities as able, provide a communicate board to increase participation in activities, to communicate effectively with resident, and willingness to provide appropriate activities he will enjoy per cultural. Review of the Activity Interest and Attendance Records for the past three (3) months from August 2024 through October 2024 revealed no data of R540 actively participating in any 1:1 activity. Interview on 11/7/2024 at 5:14 pm with Activities Director (AD) and Regional Clinical Nurse confirmed that AD did communicate with residents via communication board and some residents could speak little English, but she did not perform activities in residents' primary language. AD revealed effective 11/6/2024 all activities monthly schedule boards will be posted in residents' primary language and going forward the activities will include music in their language, television will be programmed in their language, books/audio books will be ordered in their language, subscriptions in their language to different website for activities and when she enter social for one-on-one in documentation she would be more detailed on specific activities.

Based on observations, staff interviews, record review, and review of the facility's policy titled Medication Administration: Enteral Tubes, the facility failed to ensure that one of seven residents (R) R101 received enteral feedings, as ordered and to properly label and date the formula bottle, bags, and syringes used to provide the resident with needed nutrients. Findings include: Review of the facility's policy titled Medication Administration: Enteral Tubes dated 1/30/2020 under the Policy Statement revealed, The healthcare center provides safe and effective administration of enteral formula and medications. Enteral formulas will be administered via feeding tube by the physician order following nursing assessment of the resident's condition and in consultation with the dietitian and consultant pharmacist . Review of the Electronic Medical Record (EMR) for R101, revealed he was admitted to the facility with diagnoses that included but were not limited to cerebral infarction, enterocolitis due to Clostridium difficile (c-diff), contractures of right upper arm, dysphagia, pneumonitis due to inhalation of food and gastrostomy status (G-tube). Review of the physician orders for R101, revealed orders for enhanced barrier precautions due to having a g-tube dated 9/18/2024, G-tube to be checked for residual before feeding and G-Tube placement to be checked prior to medication administration dated 8/1/2024; and Jevity 1.5 (feeding formula) to be administered through the G-tube at 55 milliliters (mL) an hour for 22 hours a day with feeding to be turned on at 10 am and then turned off at 8 am dated 10/7/2024. Review of the admission MDS dated [DATE], for R101 for Section K (Swallowing/Nutritional status) revealed, that the resident had a gastrostomy tube, and received feedings as a resident and before becoming a resident. Observation on 11/3/2024 at 3:05 pm revealed, R101 receiving enteral feeding through his G-tube at the rate of 55 milliliters per hour. The formula was in a bag, and it was labeled with his name, date of 11/2/2024, his room number and the formula. The syringe was in a bag and was labeled with a date of 10/31/2024. Observation on 11/4/2024 at 12:54 pm revealed, R10's formula bottle was labeled with a date of 11/3/2024, and a time of 5 pm. The syringe was noted to be dated 11/4/2024, 6 am. The name that was on label for the syringe was not for R101. Observation on 11/5/2024 at 9:24 am revealed, R101 formula bottled was labeled with the time of 3 pm and the date of 11/4/2024. The syringe was dated 11/4/2024 and was labeled with the name of someone else. During this observation, the pump was noted to be on pause for 42:00 minutes and connected to the resident's G-tube when the surveyor entered the room. Interview on 11/5/2024 at 9:32 am with Registered Nurse (RN) RN AA revealed, that R101 had a history of c-diff. She stated that they paused it for two hours and then she would restart it at 10 am. She then stated that she would flush it when she give him his medications at 10 am. She ended the interview by stating, that the syringe was labeled incorrectly, and she would need to replace it and label it with the correct resident's name. Interview on 11/7/2024 at 10:24 am with the Director of Health Services (DHS) revealed, that it was her expectation that all nursing staff follow doctors' orders when it comes to enteral feedings. She stated that if it was ordered, it should be taken down at 8 am and then restarted at 10 am. She stated that she expects it to be taken down, not placed on pause for two hours and left connected to the resident. She then completed her interview by stating that feedings should be labeled with the resident's name, the date, the time, and the formula. She revealed that the syringe needed to have the date, the resident's name and that it was to be changed every 24 hours.

Based on observations, resident and staff interviews, and review of the facility's policy titled Oxygen Administration, the facility failed to follow physician orders for oxygen therapy for one of 19 residents (R) (R8) on oxygen therapy. In addition, the facility failed to change nebulizer equipment weekly and cover nebulizer masks when not in use for one of 19 residents (R539) on oxygen therapy. This deficient practice posed significant risks, including potential medical complications, unmet needs, and a diminished quality of life for the resident. Findings include: Review of the facility's policy titled Oxygen Administration dated 8/2/2023 under the section titled Policy Statement revealed, It is the policy of [Name of Facility] Hospice and Healthcare Centers/Veteran Homes to provide oxygen safely and accurately to appropriate patients/residents. Under the section titled Procedure: revealed, Oxygen will be administered by licensed personnel only when ordered by the physician, PA or NP. The physician order may be written PRN for comfort/dyspnea or may specify the number of liters, method of administration and length of time the oxygen is to be administered. Oxygen ordered PRN for comfort/dyspnea will be based upon the physician/licensed nurse assessment of the patient/resident's condition including oxygen saturation levels, respiratory rate, effort used by patient/resident to breath, shortness of breath present, and respiratory distress. Use of oxygen will be based on the patient/resident's clinical condition, comfort level, and the patient/resident/family desire for oxygen therapy. Patient/residents/families have the right to refuse to use oxygen. Under the section titled Equipment revealed, 4. Regulate liter flow to ordered/desired flow rate. If using wall unit oxygen turn main control valve on completely and then regulate liter flow on flow meter. If using portable e-tank, check for full tank, and regulate flow. Turn main control valve on completely and then regulate liter flow on flow meter to ordered/desired flow rate. Review of the facility's policy titled Respiratory Oxygen Changeouts dated 1/25/2022 under the section titled, Policy Statement: revealed, To provide guidelines to help prevent infections associated with respiratory equipment and to prevent transmission of such infections to patients/residents and staff. Under the section titled Oxygen Therapy Equipment revealed, . Medication nebulizer equipment shall be changed weekly . 1. Review of the Electronic Health Record (EHR) for R8 revealed she admitted to the facility with diagnoses that included but were not limited to acute on chronic systolic (congestive) heart failure, hypertensive heart disease with heart failure, asthma, chronic respiratory failure with hypoxia, but not limited to obstructive sleep apnea, myocardial infarction, and unspecified atrial fibrillation. Review of R8's quarterly Minimum Data Set (MDS) dated [DATE] for Section C (Cognitive Patterns) revealed, a Brief Interview for Mental Status (BIMS) of 15, which indicated little to no cognitive impairment. Record review of R8's physician's orders dated 11/6/2024 revealed, oxygen at 3 (three) liters per minute (LPM) via nasal cannula, continuous. During an observation and interview on 11/3/2024 at 2:55 pm, R8's oxygen levels was administered at 2 (two) LPM via nasal cannula. R8 stated her oxygen levels was supposed to be set at 3 LPM. A follow-up observation on 11/4/2024 at 9:24 pm revealed R8's oxygen was administered at 2 LPM via nasal cannula. Observation and interview conducted on 11/5/2024 at 10:20 am with R8 revealed she was observed with no oxygen in use. R8 revealed, that her oxygen equipment started malfunctioning around 6:00 am. During observation on 11/5/2024 at 10:24 am, the call bell was activated for assistance after it was noticed that the resident's oxygen was off. Certified Nursing Assistant (CNA) VV entered the room shortly thereafter and explained that she thought she heard a call bell but was unsure from which room it was coming. CNA VV stated that she had just started working on this hall today, as she typically works on another unit. The resident's roommate then entered the room and explained that she had turned off the oxygen because, R8, expressed that she didn't like the noise and asked her to turn it off. R8 denied that she told her to turn off the oxygen. CNA VV further explained that she knows oxygen levels are supposed to be checked regularly. CNA VV mentioned that if a resident is in distress, their oxygen levels should be checked, and the floor nurse should be notified. CNA VV also noted that this was her third time in the room today, and she did not notice that R8's oxygen was off. CNA VV pointed out that some oxygen machines are silent, while others make noise, which may make it harder to detect if the oxygen is not functioning properly. An interview on 11/5/2024 at 10:32 am with Licensed Practical Nurse (LPN) XX revealed, oxygen levels were typically checked every shift, per physician's orders. LPN XX confirmed that the physician's orders must be followed, but she was unaware that the resident's oxygen had been set at 2 LPM instead of the prescribed 3 LPM for the past two days. LPN XX acknowledged that inadequate oxygen levels could lead to respiratory distress, confusion, abnormal vital signs, and other serious complications, which would be particularly risky given the resident's other health diagnoses. An interview on 11/5/2024 at 11:23 am with Director of Health Services (DHS) emphasized that it was critical for staff to follow the physician's orders. The DHS stated that it was easier for nurses to check the resident's oxygen levels while passing medications. The DHS confirmed that oxygen levels should be checked every shift, in accordance with the physician's orders. An interview on 11/5/2024 with the Administrator confirmed the expectation that all staff must follow the physician's or provider's orders to ensure proper oxygen therapy was administered at the correct rate and frequency. Failure to do so could lead to negative outcomes, such as inadequate oxygen saturation levels and other potential health risks for the resident. 50524 2. Review of the EHR for R539 revealed she admitted to the facility with diagnoses that included but not were not limited to dependence on supplemental oxygen, shortness of breath and chronic bronchitis. Review of R539's admission MDS assessment dated [DATE] revealed, it had not been completed due to recent admission into the facility. Review of R539's physician orders dated 10/31/2024 revealed, orders that included but were not limited to: arformoterol solution for nebulization; 15 microgram (mcg)/2 milliliter (mL); amount 1(one); inhalation twice a day 9:00 am, 5:00 pm; budesonide suspension for nebulization; 0.5 milligram (mg)/2 mL; 1 vial; inhalation twice a day 9:00 am, 5:00 pm; Ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg (2.5 mg base)/3 mL; amt: 1 vial; inhalation three times a day 9:00 am, 1:00 pm, 5:00 PM; Ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg (2.5 mg base)/3 mL; amt: 1 vial; inhalation every 6 (six) hours - As needed (PRN). Observation on 11/4/2024 at 12:46 pm revealed, R539's nebulization mask not dated, unbagged and not covered in the bedside table drawer. Observation on 11/4/2024 at 4:00 pm revealed, R539's nebulization mask not dated, unbagged and not covered in the bedside table drawer. Observation on 11/5/2024 at 10:52 am revealed, R539's nebulization mask not dated, unbagged and not covered in the bedside table drawer. Interview on 11/4/2024 at 12:48 pm with R539 revealed she received nebulizer treatments whenever she needed it. R539 further stated the face masks used for nebulization was always kept in the drawer of the bedside table and never covered. Interview on 11/5/2024 at 10:52 am with Licensed Practical Nurse (LPN)/ Unit Manager TT revealed, R539 required nebulization as needed. She stated the nebulization mask and tubing were to be changed weekly and that they had not changed. She confirmed the mask was not covered with a bag and it should be covered in a bag. Interview on 11/5/2024 at 12:33 pm with Infection Preventionist revealed his expectations were for the nebulization masks to be placed in a bag when not in use. He stated the outcome would be potential infection especially to the aged population who were very vulnerable. Interview on 11/5/2024 at 2:10 pm with the Assistant Director of Health Services (ADHS) revealed her expectation was for nebulization masks to be kept covered in bags when not in use. She stated the outcome would be risk of infection to the resident if the masks were placed on surfaces which may be contaminated, and the resident could get respiratory infections. Interview on 11/5/2024 at 3:35 pm with the DHS revealed her expectations were for the nebulization masks to be changed weekly and kept in bags when not in use. She stated the outcome would be infection.

Based on observations, staff interviews, record review, and review of the facility's policy titled Labeling, Dating, and Storage, the facility failed to label dry goods and discard on or before the expiration date. In addition, the facility failed to label and store frozen food items in the freezer to ensure proper food safety and to maintain proper ice machine cleaning. The facility had a census of 119 residents that received an oral diet from the kitchen. Findings include: Review of the facility's policy titled Labeling, Dating, and Storage, dated [DATE] under the section titled Policy Statement revealed, It is the policy of [Name of Facility.] for all partners who assist in handling, preparing, serving, and storing food and beverage items to follow the proper procedures for labeling, dating, and storage to ensure proper food safety. Under the section titled, Scope revealed, This applies to all Dietary partners employed by [Name of Corporation.] Under the section titled Procedure revealed, 1. Food and beverage items will have an identifying label as well as a received date and opened date, as applicable; for items prepared onsite, as 'use by' date will also be indicated. 2. Foods will be stored in their original or approved container and, if opened, shall be wrapped tightly with film, foil, etc . Observation and Interview on [DATE] at 1:04 pm of the kitchen revealed, the dry storage had nine cans of 15 ounce (oz) puree beef stew that did not have an expiration date on them; eight cans of Grape Jelly- (four cans had an expiration date of [DATE] and four cans with the expiration date of [DATE]); Thickened Juices 46 ounces -(three orange juices with expiration date of [DATE] and seven apple juices with expiration date of [DATE]) each box was labeled with delivery date of ,d+[DATE]. The Certified Food Manager (CFM) LL verified and confirmed this date was the delivery date. In addition, one box of individual packets of [Name] seasoning, 500 counts used by date of [DATE], and one opened box of individual ranch dressing packets, 200 count with opened date of [DATE] and expiration date of [DATE]. Further observation of the kitchen revealed, ,d+[DATE] bag of meatballs, 30 pieces of meatballs, and a pack of fresh toast slices 12 count- located in the walk-in freezer that were not labeled or dated and the ice machine was observed to have a dirty substance inside the machine. Interview on [DATE] at 1:46 pm with the Certified Food Manager (CFM) LL verified the expired canned goods in the pantry. CFM, LL revealed that he was responsible for removing and discarding all expired foods, produce, and dented cans. CFM, LL also revealed that he would conduct an in-service training to ensure all staff were adequately trained. Interview on [DATE] at 10:35 am with a Registered Dietitian (RD) MM revealed, the CFM was responsible for removing and discarding all expired food, produce, and dented cans. RD, MM also indicated that she completed monthly kitchen inspections, including the dry storage pantry, walk-in cooler, and kitchen, to ensure that all expired food products, dented cans were discarded, and kitchen equipment was working correctly.

Based on observations, interviews, record review, facility document review, and review of facility policies titled P.I.C.C. (peripherally inserted central catheter) Catheter Dressing Change, P.I.C.C. Infusion Access Device Maintenance, and Infection Prevention-Hand Hygiene policy, the facility failed to follow infection control practices for three of 14 residents (R) (R549, R543 and R16). Specifically, the facility failed to ensure proper hand hygiene and physicians orders for dressing change were followed when providing care of the P.I.C.C. for (R549 and R543) and failed to follow procedure for catheter care for (R16). Findings include: Review of facility's Policy titled P.I.C.C. (peripherally inserted central catheter) Catheter Dressing Change revised 10/23/2024 documented Policy Statement: [Facility name] pharmacy services requires that PICC infusion access device site care must be established in order to observe infection control policies and procedures. The procedure should be completed once a week and PRN unless physician specifies otherwise. Under Procedure: 2. Perform hand hygiene. 6. Put on non-sterile gloves and remove existing dressing pulling it towards the catheter site with a finger on the catheter site through the TSM. Review of facility's policy titled P.I.C.C. Infusion Access Device Maintenance reviewed 1/3/2024 documented Policy statement: P.I.C.C. infusion access devices must be maintained regardless if medications are being infused to maintain patency and infection control standards . All PICC infusion access devices will have the site dressing changed at least once a week and PRN if it becomes wet, loose or soiled. Review of the facility policy titled, Infection Prevention-Hand Hygiene policy revised 8/15/2023 revealed under, Handwashing with soap with water, 2. Hand Rub with Alcohol based antiseptic is recommended when hands are not visibly soiled or contaminated with blood or body fluids or when /where running water is not available. Indications requiring hand wash or hand rub:1. before and after contact with the resident 2. Before donning gloves, including sterile gloves. 3. Before inserting indwelling urinary catheters, peripheral vascular catheters or other invasive device 6. When hands move from a contaminated body site to a clean body site during resident care.7. Immediately after removal of personal protective equipment (gloves, gown, facemasks).8. After contact with inanimate objects in the immediate vicinity of the resident. Review of the facility procedure document titled, How to empty a urinary catheter drainage bag, revealed Step 7 (seven) when the bag is empty, clean the tip of the drainage tube with an alcohol wipe, assure the valve is closed, and re-insert the drainage tube in its pocket. 1.Review of Electronic Medical Records (EMR) revealed R549 was admitted to the facility on [DATE] with a right upper arm PICC line (a long, flexible tube that is inserted into a vein in the arm and threaded into a large vein near the heart) for the administration of antibiotics. Review of Care Plan dated 11/7/2024 documented Problem Start Date: 11/7/2024 Category: Resident requires IV medication through PICC LINE. Short Term Goal Target Date: 2/28/2025 R549 will not exhibit signs of complications from IV through PICC Line, localized infection, systemic infection, electrolyte imbalance, air embolus, dislodgement, infiltration, extravasation, phlebitis, fluid overload, dehydration. Nursing Approach Start Date: 11/7/2024 Follow regimen when caring for IV site, monitor for sign of infection. Review of Physician orders for R549 dated 11/5/2024 documented orders included but not limited to central access device maintenance: Change dressing every (Q) week, change injection caps with or without extension tubing Q week, after blood draws once a day on Mondays 7:00 am - 7:00 pm. Observation and interview on 11/4/2024 at 1:16 pm revealed R549 had dual lumen PICC line with dressing dated 10/27/2024. The Assistant Director of Health Services (ADHS) stated PICC lines are changed every seven days. She confirmed that R549's PICC line dressing was dated 10/27/2024 which indicated the dressing should have been changed on 11/3/2024. Her expectation was for the dressings to be changed every seven days. Interview on 11/5/2024 at 12:23 pm with Infection Preventionist (IP) revealed PICC line dressings are to be changed weekly and as needed if soiled. He stated his expectation was for PICC line dressings to be changed as ordered. Interview on 11/5/2024 at 3:38 pm with Director of Health Services (DHS) revealed her expectation was for PICC line dressings to be changed every seven days. She stated the outcome would be infection to the resident. 2. Review of the EMR revealed R543 was admitted to the facility on [DATE] with a PICC line for Total Parenteral Nutrition (TPN) for six weeks. Review of the Care Plan for R543 dated 10/21/2024 documented Problem: Nutritional Status Resident requires parenteral nutrition TPN/intravenous (IV) related to (R/T) gastrostomy tube (G-tube) site malfunction/wound, nil per oral (NPO) status r/t severe dysphagia. Observation on 11/4/2024 at 2:00 pm revealed ADHS entered R543's room without donning gown and without sanitizing her hands. Resident was on Enhance Based Precaution (EBP) due to PICC line. The ADHS did not sanitizer her hands before entering R543'S room, before donning gloves, after removing gloves, and after blood draw from PICC line. Interview on 11/4/2024 at 2:10 pm with ADHS revealed she stated she was responsible for taking the labs from PICC lines. She stated the R543 was on enhanced barrier precaution for PICC line which required her to put on a gown, and she did not put on a gown before entering R543's room. She confirmed she did not sanitize her hands, and she should have sanitized her hands before accessing R543's PICC line, before putting on gloves, after removing gloves and before exiting R543's room. She stated the outcome would be the resident could get an infection if hand hygiene is not performed before, during and after accessing a PICC line. Interview on 11/5/2024 at 3:40 pm with Director of Health Services (DHS) revealed hands were to be washed or sanitized before putting on gloves and accessing PICC lines. Hands were to be sanitized after removing gloves and while providing care to residents including residents with PICC lines. 46579 3. Review of the EMR for R16 revealed he was admitted to the facility with diagnoses that included but not limited to retention of urine, pressure ulcer of sacral region, urinary tract infection. Review of the physician orders for R16 revealed that catheter care was to be performed every shift and Enhanced Barrier Precautions due to indwelling devices: a foley catheter and a gastrostomy tube (g-tube). Review of the care plan for R16 revealed that he required an indwelling urinary catheter related to urinary retention. Intervention included but not limited to, provide catheter care each shift and as needed. Observation and interview on 11/6/2024 at 2:15 pm revealed Certified Nursing Assistant (CNA) EE was observed providing catheter care to R16. During that observation, CNA EE was observed, donning (putting on) two pairs of gloves (double gloving), and provided catheter care for the resident by emptying the catheter bedside drainage bag in a urinal, shaking off the tube, and then returning the tube to the holder. After providing care, she then doffed (removed) the top pair of gloves and continued with the rest of the care for R16. CNA EE was asked after leaving the room, if she was supposed to be double gloving. She stated that she was never told that she could not double glove, and that she always doubled gloved when providing care for this resident. Interview on 11/6/2024 at 2:48 pm with the Infection Preventionist revealed that with EBP, staff would use gown and gloves, and it is used for resident that have a PICC line, Urinary catheters, and a feeding tube. He then stated that we do not double glove. Interview on 11/7/2024 at 10:24 am, with the DHS revealed that double gloving was not encouraged, however there was nothing in the policy that addressed double gloving. She stated that if they are double gloving, then she expects that both pair be removed, because we do not know what kind of germs or bacteria could have traveled in between the gloves.

Based on observations and staff interviews the facility failed to provide a safe and comfortable environment for the residents, staff and the public as evidenced by an unpleasant odor on one hall (South Wing) of three halls. This deficient practice had the potential to cause diminished quality of life. The facility census was 128 residents. Findings include: Observations from 11/3/2024 through 11/7/2024 during survey revealed an unpleasant odor was present on the South Wing of the facility. Review of facility's documents revealed there was no evidence of a facility's policy regarding environment - free from unpleasant odors. Interview on 11/7/2024 at 11:26 am with Floor Technician WW revealed, he sweeped and vacuumed the hallways daily. He also stated he would apply liquid disinfectant on the carpet only if there was a stain on the carpet. Interview on 11/7/2027 at 11:35 am with the Housekeeping Supervisor, confirmed the South Wing hallway had an odor which could be due to the area having heavy wetters. Interview on 11/7/2024 at 11:36 am with Administrator, she confirmed there had been an unpleasant odor on the South Wing hallway and at times throughout the facility. She stated she had been at the facility for about two months and the odor had been present since then. She stated her expectations were for the facility to have a homelike environment which would include lack of offensive /unpleasant odors. She stated the outcome would be the residents would not have a homelike environment and the odor would not be pleasant for the residents when they are eating or resting. She further stated the odor would also be unpleasant for staff and members of the public.

Based on observations, record review, staff interviews, and review of the policies titled Infection Prevention and Control Program Surveillance Reporting and Hand Hygiene and Contact Precaution Compliance and review of the RN/LPN Annual Skills Fair 2023, the facility failed to ensure infection control practices were maintained to prevent the potential for infections and cross contamination. Specifically, the infection control data for August 2023 was not analyzed for trends in urinary tract infections that include appropriate corrective actions and staff failed to wash/sanitize hands after glove removal and prior to donning clean gloves during wound care for one resident (R) (R34). The census was 110. Findings include: 1. Review of the facility policy titled Infection Prevention and Control Program Surveillance Reporting revised 11/30/2023 revealed the policy is to establish and maintain an Infection Control Program that includes detection, prevention, and control of the transmission of disease and infections among residents and partner. Procedure: Number 1. Patient/resident infection cases are monitored and documented by the Infection Preventionist (IP). The IP reviews cases of infections, including tracking and analysis of the findings, and develops an action plan to resolve identified concerns. Number 5. Compliance with Infection Control practices are monitored and documented by staff competency and observation practices. The IP, Director of Health Services (DHS) and Department Managers review the compliance monitoring and initiate appropriate corrective measures. Review of the Monthly Healthcare Associated Infection Summary Report dated August 2023 revealed nine cases of urinary tract infections (UTI). Eight of the nine identified cases of UTI were for residents who resided on the 300 East Hall. During an interview on 6/4/2024 at 1:58 pm, the IP revealed he has been employed since 1/15/2024. He confirmed nine residents had a UTI during August 2023, and eight of the nine resided on the 300 Hall. He further stated the high number of UTIs was from inappropriate hand washing, and stated staff should be washing their hands between dirty and clean tasks. The IP stated he felt there was a need for continued education on hand washing, urinary catheter care, and perineal care. 49479 2. Review of the facility policy titled Hand Hygiene and Contact Precaution Compliance, revised 12/4/2023, revealed hand hygiene refers to cleaning your hands by using the organization approved alcohol-based hand rub or by washing hands with soap and water. Hand Hygiene opportunities include: 1. Hand hygiene performed before resident contact. 2. Hand hygiene performed before donning gown/gloves. 3. Hand hygiene performed after removing gown/gloves. 4. Hand hygiene performed after resident contact. Review of R34's electronic medical record (EMR) revealed resident was admitted to the facility on [DATE] with diagnoses including spastic hemiplegia, hypomagnesemia, systemic inflammatory response syndrome (SIRS), hypertension, metabolic encephalopathy, unstageable pressure ulcers to right hip, left hip, and part of back. Observation on 5/21/2024 at 10:41 am Licensed Practical Nurse (LPN) YY who was assisted by Registered Nurse (RN) UU, performed wound care for R34. LPN YY washed her hands before the procedure, donned clean gloves, and cleansed R34's right hip wound. She then removed the soiled gloves, and without washing her hands or using hand sanitizer, she donned new gloves. LPN YY then applied the treatment to the wound, removed the soiled gloves, and washed her hands. Review of the document titled RN/LPN Annual Skills Fair 2023, indicated that LPN YY completed the annual skills fair on 9/12/2023. Under the section titled Wound Care Assessment describes the process for performing a dressing change. Step 1. Remove the old dressing Remove gloves, perform hand hygiene, and apply clean gloves. Step 2. Cleanse the wound Remove gloves, perform hand hygiene, and apply clean gloves. Step 3. Apply new dressing per order. If your gloves become soiled at any time, remove them, perform hand hygiene, and apply clean gloves. Interview on 5/21/2024 at 10:56 am, LPN YY and RN UU stated hand hygiene should be performed before and after all resident care. Both nurses revealed staff members only need to wash their hands before and after the wound care was provided, not in between glove changes. Interview on 5/21/2024 at 1:00 pm, Regional Nurse Consultant (RNC) KK stated when providing wound care, the nurse should wash their hands before performing the wound care, when going from dirty to clean, and after the wound care. She stated hand sanitizer could be used as well for hand hygiene. RNC KK stated LPN YY had not performed the wound care correctly. Interview on 6/4/2024 at 1:58 pm, Infection Control Preventionist (ICP) BBBB revealed all staff should be performing hand hygiene between dirty and clean tasks. ICP BBBB confirmed LPN YY should have performed hand hygiene before beginning the wound care, after cleansing the wound, and after the clean dressing is applied. ICP BBBB revealed there needed to be additional education and training regarding infection control practices.

Based on record review, staff interviews, and review of the facility policy titled Abuse Prevention and Reporting, the facility failed to protect one of five sampled residents (R) (R#1) from neglect during Activities of Daily Living (ADL) care. Specifically, Certified Nursing Assistant (CNA) BB was providing ADL care to R#1 unassisted, when R#1 fell out of bed, landing on her abdomen and chest for approximately 15 minutes before staff could reposition her. R#1 expired in the facility one hour post fall. On [DATE], it was determined that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and the Director of Nursing were informed of the Immediate Jeopardy on [DATE] at 3:07 p.m. The noncompliance related to the Immediate Jeopardy was determined to have existed on [DATE]. An Acceptable Removal Plan was received on [DATE]. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. Findings include: Review of the policy titled Abuse Prevention and Reporting dated [DATE], defined Neglect as the failure to provide goods and services necessary to avoid harm, mental anguish, or mental illness. The policy statement indicated the center will not tolerate abuse, neglect, or exploitation of its residents by anyone. Review of the clinical record revealed R#1 was admitted to the facility on [DATE] with diagnoses of morbid obesity, bilateral lower extremity lymphedema, congestive heart failure (CHF), sleep apnea, atrial fibrillation, chronic obstructive pulmonary disease (COPD), diabetes, hypertension (HTN), and history of pulmonary embolism. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section G revealed resident required extensive two person assist with ADL care. Section J revealed resident had shortness of breath with exertion and shortness of breath when lying flat. Section K revealed resident was 62 inches tall and weighed 508 pounds. Review of the Resident Progress Note dated [DATE] at 12:10 a.m. revealed Licensed Practical Nurse (LPN) AA was summoned to resident room by CNA. Resident observed on the floor next to the bed. Resident in a prone position on the floor. Resident able to verbally response {sic} when addressed by staff. Writer gather {sic} assistance, CNA left with resident. 911 called at 3:15 a.m. Assistance requested from fire rescue. All hands-on deck called made of staff. Head to toe assessment done and resident noted with a laceration to right breast that was bleeding. At 3:20 a.m. resident noted to have respiratory difficulty. EMS called. Resident rolled to her back and O2 placed with re- breather mask. Fire rescue at bedside. EMS arrived at 3:25 a.m. Resident assessed and noted to have no respiration and no pulse. CPR initiated. NP notified of resident condition. DHS Notified. resident responsible party notified. Review of a document provided by facility identified with R#1's name revealed a timeline of events. Sunday [DATE]: 1:00 a.m. - CNA BB checked on R#1, offered to change her, R#1 stated No, I'm fine. 2:49 a.m. - CNA BB enters R#1 room with supplies to change resident and bed linen, checks bedrails and wheels, ensuring they were locked, instructs R#1 to turn on her side with CNA BB assisting with turning. ADL care provided and bed linens changed. While R#1 was holding onto siderail, the rail gave out with R#1 falling off the bed onto the floor, face down. CNA BB attempted to roll R#1 over with R#1 saying, I need help, I need help. 2:57 a.m. - CNA BB left R#1's room to get help. 2:58 a.m. - LPN AA and CNA BB return to R#1's room, with R#1 face down on the floor, saying help me. LPN AA and CNA BB attempt to roll R#1 over but need more help. R#1 was breathing and asking for help. 3:00 a.m. - LPN AA went to search for help from CNA DD and LPN EE. LPN AA calls 911 requesting Fire Department to help get R#1 off the floor. R#1 states to CNA BB help me, I'm about to pass out. CNA BB attempts to turn R#1 over again but is unsuccessful. 3:04 a.m. - LPN AA leaves R#1 room and summons help from CNA CC to go to other units seeking more assistance. R#1 is moving her head struggling to breathe while LPN AA attempts to turn R#1 over but is unsuccessful. CNA FF at front door to let fire department in when they arrive. 3:09 a.m. - R#1 was repositioned on her back by four staff members (Certified Medication Aide (CMA) GG, LPN AA, CNA CC, CNA BB). LPN AA assessed R#1 to have blue lips, with chest rising with breathing, and a laceration on chest. 3:11 a.m. - R#1 assessed to have thready pulse; LPN AA called for crash cart and Automatic External Defibrillator (AED) and to call 911. 3:12 a.m. - unable to locate re-breather mask on crash cart. 3:13 a.m. - CNA II arrives to R#1 room with vital sign machine. 3:14 a.m.- staff leave R#1 room to locate rebreather from supply closet. 3:17 a.m. - CMA GG returns to R#1 room with rebreather mask and oxygen turned to ,d+[DATE] liters. AED analyzing. 3:18 a.m. - three members from fire department arrive with CNA FF and hear AED alert shock not advised. Fire department checks for carotid pulse, no pulse found, initiated CPR. 3:20 a.m. - Fire Department replaces non-rebreather with Ambu bag. Airway unclear requiring intubation. CPR continues. 3:30 a.m. - Fire Department attempt to start IV, unsucessful, CPR continues. 3:41 a.m. - two emergency medical technicians (EMTs) arrive with stretcher. CPR continues. LPN AA retrieves facesheet for Fire Department. 3:47 a.m. - EMT infoms LPN AA we've called it. 3:50 a.m. - Fire Department leave, informs LPN AA Medical Examiner will be coming. LPN AA instructs staff to leave R#1 on the floor, covers her with a sheet. Interview on [DATE] at 3:03 p.m. with CNA BB revealed she gathered supplies and entered R#1's room to provide incontinence care. She stated R#1 was able to assist with turning so she did not feel she needed assistance with providing incontinence care. She stated R#1 grabbed onto the trapeze bar with her left hand and the siderail with her right hand and assisted in turning herself onto her right side. She stated after ,d+[DATE] minutes, she instructed R#1 to turn onto her back, at which time the siderail gave out and R#1 fell on to the floor. She stated she ran around to the side of the bed and saw resident lying face down on the floor and tried to turn her over but could not do so because of the resident's size. She stated she went to get help and together she and LPN AA tried to roll R#1 onto her side but was unsuccessful. During further interview, she confirmed she did not ask for help to provide incontinence care to resident. Stated she has been working at the facility for three months and had never received assistance with resident before. Interview on [DATE] at 3:07 p.m. with LPN AA stated CNA BB summoned her to R#1's room but did not state R#1 had fallen out of bed. She stated once she entered the room, she saw R#1 lying on the floor face down on the right side of the bed. She asked R#1 if she was ok and R#1 replied, I need help. She stated that the two of them were unable to turn resident over, so she left the room to find assistance, leaving CNA BB with R#1. During further interview, she stated it took ,d+[DATE] minutes to get enough staff to get R#1 turned over, and at that time her lips were blue, and she was struggling to breath. LPN AA stated she offered CNA BB assistance with providing care for R#1, but CNA BB denied needing assistance. Interview on [DATE] at 3:35 p.m., Administrator JJ revealed CNA BB was suspended pending outcome of the investigation to determine what happened with R#1 incident. She stated R#1 was able to assist with turning and repositioning, and during care provided by CNA BB, the side rail on R#1 bariatric bed broke, and resident fell off the bed. She stated after the investigation, the Maintenance Director did an audit of all siderails in the facility. During further interview, she stated there should be a policy developed so there should always be at least two staff members present during care for bariatric residents.

Based on record review, interviews, and review of the policy titled Abuse Prevention and Reporting, the facility failed to report an incident to the State Survey Agency (SSA) in which R#1 fell out of bed resulting in her death in the facility. The sample size was five. On [DATE], it was determined that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and the Director of Nursing were informed of the Immediate Jeopardy on [DATE] at 3:07 p.m. The noncompliance related to the Immediate Jeopardy was determined to have existed on [DATE]. An Acceptable Removal Plan was received on [DATE]. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. Findings include: Review of the policy titled Abuse Prevention and Reporting dated [DATE], defined Neglect as the failure to provide goods and services necessary to avoid harm, mental anguish, or mental illness. The policy statement indicated the center will not tolerate abuse, neglect, or exploitation of its residents by anyone. Procedure 3. In the event the Administrator has knowledge that the resident has been abused, neglected, or exploited while resident in the facility, he/she will immediately make a report by phone or in person to the Department of Community Health. In the event that an immediate report to the Department is not possible, the Administrator shall make the report to the appropriate law enforcement agency. Number 5. Within 24 hours of the initial report, the Administrator shall also make a written report, using the Incident Report Form, documenting all known and relevant information, the investigation results, and any corrective or protective actions taken. Review of the clinical record revealed R#1 was admitted to the facility on [DATE] with diagnoses of morbid obesity, bilateral lower extremity lymphedema, congestive heart failure (CHF), sleep apnea, atrial fibrillation, chronic obstructive pulmonary disease (COPD), diabetes, hypertension (HTN), and history of pulmonary embolism. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section G revealed resident required extensive two person assist with ADL care. Section J revealed resident had shortness of breath with exertion and shortness of breath when lying flat. Section K revealed resident was 62 inches tall and weighed 508 pounds. Review of the Resident Progress Note dated [DATE] at 12:10 a.m. revealed Licensed Practical Nurse (LPN) AA was summoned to resident room by Certified Nursing Assistant (CNA). Resident observed on the floor next to the bed. Resident in a prone position on the floor. Resident able to verbally response {sic} when addressed by staff. Writer gather {sic} assistance, CNA left with resident. 911 called at 3:15 a.m. Assistance requested from fire rescue. All hands-on deck called made of staff. Head to toe assessment done and resident noted with a laceration to right breast that was bleeding. At 3:20 a.m. resident noted to have respiratory difficulty. EMS called. Resident rolled to her back and O2 placed with re- breather mask. fire rescue at bedside. EMS arrived at 3:25 a.m. Resident assessed and noted to have no respiration and no pulse. Cardiopulmonary resuscitation (CPR) initiated. Nurse Practitioner (NP) notified of resident condition. Director of Health Services (DHS) Notified. Resident responsible party notified. Review of Facility Reported Incidents for the past six months revealed no evidence a report involving the death of R#1 post fall from the bed had been reported to the State Survey Agency. Interview on [DATE] at 3:35 p.m. with Administrator JJ confirmed she is the abuse coordinator. She stated the incident with R#1 was investigated in house, and it was determined CNA BB followed policy and procedures and the incident did not need to be reported to the State Agency. The Administrator confirmed the incident involving the death of R#1 status post fall from bed was not reported to the State Agency. During further interview, she stated because the facility knew what happened during the fall from the bed with R#1, she did not feel it needed to be reported. Follow-up interview on [DATE] at 1:23 p.m. with Administrator JJ stated the incident with the death of R#1 was being re-investigated and that a report would be submitted to the State Survey Agency.

Based on record review, staff interviews, and review of the policy titled Care Plan, the facility failed to develop and implement a person-centered comprehensive care plan for one resident (R) (R#1) that specified the need for two-person assistance with Activities of Daily Living (ADL) care. The sample size was five. On 8/1/2023, it was determined that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and the Director of Nursing were informed of the Immediate Jeopardy on 8/1/2023 at 3:07 p.m. The noncompliance related to the Immediate Jeopardy was determined to have existed on 5/28/2023. An Acceptable Removal Plan was received on 8/5/2023. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 8/4/2023. Findings include: Review of the facility policy titled Care Plans revised 7/27/2023 revealed it is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the patient/resident choice. Admission Comprehensive Care Plan: Number 3. The comprehensive care plan should describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Number 4. The care plan will contain 4 main components: Problem, Goal, Approaches and Role or Accountability . The care plan approach serves as instructions for the patient/resident's care and provides continuity of care by all partners. When approaches that involve the CNA have been added to the care plan, those approaches should also be included on the CNA Care Record or Resident Profile/Care Plan. Review of the clinical record revealed R#1 was admitted to the facility on [DATE] with diagnoses of morbid obesity, bilateral lower extremity lymphedema, congestive heart failure (CHF), sleep apnea, atrial fibrillation, chronic obstructive pulmonary disease (COPD), diabetes, hypertension (HTN), and history of pulmonary embolism. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section G revealed resident required extensive two person assist with ADL care. Section J revealed resident had shortness of breath with exertion and shortness of breath when lying flat. Section K revealed resident was 62 inches tall and weighed 508 pounds. Review of the Care Area Assessment Summary (CAAS) on 9/26/2022 Annual Assessment revealed that ADL function triggered as an area of concern, with the decision made to care plan for it. Review of the care plan revised 4/29/2023 revealed resident has ADL decline related to impaired mobility, chronic respiratory failure, morbid obesity, diabetes, lymphedema, and congested heart failure. Resident uses bedrails for mobility and repositioning. Approaches to care include bathe/shower as scheduled, stand and pivot with walker, daily grooming, keep call light in reach, observe for signs/symptoms during ADL care, provide assistive devices as needed, provide, incontinence care after each episode, and set up and assist with ADL's and transfers. There is no evidence addressing the residents' need for two-person assistance with ADL care. Interview on 7/25/2023 at 3:03 p.m. with CNA BB revealed R#1 was able to assist with turning so she did not feel she needed assistance with providing incontinence care. She stated she has been working at the facility for three months and had never received assistance with resident before. Interview on 8/1/2023 at 10:32 a.m. with Registered Nurse Case Mix Director KK confirmed section G of R#1's MDS specified two-person assistance with ADL care. She stated the care plan usually does not specify the number of people needed to assist a resident with care. She stated the care plan should have been more specific about the need for two or more staff members to assist with ADL care for R#1 due to her size. Interview on 8/1/2023 at 11:00 a.m. with the Director of Health Services (DHS) revealed the expectation is for the care plan to be as accurate and detailed as possible. She stated the care plan should have specified the number of staff needed to assist R#1 with ADL care.

Based on record review, interviews, and review of the policy titled Occurrences, the facility failed to provide adequate assistance for bed mobility for one of five residents (R) (R#1) reviewed for falls. Specifically, R#1 fell from the bed during ADL care on [DATE], resulting in death within one hour post fall. On [DATE], it was determined that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and the Director of Nursing were informed of the Immediate Jeopardy on [DATE] at 3:07 p.m. The noncompliance related to the Immediate Jeopardy was determined to have existed on [DATE]. An Acceptable Removal Plan was received on [DATE]. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. Findings include: Review of the facility policy titled Occurrences revised [DATE] revealed the healthcare center recognizes that due to the frailty of the patients/residents served, there is an increased risk of occurrences that may result in injury to the patient/resident and/or others. To prevent occurrences, each patient/resident will be observed and assessed for risks. Appropriate, realistic interventions will be implemented in accordance with their plan of care. Occurrence hazards are physical features in the healthcare center environment which may pose a risk to a patient/resident's safety, including but not limited to: Any event, accident, or incident, on or off healthcare center property which results in an injury or has the potential for injury.' Review of the clinical record revealed R#1 was admitted to the facility on [DATE] with diagnoses of morbid obesity, bilateral lower extremity lymphedema, congestive heart failure (CHF), sleep apnea, atrial fibrillation, chronic obstructive pulmonary disease (COPD), diabetes, hypertension (HTN), and history of pulmonary embolism. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section G revealed resident required extensive two person assist with ADL care. Section J revealed resident had shortness of breath with exertion and shortness of breath when lying flat. Section K revealed resident was 62 inches tall and weighed 508 pounds. Section J revealed no falls prior to admission or after admission. Review of a document titled Post Fall Observation dated [DATE] at 5:03 a.m. completed by Licensed Practical Nurse (LPN) AA, indicated R#1 was receiving care and turned to her right side, fell out of the bed landing on her abdomen and chest. R#1 received CPR (cardiopulmonary resuscitation) due to injury. Review of a document titled SBAR (situation, background, appearance, review) dated [DATE] revealed the [Situation] The change in condition, symptoms, or signs observed and evaluated is/are R#1 fell from bed, SOB (shortness of breath). [Background] revealed altered level of consciousness, decreased mobility, needs more assistance with ADLs, weakness, abnormal lung sounds (rales, rhonchi, wheezing), labored or rapid breathing, shortness of breath, chest pain/tightness, contusion-right breast with bloody drainage noted, pain-yes/new. Resident was a Full Code. [Appearance] resident fell to the floor from bed. Nurses Note revealed 'Writer summoned to resident room by CNA. Resident observed lying on the floor next to bed. Resident in prone position on floor. Resident able to verbally response when addressed by staff. Writer left room to gather assistance. CNA left with resident. 911 called at 3:15 a.m. assistance requested from fire rescue. All hands-on deck called made of staff. At 3:20 a.m. resident noted to have respiratory difficulty. Interview on [DATE] at 3:03 p.m. with CNA BB revealed she entered R#1's room to provide incontinence care. She stated resident was able to assist with turning so she did not feel she needed assistance despite her weighing 508 pounds. She stated R#1 grabbed onto the trapeze bar with her left hand and the siderail with her right hand and assisted in turning onto her right side. During further interview, she stated after providing ADL care for about ,d+[DATE] minutes, she told R#1 it was time for her to turn onto her back. Before resident was able to turn over on her back, the siderail gave out causing R#1 to fall off the bed onto the floor. She stated she went around to the right side of the bed and saw R#1 lying face down on the floor. She stated R#1 was talking to her and she attempted to roll her onto her back but was unsuccessful. She left the resident and went to get Licensed Practical Nurse (LPN) AA. Together they tried to roll R#1 onto her back but was unsuccessful. Eventually there were enough staff to turn R#1 over onto her back and they noticed her lips were blue and she appeared to be struggling for air. She stated cardiopulmonary resuscitation was done, but resident didn't make it. Interview on [DATE] at 3:07 p.m. with LPN AA revealed CNA BB summoned her to R#1's room. She stated when she entered the room, she noticed R#1 was not in her bed. She stated she asked CNA BB where she was, and she told her the resident had fallen out of bed. She stated CNA BB had not informed her the R#1 was on the floor prior to her entering the room. LPN AA walked to the right side of the bed and saw R#1 lying on the floor face down. She asked R#1 if she was ok and R#1 replied, I need help. During further interview, she revealed she and CNA BB were unable to turn resident over, so she left the room to find assistance, leaving CNA BB to stay with resident. She stated it took ,d+[DATE] minutes for enough staff to get R#1 turned over. She stated R#1 lips were blue and she was struggling to breath.

Based on record review, interviews, and review of the Administrator and Director of Health Services (DHS) job descriptions, the facility Administration failed to ensure one resident (R) (R#1) was free from neglect during Activities of Daily Living. This failure resulted in R#1 falling from the bed and expiring in the facility one hour post fall. The sample size was five. On 8/1/2023, it was determined that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and the Director of Nursing were informed of the Immediate Jeopardy on 8/1/2023 at 3:07 p.m. The noncompliance related to the Immediate Jeopardy was determined to have existed on 5/28/2023. An Acceptable Removal Plan was received on 8/5/2023. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 8/4/2023. Findings include: Review of the document titled Position Description-Administrator dated 12/27/2016, revealed the job purpose is to direct the day-to-day functions of the nursing center in accordance with federal, state, and local regulations that govern long-term care centers, and as may be directed by the Area [NAME] President, to provide appropriate care for our patients/residents. Review of the document titled Position Description-Director of Health Services dated 12/27/2016, revealed the job purpose is plans, organizes, develops, and directs the overall operation of our 'Nursing Services Department' in accordance with current federal, state, and local regulations governing our nursing center, and as may be directed by the Administrator and the Medical Director, to provide appropriate care. Facility Administration, specifically the Administrator and Director of Health Services (DHS), failed to protect residents and effectively oversee areas of the facility that were included in their job descriptions. 1. Facility failed to ensure R#1 was free from neglect by facility staff during provision of activities of daily living care. Cross refer F600 2. Facility failed to report the death of R#1 following a fall from bed during ADL care. Cross refer F609 3. Facility failed to develop a comprehensive person-centered care plan that specified the need for two person assistance with ADL care. Cross refer F656 4. Facility failed to protect R#1 from a fall during ADL care, resulting in her death in the facility. Cross refer F689 5. Facility failed to thoroughly document the events related to R#1's fall from bed, cardiopulmonary arrest, and death. Cross refer F842 Interview on 8/1/2023 at 11:00 a.m. with the DHS, revealed the Certified Nursing Assistant (CNA) should have gotten help with providing activities of daily living (ADL) care for R#1, due to the residents' size. During continued interview, she stated the nursing staff on duty the night of the occurrence with R#1, did not thoroughly document the events leading up to and after R#1's death. She stated her expectation is for the nursing staff to thoroughly document in the electronic health record in real time. Interview on 8/1/2023 at 1:23 p.m. with Administrator JJ, revealed when she performed the investigation of the incident with R#1, she had to rely on camera footage, statements from the staff, and the fire department documentation to get a timeline of events. She stated that after the investigation was completed, it was determined that the CNA followed facility policies or procedures regarding the occurrence with R#1 fall from the bed and her death in the facility. During further interview, she confirmed the nursing staff did not appropriately document in the electronic health record the details of the incident involving R#1.

Based on record review, facility documents, staff interviews, and review of 'Position Description', the facility failed to ensure licensed nursing staff accurately documented in the electronic medical records (EMR) the detailed events regarding the occurrence for one resident (R) (R#1) fall from bed during care, resulting in her death in the facility. Specifically, Licensed Practical Nurse (LPN) AA failed to thoroughly document the events related to the fall from bed, cardiopulmonary resuscitation, death, and release of body to the mortuary. The sample size was five. On [DATE], it was determined that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and the Director of Nursing were informed of the Immediate Jeopardy on [DATE] at 3:07 p.m. The noncompliance related to the Immediate Jeopardy was determined to have existed on [DATE]. An Acceptable Removal Plan was received on [DATE]. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. Findings include: Review of the document titled Position Description- LPN (licensed practical nurse) Charge Nurse revised ,d+[DATE], revealed key responsibilities number 1. Provides care ensuring patient/resident safety. Number 3. Completes documentation procedures on patients (appropriate use of forms, timelines, and Medicare documentation, etc.). Review of the clinical record revealed R#1 was admitted to the facility on [DATE] with diagnoses of morbid obesity, bilateral lower extremity lymphedema, congestive heart failure (CHF), sleep apnea, atrial fibrillation, chronic obstructive pulmonary disease (COPD), diabetes, hypertension (HTN), and history of pulmonary embolism. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section G revealed resident required extensive two person assist with ADL care. Section J revealed resident had shortness of breath with exertion and shortness of breath when lying flat. Section K revealed resident was 62 inches tall and weighed 508 pounds. Review of the Resident Progress Note dated [DATE] at 12:10 p.m. revealed Licensed Practical Nurse (LPN) AA was summoned to resident room by CNA. Resident observed on the floor next to the bed. Resident in a prone position on the floor. Resident able to verbally response {sic} when addressed by staff. Writer gather {sic} assistance, CNA left with resident. 911 called at 3:15 a.m. Assistance requested from fire rescue. All hands-on deck called made of staff. Head to toe assessment done and resident noted with a laceration to right breast that was bleeding. At 3:20 a.m. resident noted to have respiratory difficulty. EMS called. Resident rolled to her back and O2 placed with re- breather mask. Fire rescue at bedside. EMS arrived at 3:25 a.m. Resident assessed and noted to have no respiration and no pulse. CPR initiated. NP notified of resident condition. DHS Notified. resident responsible party notified. Further review of the EMR revealed no evidence of documentation regarding the attempt at cardiopulmonary resuscitation (CPR) for R#1 by facility staff or emergency medical staff (EMS), no documentation of orders to stop CPR, no documentation of pronouncement of death, and no documentation for the release of the body and to whom the body was released to. Interview on [DATE] at 3:03 p.m. with LPN AA revealed there was so much going on at that time, that she forgot to finish the documentation regarding the events with the resident. She stated she should have had a staff member taking notes of the events so she could accurately document what happened during the incident with R#1 but confirmed she did not do that. Interview on [DATE] at 11:00 a.m. with the Director of Health Services (DHS) stated the nursing staff on duty the night of the occurrence with R#1, did not thoroughly document the events leading up to and after R#1's death. She stated her expectation is for the nursing staff to thoroughly document in the electronic health record in real time, all events surrounding any incidents with the residents. Interview on [DATE] at 3:35 p.m. with Administrator JJ confirmed the nursing staff did not accurately document in the EMR the events of R#1 incident and death. During further interview, she revealed she had to rely on camera footage, employee statements, and the fire department documentation to get details of the incident, because the details were not documented.

Based on observations, interviews, record review, and review of the facility policy titled, Occurrences, and review of the policy Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property the facility failed to protect one of eight sampled residents, R#1, from neglect by not making observations of R#1 throughout one shift during which time R#1 eloped from the facility undetected. The elopement of R#1 was not identified for 10.5 after the last documented observation. On September 27, 2021, it was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator and Regional Nurse Consultant were informed of the Immediate Jeopardy (IJ) on September 27, 2021, at 11:48 a.m. The noncompliance related to the IJ was identified to have existed on September 18, 2021, when staff failed to determine that R#1 was missing from the facility for 10.5 hours, until a family member arrived to visit and the resident's elopement was discovered. The IJ is outlined as follows: R#1 was a [AGE] year-old female admitted to the facility on [DATE], after a prolonged hospital stay, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/18/2021 at 10:30 a.m., the Responsible Party (RP) of R#1 arrived at the facility to visit the resident, prompted by their inability to reach the resident on her mobile phone earlier that morning. When they arrived, Licensed Practical Nurse (LPN) AA informed them that R#1 was missing from the facility. Review of the surveillance video, timestamped at 3:30 a.m. on 9/18/21, revealed R#1 leaving her room with her baggage and then disappeared from the camera view. At 3:38 a.m., R#1 was seen outside the facility walking down the driveway from the back of the facility towards the street. Interviews with LPN AA and Certified Nursing Assistant (CNA) BB revealed neither actually saw R#1 on 9/18/2021 on the Day Shift, 7:00 a.m. to 7:00 p.m. (7A-7P) and were not aware she was missing from the facility until the resident's family arrived to visit at 10:30 a.m. Interviews with CNA DD and Registered Nurse (RN) CC, who worked the Night Shift, 7:00 p.m. to 7:00 a.m. (7P-7A) revealed CNA DD never saw R#1 after 12:00 a.m. on 9/18/2021 and RN CC revealed she arrived late for her shift and never saw R#1 during her work hours of 12:33 a.m. until 6:58 a.m. on 9/18/2021, even though RN CC signed off as giving the resident's 6:00 a.m. medications which were left on the resident's bedside table. Interview with the assigned Detective from the local police precinct revealed the police located R#1 between 2:30 p.m.-3:00 p.m. on 9/18/21 at a local hotel approximately four miles from the facility. She was unharmed and declined medical attention. There was no evidence any facility staff observed R#1 or identified that R#1 was missing from the facility for 10.5 hours. The IJ was related to the facility's noncompliance with program requirements as follows: 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F 600, Scope and Severity (S/S): J) 42 CFR 483.25 Quality of Care (F 689, S/S: J) Additionally, Substandard Quality of Care was identified with requirements at 42 CFR 483.12, Freedom from Abuse, Neglect, and Exploitation (F 600, S/S: J) and 42 CFR 483.25, Quality of Care (F 689, S/S: J) An acceptable IJ Removal Plan was received on 9/28/2021. Based on observation, clinical record review, review of facility policies as outlined in the IJ Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 9/28/2021. The facility remained out of compliance while the facility continued management level oversight for neglect and to prevent further elopement and the staff conformance with the facility's policies and procedure. Findings include: Review of Occurrences policy effective 7/1/12, last reviewed 9/9/19 revealed the center recognizes that due to the frailty of the patients/residents served, there is an increased risk of occurrences that may result in injury to the patient/resident and/or others. In an effort to prevent occurrences, each patient/resident will be observed and assessed for risks. Appropriate, realistic interventions will be implemented in accordance to (sic) their plan of care. Further review revealed occurrence hazards are physical features in the healthcare center environment which may pose a risk to a patient/resident's safety, including but not limited to: (1) any event, accident, or incident, on or off healthcare center property which results in an injury or has the potential for injury. (2) Medication discrepancy and adverse drug reaction. (3) Unexplained injury to a patient/resident where no specific or actual incident was observed; yet the patient/resident exhibits evidence of an injury, such as a bruise or skin tear. (4) complaint of mental or physical abuse or neglect or witnessed abuse or neglect (abuse and/or neglect may be inflected by family, visitors, other patients/residents or staff). (5) elopement from healthcare center property regardless of whether or not there was an injury with the elopement. Review of Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property policy effective 12/1/01, last reviewed 7/29/19 revealed any allegation, suspicion or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the Administrator of the provider entity. Notwithstanding anything contained in this policy to the contrary, in any case in which there is a reasonable suspicion that a crime has been committed against a patient of a Health Care Center, in addition to reporting to the appropriate state agency (or agencies) the incident should be reported to local law enforcement within 24 hours after forming the suspicion. Review of the Facility Incident Report Form, dated 9/18/2021, documented the elopement was identified at 11:15 a.m. and reported to the State Survey Agency (SSA) at 1:15 p.m. The final Facility Incident Report, dated 9/19/2021 revealed a thorough investigation and appropriate interventions, including staff education related to elopement protocol, identifying behaviors related to potential elopement, staff attendance, resident rounds, and medication administration. Record review revealed that R#1 was a [AGE] year-old female admitted to the facility on [DATE], from a prolonged hospital stay, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) Assessment revealed an Admission assessment was not completed. The Discharge Assessment for R#1 dated 9/18/2021 revealed the following: Short-term memory was okay; she was independent for daily decision-making skills, had a Mood score of zero indicating no depression, displayed no behaviors, independent for eating, bed mobility; required supervision for transfers, walking in room/corridor, locomotion on/off unit, dressing, toilet use, bathing; required limited assistance for personal hygiene, always continent of bladder/bowel, no unhealed pressure ulcers, and antibiotic medication. Review of the Progress Notes dated 9/17/2021 at 4:43 p.m. revealed the Responsible Party (RP) called the Unit Manager to request an early discharge with home health because the RP did not like that her family member had to be in quarantine for 14 days. Review of the Progress Notes dated 9/18/2021 at 11:15 a.m. (recorded as a late entry on 9/20/2021, 11:23 a.m. by the DON) revealed the Administrator was informed of R#1's elopement at approximately 11:15 a.m. Facility was searched inside and outside until the police arrived and searched off the property. Family was already at the facility. Law enforcement located R#1 later in the day at a local hotel. She was unharmed and uninjured. Facility considers resident discharged against medical advice (AMA). The Administrator attempted to contact the RP or follow-up with R#1 to ensure all needs were met but got no response. Review of the Police Report dated 9/18/21 at 11:04 a.m. revealed that when the officer arrived at the facility, he met with the family member and Licensed Practical Nurse (LPN) AA at the entrance to the facility. The family member advised that elderly female was suffering from early dementia and that LPN AA was assigned to care for the resident (R#1). The family member stated her last contact with R#1 was the day before at 18:30 (6:30 p.m.) and that the resident had expressed a desire to leave the facility although the facility had advised to wait until Monday, 9/20/21. The family member stated coming to the facility to visit R#1 today (9/18/21) at 10:30 a.m. and when she came to the front desk of the facility, she was advised by staff that they were looking for R#1. Shortly after the facility staff stated they were unable to find the resident. LPN AA stated she checked for R#1 in her room around 8:30 a.m. to provide medication but the resident was not in her room. LPN AA stated she made a second attempt just before 11:00 a.m. although the resident still was not in her room. Staff advised that the facility has cameras, but the facility Administrator is the only person with access and was reviewing from her home. The police asked the Administrator to come to the facility to allow the police to review the cameras with her. The Administrator arrived at the facility at approximately 12:15 p.m. A passerby alerted the police of some clothing, bags and a purse at the southern end of the facility driveway. The family confirmed they belonged to the R#1. Further review of the Police Report revealed a lengthy review of the facility surveillance, it was determined that R#1 had left the facility through a window in room [ROOM NUMBER] at approximately 3:32 a.m. on 9/18/21 then traveled on foot out of sight to the southern end of the property. Through a series of investigative actions R#1 was tracked to a hotel in a surrounding city and the family was informed. Review of the Daily Schedule for 9/17/21 revealed that two nurses were assigned to the Transitional Care Unit (TCU) where the R#1 was located for the 7:00 p.m. to 7:00 a.m. shift, LPN EE and Registered Nurse (RN) CC. Review of the timecard punch details for 9/17/21 and 9/18/21 revealed that RN CC clocked in at 0.33 (12:33 a.m.) on 9/18/21 and clocked out on 9/18/21 at 6:58 a.m. LPN AA clocked in on 9/18/21 at 8:38 a.m. and clocked out at 20:13 (8:13 p.m.). Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility staff investigation statements revealed that RN CC on 9/18/21 during 6:00 a.m. med pass, she thought the resident was in the bathroom and it was not unusual for the resident to be out of bed since she was independent for ambulation. Unfortunately, I made a mistake and did not physically lay eyes on her during my morning rounds. Further review revealed that CNA DD's written statement stated she checked on the resident on 9/18/21 at 12:00 a.m., 4:00 a.m., and 7:00 a.m. and that was the last time she saw the resident. An interview with Maintenance Director (MD1) on 9/22/21 at 10:00 a.m. revealed he has worked at the facility for 5 years and currently works 7 days a week. The MD1 further revealed that he has been at the facility since the recent elopement of R#1 to ensure the security of the exit doors and all windows to prevent additional elopements. He further revealed that he discovered the resident escaped through a window in room [ROOM NUMBER] and that the resident climbed out of the window on 9/18/21 by lifting the base of the window seal in order to climb out the window. MD1 stated he did see the window screen on the ground outside the window on 9/18/21. He continued to state that he has been working to test the exit doors to ensure they currently work, as well as, reinforcing all windows with two nails (one at the top of the window seal and one at the bottom of the window seal) to prevent residents from forcing the window open. He continued to state windows can be forced open in the event of an emergency by facility staff or emergency personnel. An interview with Certified Nursing Assistant (CNA) BB on 9/22/21 at 2:30 p.m. revealed she was working at the facility from 7:00 p.m. Friday, 9/17/21 to 11:00 a.m. Saturday 9/18/21. She further revealed first seeing R#1 on 9/17/21 at approximately 7:15 p.m. during shift change when she was counting all residents present on the Transitional Care Unit (TCU). She further revealed seeing the resident at this time in her room, sitting on her bed with her back facing the door. She further revealed that she did not see the resident again during her shift although she was not assigned the resident's room. CNA BB revealed that she did stay late to assist in passing out the breakfast trays to the residents on TCU on Saturday 9/18/21 morning (CNA BB was unsure of the time). CNA BB further revealed that the resident was not in her room when she brought the breakfast tray into her room although she assumed the resident was nearby because she was able to self-ambulate and left the tray for her return. CNA BB confirmed not returning to the resident's room to collect the tray or to check if she had eaten her meal. An interview with Licensed Practical Nurse (LPN) AA on 9/22/21 at 2:50 p.m. revealed she did not work at the facility on Friday 9/17/21. She stated she was scheduled to work at the facility on Saturday 9/18/21 from 7:00 a.m. to 7:00 p.m. but she was late and did not report to work until 8:30 a.m. LPN AA stated she was scheduled to relieve RN CC who was scheduled to work 7:00 p.m. to 7:00 a.m. and when she arrived to work RN CC had already left and did not leave a report concerning the residents on Transitional Care Unit (TCU). She continued to state when she reported to work, she noticed R#1's family in the lobby but did not know at the time there was a potential issue until she arrived on TCU and went to R#1's room and noticed she was not present. She continued to state when she arrived at R#1's room she noticed all her personal belongings were gone, her breakfast tray was on her table tray untouched and there was a clear, medication cup with two pills, [MEDICATION(S)] ([MEDICATION(S)]) and [MEDICATION(S)], in the medication cup on her breakfast tray. She continued to say she did not touch anything in R#1's room and began the search to locate R#1. LPN AA stated it was after 9:00 a.m. when she noticed R#1 was not in her room. LPN AA did not call a Code Pink (code to alert the staff a resident is missing and to begin a search) or inform the Unit Manager on duty until after R#1's family arrived. She stated when she realized R#1 was not in the building she called DHS at approximately 11:10 a.m., the Administrator at approximately 11:15 a.m. and the Unit Supervisor (US) after speaking with the Administrator to advise them of the missing resident then went to the lobby to inform R#1's family that she was missing. LPN AA stated after informing R#1's family of her status she then called 911 to get the local police involved. She continued to state there was no weekend supervisor on duty in the building on Saturday. An interview with LPN FF on 9/22/21 at 3:20 p.m. revealed she worked at the facility on Saturday 9/18/21 from 7:00 a.m. to 7:00 p.m. She continued to state she was responsible for caring for the residents in rooms 200 through 211 and LPN EE was responsible for caring for the residents in rooms 216 through 232. LPN FF stated when she reported to work, she received hand-off report from LPN EE with regards to any issues or concerns for the residents in the Transitional Care Unit (TSU). She continued to state that his report included the residents on her hall because RN CC left before she arrived and was not available to do hand-off and give report on residents. LPN FF continued to state she was familiar with R#1 but had little interaction with her. She continued to state when she did have the opportunity to speak to R#1 she never expressed wanting to go home or plans to go home. She stated R#1 was always pleasant and made her needs known, she would ambulate and was independent in toileting. An interview with CNA HH on 9/22/21 at 4:30 p.m. revealed she has worked at the facility on Friday 9/17/21 from 7:00 a.m. to 7:00 p.m. but worked until 11:00 p.m. to assist on the Transitional Care Unit (TCU) but did not work on 9/18/21. CNA HH revealed that she was assigned to residents in rooms 200 through 208. She further revealed that the residents in room [ROOM NUMBER] were moved from that room earlier in the day due to the end of the duration of their quarantine. She revealed this room was empty at this time and was the room that R#1 eloped. CNA HH further revealed that she was familiar with R#1 and recalled her to be quiet, kept to herself, she took her medication well, she ate her meals and did not complain about anything. CNA HH stated she did not interact with R#1 on Friday during her shift. An interview with CNA II on 9/22/21 at 4:40 p.m. revealed she worked at the facility on Friday 9/17/21 from 7:00 a.m. to 7:00 p.m. and did not work on 9/18/21. CNA II revealed being assigned to the R#1 and did recall seeing her in her room during her shift when she went back to her room to pick up her dinner tray approximately between 6:00 p.m. and 6:30 p.m. She further revealed that R#1 was sitting on her bed and did not respond to cues to talk when CNA asked how she was doing or if she needed anything. A telephone interview with RN CC on 9/23/21 at 11:50 a.m. revealed she worked at the facility on Saturday, 9/18/21, from 12:00 a.m. to 7:00 a.m. She confirmed that she was scheduled to work from 7:00 p.m. to 7:00 a.m. on Friday 9/17/21 and Saturday 9/18/21 but she called out on Friday 9/17/21 and reported late (12:33 a.m.) to work on Saturday 9/18/21. RN CC revealed that when she arrived to work on 9/18/21, that LPN EE was the only nurse on the floor, and was working alone. She stated she could see LPN EE was behind in passing medications to the residents therefore she began passing medications (med pass) as soon as she arrived. RN CC stated she started with room [ROOM NUMBER] and passed meds to only a few residents but could not remember them all. She stated one of the rooms she entered to pass medications was R#1's room although the resident was not present at this time during the med pass. She further revealed that after passing medications she sat down at the nurses' station and began charting (update residents medical records with current activity performed by the nurse who enters documentation). RN CC revealed that she did not go back into R#1's room until 6:00 a.m. to administer her medication. She further revealed that she did not see R#1 in her bed or in her room. RN CC revealed that R#1's bathroom light was on, the door was slightly open, and she thought she heard water running therefore, she thought R#1 was in the bathroom. RN CC stated because she thought R#1 was in her bathroom she put her medication cup on her breakfast tray that was sitting on her table tray untouched. She continued to state after placing R#1's medication cup down on the breakfast tray, unattended, she continued with the medication pass on the unit. RN CC further stated it was normal and routine for her to leave R#1's medication for her to take on her own and she does not stay to witness R#1 taking her medication because she is very independent. RN CC revealed that LPN EE administered medication, and that she charted giving the medications, although she wasn't in the facility. RN CC continued to confirm she could not verify when the vitals were actually taken although she documented she was present and had taken R#1's vital information. RN CC further stated that at the end of her shift on Saturday 9/18/21 that LPN EE helped her count the narcotic drawer. She continued to state that when she clocked out for the day she did not wait for the on-coming nurse, LPN AA. RN CC stated she started to receive phone calls from the DHS, LPN EE, and CNA JJ regarding R#1. She revealed receiving phone calls asking when the last time was she saw R#1 and if she actually saw the resident when she administered medication pass which she reported the last time she saw R#1 was at midnight. An interview with the Administrator on 9/22/21 at 5:23 p.m. revealed she received a call on 9/18/21 at approximately 11:15 a.m. from Guest Services Manager (GSM), to advise a Code Pink (missing/eloped resident) has been called at the facility. She stated she began to question GSM as to the resident's name and room number, then gave instructions to search the entire facility twice, if resident is not found to expand the search to the outside grounds around the building, and if resident was not found outside to call 911 immediately. She further revealed that after phone call with GSM she checked her facility computer at home and then contacted the police department were the resident lived and ask for a welfare check after explaining the situation. The Administrator revealed that the local police department had responded to the facility, and she was advised that detectives will be taking over the investigation and will be onsite shortly. The Administrator stated she arrived at the facility at approximately noon on 9/18/21. When the Administrator arrived at the facility the family of R#1's was already present, talking with police officers and engaged in the search for R#1. The Administrator further revealed that she shared facility camera footage of the early morning hours with R#1's family which indicates R#1 was outside walking on the side of the building through the alley at 3:38 a.m. on 9/18/21. Review of the surveillance camera video revealed that the resident exited her room, walked down the hallway and entered room [ROOM NUMBER], which at the time was empty, and dislodged the base of the window in order to push the window open and remove the screen so she could climb out of the window with her personal belongings and leave the facility. The Administrator revealed that the Corporate Nurse Consultant (NC) arrived at the facility on 9/18/21, cannot recall time, and a head count of remaining residents on TSU and instructed maintenance to check all doors and windows for security. The Administrator revealed that phone calls were being made to the area hospitals for any recent admissions that fit R#1s description although no one fit the description. The Administrator revealed that R#1's purse and clothing were found in the trees and bushes just outside the facility property, but R#1's wallet and cell phone were missing among her personal items. The Administrator further stated the family and facility tried continuously to reach R#1 by phone until approximately 4:30 p.m. when it was determined the phone was turned off. The Administrator revealed that the Detectives advised the family to check the resident's bank records to determine if the resident had used her credit card. The family was able to gain access to R#1's bank account and was able to determine that R#1's credit card had been used at a drug store and a local hotel. The Detective contacted her stating the resident had been located and is safe and with her family. The Administrator further revealed that the investigation determined that CNA DD was the last person to see the resident and that RN CC charted giving medications to R#1 but did not and did not attempt to locate the resident. The Administrator revealed that RN CC should have waited for LPN AA to give report and that the Administrator was not aware that RN CC had been 5.5 hours late for her shift. An interview with Director of Health Services (DHS) on 9/22/21 at 5:52 p.m. revealed she did not work at the facility on Friday 9/17/21 and was called to come to the facility by the Administrator on Saturday 9/18/21 due to the circumstances taking place regarding the missing resident. The DHS revealed that all nursing staff should stay on duty until the on-coming nurse arrives and a proper resident review and hand-off is completed. She further revealed that the nurses did not follow policy or nursing standards on 9/17/21 through 9/18/21. The DHS revealed that it is unacceptable for any nurse to leave any type or kind of medication unattended with the expectation that the resident who it is intended for will see it and take their medication. She continued to state she would expect the nurse who dispensed the medication to keep the medicine with her until the resident is available to take the medication and to return later to give the medications. An interview with LPN EE on 9/22/21 at 7:04 p.m. revealed he worked at the facility on Friday 9/17/21 from 7:00 p.m. to 7:00 a.m. and on Saturday 9/18/21 from 7:00 p.m. to 7:00 a.m. He stated he was responsible for caring for the residents in rooms 214 through 232. LPN EE further revealed that he was working with CNA JJ and DD on 9/17/21 and that CNA DD was assigned to R#1. A telephone interview with CNA JJ on 9/23/21 at 9:35 a.m. revealed she did not work at the facility on Friday 9/17/21 but she did work at the facility on Saturday 9/18/21 from 7:00 a.m. to 3:00 p.m. CNA JJ stated after reporting to work Saturday morning she began to pass breakfast trays at approximately 7:15 a.m. and that CNA BB was responsible for passing breakfast trays for her residents that included R#1. CNA JJ further revealed that LPN AA reported to work late on 9/18/21 and reported to the facility at approximately 9:45 a.m. At approximately 10:00 a.m. she overheard LPN AA talking with LPN FF telling her that the family for R#1 was at the front desk and want to see her, but she is not in her room. CNA JJ revealed that staff began to look for the resident at that time. CNA JJ revealed that she went to R#1's room and noticed her breakfast tray on her tray table had been untouched. CNA JJ stated she asked CNA BB if she saw R#1 when she brought her breakfast tray to her room and CNA BB replied, no. A telephone interview with LPN KK, Unit Supervisor, on 9/23/21 at 9:45 a.m. revealed she was at the facility on Friday 9/17/21 and worked from 7:00 a.m. to 7:00 p.m. although she did not work on 9/18/21. LPN KK revealed being familiar with R#1 and that the resident did not like to be in isolation, was very alert, and cooperative in taking medication. She continued to state during her interactions with R#1 she never displayed signs and never voiced wanting to leave the facility. LPN KK stated she encountered R#1 twice during her shift on Friday, the first time the resident came to the Nurses' Station at approximately 3:00 p.m. without her oxygen on. LPN KK redirected the resident to her room and explained she could not be out of her room due to isolation status. She further revealed she last saw R#1 on Friday at approximately 4:30 p.m. during medication pass and she witnessed R#1 take her medication at that time. A telephone interview with LPN LL on 9/23/21 at 10:25 a.m. revealed she was at the facility on Friday 9/17/21 and worked from 7:00 a.m. to 7:00 p.m. and again on Saturday 9/18/21 from 7:00 p.m. to 7:00 a.m. She further revealed that although she did not personally care for R#1 she was familiar with her and on two occasions witnessed R#1 walk out of her room on Friday afternoon at approximately 3:00 p.m. without her oxygen and without her mask on. LPN LL further revealed that the second occasion she witnessed R#1 out of her room and walk to the nurse's station and staff redirected her back to her room and explained to R#1 she could not be out of her room due to her isolation status. LPN LL continued to state on the few occasions she interacted with R#1 she did not express wanting to go home or that she was being discharged . A telephone interview with CNA DD on 9/23/21 at 12:36 p.m. revealed that she worked at the facility on Friday 9/17/21 from 7:00 p.m. to 7:00 a.m. although she arrived late, 7:33 p.m., for her shift and was assigned to R#1. CNA DD further revealed that R#1 was independent and could ambulate independently. She revealed that she did see resident in her room during her rounds on Friday 9/17/21 at 8:00 p.m. and 10:00 p.m., then again on Saturday 9/18/21 at 12:00 a.m. during her shift. CNA DD stated when she made her rounds again at 2:00 a.m. and she entered R#1's room she was not in her bed. She further revealed notifying RN CC that the resident was not in her room at 2:00 a.m. and then took her thirty-minute break. CNA DD further revealed that she could not find the resident at 3:00 a.m. and reported this to RN CC. CNA DD revealed that she went back to R#1's room for the last time at 7:00 a.m. to double check and see if she was back in her room and she was not. She stated receiving a call from LPN EE at 9:00 a.m. asking her when she last saw R#1 and she reported that she last saw R#1 at 12:00 a.m. Saturday 9/18/21 morning. CNA DD continued to state she did not give oral report to on-coming CNA before she left the facility at 7:00 a.m. An interview with Staffing Coordinator (SC) on 9/23/21 at 5:52 p.m. revealed the facility policy for Call Outs and Late Arrivals is that employees are required to notify the staffing coordinator at least two hours or as soon as possible, in advance of their scheduled time to start their shift. She continued to state employees are considered late if they clock-in 5 minutes after their scheduled shift start time. SC stated on Friday 9/17/21 she called CNA DD to ask where she was and why she has not reported to work yet. She further revealed that CNA DD informed her that she was on her way. SC stated CNA DD arrived to work at 7:30 p.m. and was scheduled to report at 7:00 p.m. SC further revealed that RN CC did not call SC to advise she was going to be late on Friday 9/17/21 and DHS did not communicate this information either. SC revealed that LPN EE did not call SC to advise he was going to be late on Friday 9/17/21 nor did LPN AA call to say she would be late on Saturday 9/18/21. She revealed that the DHS was not notified by either nurse. The Facility implemented the following actions to remove the IJ: 1. On 9/18/21 by utilizing a current facility census a visual full facility Head Count Audit was conducted, and all other residents were accounted for. 2. On 9/18/21, Nurse Consultant provided education on frequent rounding standard of practice and abuse policy as it relates to neglect for all nursing staff and medication administration for all nurses and to be completed prior to staff working thereafter. As of 9/27/21, sixty-three (63), or ninety-six (96) percent of licensed and certified nursing staff had received this in-service training. As of 9/27/21, twelve (12) or one hundred (100) percent of the facility's Registered Nurses, had receive this in-service training. As of 9/27/21, nineteen (19) or ninety-five (95) of the facility's twenty (20) Licensed Practical Nurses had received this in-service training. As of 9/27/21, thirty (30) or ninety-seven (97) percent of the facility's thirty-one (31) Certified Nursing Aides had received this in-service training. The remaining two (2), staff who were unavailable for training at that time due to being one (1) being off-duty and one (1) on leave, were to receive this in-service training upon their return to work; these licensed staff would not be allowed to provide direct resident care until completion of this in-service. Administrator and/or Director of Nursing will continue training until all necessary staff have been trained. Refer to #12 for auditing tool. 3. On 9/18/21, Nurse Consultant provided education on medication administration, specifically as it relates t [TRUNCATED]

Based on family, staff, and law enforcement interviews; record review; and review of facility policy titled, Occurrences, the facility failed to provide supervision and monitoring to prevent the elopement of one resident (R) #1 from a sample of eight (8) residents. Staff did not actually observe R#1 in the facility for 10.5 hours, during which time she eloped from the facility. R#1 was located approximately four (4) miles from the facility. R#1 was found unharmed but the potential for harm met the level of Immediate Jeopardy. On September 27, 2021, it was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator and Regional Nurse Consultant were informed of the Immediate Jeopardy (IJ) on September 27, 2021, at 11:48 a.m. The noncompliance related to the IJ was identified to have existed on September 18, 2021, when staff failed to determine that R#1 was missing from the facility for 10.5 hours, until a family member arrived to visit and the resident's elopement was discovered. The IJ is outlined as follows: R#1 was a [AGE] year-old female admitted to the facility on [DATE], after a prolonged hospital stay, with diagnoses to include personal history of COVID-19, acute [CONDITION(S)] with [CONDITION(S)], [CONDITION(S)], and cognitive communication deficit. On 9/18/2021 at 10:30 a.m., the Responsible Party (RP) of R#1 arrived at the facility to visit the resident, prompted by their inability to reach the resident on her mobile phone earlier that morning. When they arrived, Licensed Practical Nurse (LPN) AA informed them that R#1 was missing from the facility. Review of the surveillance video, timestamped at 3:30 a.m. on 9/18/21, revealed R#1 leaving her room with her baggage and then disappeared from the camera view. At 3:38 a.m., R#1 was seen outside the facility walking down the driveway from the back of the facility towards the street. Interviews with LPN AA and Certified Nursing Assistant (CNA) BB revealed neither actually saw R#1 on 9/18/2021 on the Day Shift, 7:00 a.m. to 7:00 p.m. (7A-7P) and were not aware she was missing from the facility until the resident's family arrived to visit at 10:30 a.m. Interviews with CNA DD and Registered Nurse (RN) CC, who worked the Night Shift, 7:00 p.m. to 7:00 a.m. (7P-7A) revealed CNA DD never saw R#1 after 12:00 a.m. on 9/18/2021 and RN CC revealed she arrived late for her shift and never saw R#1 during her work hours of 12:33 a.m. until 6:58 a.m. on 9/18/2021, even though RN CC signed off as giving the resident's 6:00 a.m. medications which were left on the resident's bedside table. Interview with the assigned Detective from the local police precinct revealed the police located R#1 between 2:30 p.m.-3:00 p.m. on 9/18/21 at a local hotel approximately four miles from the facility. She was unharmed and declined medical attention. There was no evidence any facility staff observed R#1 or identified that R#1 was missing from the facility for 10.5 hours. The IJ was related to the facility's noncompliance with program requirements as follows: 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F 600, Scope and Severity (S/S): J) 42 CFR 483.25 Quality of Care (F 689, S/S: J) Additionally, Substandard Quality of Care was identified with requirements at 42 CFR 483.12, Freedom from Abuse, Neglect, and Exploitation (F 600, S/S: J) and 42 CFR 483.25, Quality of Care (F 689, S/S: J) An acceptable IJ Removal Plan was received on 9/28/2021. Based on observation, clinical record review, review of facility policies as outlined in the IJ Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 9/28/2021. The facility remained out of compliance while the facility continued management level oversight for neglect and to prevent further elopement and the staff conformance with the facility's policies and procedure. Findings include: Review of the facility policy titled, Occurrences, last reviewed 9/9/2019, revealed the following: Definitions: Occurrence hazards are physical features in the healthcare center environment which may pose a risk to a patient/resident's safety, including but not limited to: Any event, accident or incident, on or off healthcare center property, which results in an injury or has the potential for injury . Elopement from healthcare center property regardless of whether or not there was an injury associated with the elopement. R#1 was a [AGE] year-old female admitted to the facility on [DATE], after a prolonged hospitalization , with diagnoses to include acute [CONDITION(S)] with [CONDITION(S)], personal history of Covid-19, 2019-nCoV acute respiratory disease, cognitive communication deficit, and [CONDITION(S)]. Review of the Minimum Data Set (MDS) Assessment revealed an admission assessment was not completed. The Discharge Assessment for R#1 dated 9/18/2021 revealed the following: 1. Short-term memory was okay; she was independent for daily decision-making skills, had a Mood score of zero (0)-indicating no depression, displayed no behaviors 2. Independent for eating, bed mobility; required supervision for transfers, walking in room/corridor, locomotion on/off unit, dressing, toilet use, bathing; required limited assistance for personal hygiene 3. Always continent of bladder/bowel 4. No unhealed pressure ulcers 5. Antibiotic medication Review of the Care Plan for R#1 dated 9/13/2021 revealed she was care planned for advanced directives, pain, fall risk, activities of daily living (ADL) functional/ rehabilitation potential, and discharge planning. Discharge planning goals were to begin discharge planning upon admission and to meet the initial goals of care and discharge. Interventions for discharge planning included promoting education to resident/family/caregiver as needed and involve resident, representative, and interdisciplinary team (IDT) in the discharge planning process. Review of the Progress Notes dated 9/17/2021 at 4:43 p.m. revealed the RP called the Unit Manager of the 200 Hall to request an early discharge with home health because she did not like that the resident had to be in quarantine for 14 days. Review of the Progress Notes dated 9/18/2021 at 11:15 a.m. (recorded as a late entry on 9/20/2021, 11:23 a.m. by the DHS) revealed the Administrator was informed of R#1's elopement at approximately 11:15 a.m. Facility was searched inside and outside until the police arrived and searched off the property. Family was already at the facility. Law enforcement located R#1 later in the day at a local hotel. She was unharmed and uninjured. Facility considers resident discharged against medical advice (AMA). Administrator attempted to contact the RP or follow-up with R#1 to ensure all needs were met but got no response. Review of the Facility Incident Report Form, dated 9/18/2021, documented the elopement was identified at 11:15 a.m. and reported to the State Survey Agency (SSA) at 1:15 p.m. The final Facility Incident Report, dated 9/19/2021 revealed a thorough investigation and appropriate interventions, including staff education related to elopement protocol, identifying behaviors related to potential elopement, staff attendance, resident rounds, and medication administration. Review of the Police Report and Investigation Notes dated 9/18/2021 revealed the local precinct received a report of elopement from the facility at 11:04 a.m. and arrived at the facility at 11:07 a.m. Review of the Police Report dated 9/18/21 at 11:04 a.m. revealed that when the officer arrived at the facility, he met with the family member and Licensed Practical Nurse (LPN) AA at the entrance to the facility. The family member advised that elderly female was suffering from early dementia and that LPN AA was assigned to care for the resident (R#1). The family member stated her last contact with R#1 was the day before at 18:30 (6:30 p.m.) and that the resident had expressed a desire to leave the facility although the facility had advised to wait until Monday, 9/20/21. The family member stated coming to the facility to visit R#1 today (9/18/21) at 10:30 a.m. and when she came to the front desk of the facility, she was advised by staff that they were looking for R#1. Shortly after the facility staff stated they were unable to find the resident. LPN AA stated she checked for R#1 in her room around 8:30 a.m. to provide medication but the resident was not in her room. LPN AA stated she made a second attempt just before 11:00 a.m. although the resident still was not in her room. Staff advised that the facility has cameras, but the facility Administrator is the only person with access and was reviewing from her home. The police asked the Administrator to come to the facility to allow the police to review the cameras with her. The Administrator arrived at the facility at approximately 12:15 p.m. A passerby alerted the police of some clothing, bags, and a purse at the southern end of the facility driveway. The family confirmed they belonged to the R#1. A telephone interview with the local police Detective on 9/21/2021 at 4:24 p.m., he stated his officers arrived at the facility on 9/18/2021 at 11:07 a.m. in response to a report of a missing nursing home resident and continued to search for R#1 outside the facility. He stated a passerby notified them of clothes/personal items left on the side of the road within the subdivision minus R#1's wallet and mobile phone. He stated he requested the Administrator come to the facility to view the surveillance video which showed R#1 leaving her room at 3:00 a.m. without oxygen or a face mask. She returned to her room and left the room again with her baggage at 3:30 a.m.; seen again on video at 3:38 a.m. outside the facility walking down the driveway away from the facility. He stated they determined R#1 left through a window in a vacant room 209 on her unit. He stated R#1 dislodged the window, removed the screen and climbed out of the window. He stated at 1:38 p.m., he and R#1's Responsible Party (RP) tracked R#1 via her bank card to a drug store approximately four (4) miles away in [NAME] Springs and then to a hotel near the drug store between 2:30 p.m.-3:00 p.m. He stated R#1 told him when she left the facility, she stayed in front of the nearby grocery store, 0.6 miles from the facility (14-minute walk), until it opened that morning at 7:30 a.m., having crossed three (3) lanes of traffic. He was not certain how R#1 got to [NAME] Springs, but she was not injured or harmed in any way. He stated R#1 told him she didn't want to wait until Monday for her scheduled discharge from the facility. He stated R#1 last spoke with her RP on Friday afternoon (9/17/2021) and based on that conversation, her RP daughter decided to discharge her R#1 on Sunday, 9/19/2021 instead, feeling her mother was getting restless. R#1's called several times on Saturday morning (9/18/2021) but was unable to contact the resident so the RP decided to go to the facility to check on the resident. He stated R#1 left her personal effects on the side of the road and strewn onto trees because they were too heavy to carry. He stated he tried to locate R#1 via her phone company but was unable as R#1 had either turned the phone off or turned off the locator. He stated R#1 was upset with the RP because of the long hospital stay and then transfer to the skilled nursing facility (SNF). He stated R#1 had planned to stay at hotel for one to two (1-2) days, then go to the RP's house. He stated R#1's RP wanted to take R#1 to the hospital for evaluation but the resident declined emphatically. A telephone interview with R#1's RP on 9/21/2021 at 4:50 p.m., she stated they all [the family] got Covid-19 in July 2021 from attending a family member's wedding. She stated R#1 became progressively ill and remained in the hospital for two months. She stated the hospital practically insisted on sending her R#1 to rehabilitation unit so she was transferred to the facility on [DATE]. The RP revealed that she was skeptical because there were only three online reviews. She stated R#1 tested negative for Covid-19 twice before the transfer but the facility's admission protocol for unvaccinated admissions was a 14-day quarantine in the Observation Unit on the 200 Hall/Transitional Care Unit (TCU). The RP revealed having a video-chatted with the resident on Monday, Tuesday, and Wednesday but on Thursday, R#1 said she was miserable. The RP revealed that she spoke with the Unit Manager who contacted the doctor who said R#1 could discharge on Monday, 9/20/2021 when oxygen (O2) could be setup at home. The RP revealed that she called the resident several times on Saturday morning, 9/18/2021 but got no answer. The RP revealed that she and another family member decided to go to the facility to check on R#1 and arrived at 10:30 a.m. The RP revealed that she asked about the resident to a lady left the front desk and returned with Licensed Practical Nurse (LPN) AA who informed them that R#1's belongings were gone, and she was missing from the facility. She stated she called 9-1-1 and, when the police arrived, they asked staff to stop searching so they could employ the canine unit to continue the search. The RP revealed that R#1's clothes and handbag were strewn on the side of the road and hanging on trees near the facility. She stated she was allowed to view the facility's surveillance video where she saw R#1 walking around outside the Observation Unit passing one (1) male seated at the nurses' station in the middle of the unit at 3:00 a.m. She stated R#1 was seen again at 3:30 a.m. leaving her room with her baggage. The RP revealed that the resident was seen again outside the facility at 3:38 a.m. walking down the driveway away from the facility with her baggage. The RP revealed that between 5:30-6:00 p.m., the police asked her to access R#1's bank account where she noted four (4) transactions: two at 7:00 a.m. and two at 1:30 p.m. The RP revealed that R#1 later told her she stood in front of the grocery store, 0.6 miles away from the facility, for four hours until they opened. The resident further revealed to the RP that she tapped on a stranger's window and asked a man to take her to a hotel at approximately 9:00 a.m. The resident further revealed to the RP that the stranger paid for the hotel room and called the police. She was not sure why R#1 would have left that hotel and paid for another, but the resident was diagnosed with mild dementia. The RP was grateful that the resident was located safe and sound. Timeline of Elopement per the Administrator and Local Detective: 9/17/21 at 06:30 p.m.: R#1 had video chat with the RP. 9/17/21 at 07:33 p.m.: CNA DD arrived to work (7P-7A) 9/17/21 at 09:32 p.m.: CNA DD last documented ADL care for R#1 9/18/21 at 12:00 a.m.: CNA DD stated she saw R#1 in her room in bed 9/18/21 at 12:33 a.m.: RN CC arrived to work (7P-7A) 9/18/21 at 03:30 a.m.: Surveillance video captured R#1 leaving her room with her baggage 9/18/21 at 03:38 a.m.: Surveillance video captured R#1 outside the facility walking down the driveway away from the facility. 9/18/21 at 06:00 a.m.: RN CC left morning meds at bedside but did not see R#1. 9/18/21 at 07:30 a.m.: CNA BB left breakfast tray but did not see R#1; time approximate. 9/18/21 at 08:38 a.m.: LPN AA arrived to work (7A-7P) 9/18/21 at 09:00 a.m.: LPN AA did not see R#1 in her room; began to think R#1 was actually missing; time approximate. 9/18/21 at 10:30 a.m.: R#1's RP and another family member arrived at the facility where LPN AA informed them that R#1 was missing from the facility. 9/18/21 at 11:07 a.m.: Local Police arrive at the facility and continue to search for R#1. 9/18/21 at 11:15 a.m.: Administrator notified of the elopement by the Manager on Duty 9/18/21 at 12:15 p.m.: Administrator arrived at the facility and reviewed surveillance video with police officers. 9/18/21 at 01:38 p.m.: Police identify bank card purchase at a drug store approximately four (4) miles away from the facility. 9/18/21 at 03:00 p.m.: Police locate R#1 at a local hotel between 2:30 p.m.-3:00 p.m. near the drug store. R#1 returned home with her RP and declined medical attention. Review of the Daily Schedule for 9/17/21 revealed that two nurses were assigned to the Transitional Care Unit (TCU) where the R#1 was located for the 7:00 p.m. to 7:00 a.m. shift, LPN EE and Registered Nurse (RN) CC. Review of the timecard punch details for 9/17/21 and 9/18/21 revealed that RN CC clocked in at 0.33 (12:33 a.m.) on 9/18/21 and clocked out on 9/18/21 at 6:58 a.m. LPN AA clocked in on 9/18/21 at 8:38 a.m. and clocked out at 20:13 (8:13 p.m.). Review of the Medication Administration Record (MAR) for R#1 revealed she was scheduled for [MEDICATION(S)] 8 milligrams (mg) and [MEDICATION(S)] 40 mg at 6:00 a.m. both were signed as given by RN CC although per the police report and surveillance cameras the resident had eloped from the facility at 3:30 a.m. Review of the facility staff investigation statements revealed that RN CC on 9/18/21 during 6:00 a.m. med pass, she thought the resident was in the bathroom and it was not unusual for the resident to be out of bed since she was independent for ambulation. Unfortunately, I made a mistake and did not physically lay eyes on her during my morning rounds. Further review revealed that CNA DD's written statement revealed that she checked on the resident on 9/18/21 at 12:00 a.m., 4:00 a.m., and 7:00 a.m. and that was the last time she saw the resident. A telephone interview with RN CC on 9/23/21 at 11:50 a.m. revealed she worked at the facility on Saturday, 9/18/21, from 12:00 a.m. to 7:00 a.m. She confirmed that she was scheduled to work from 7:00 p.m. to 7:00 a.m. on Friday 9/17/21 and Saturday 9/18/21 but she called out on Friday 9/17/21 and reported late (12:33 a.m.) to work on Saturday 9/18/21. RN CC revealed that when she arrived to work on 9/18/21, that LPN EE was the only nurse on the floor, and was working alone. She stated she could see LPN EE was behind in passing medications to the residents therefore she began passing medications (med pass) as soon as she arrived. RN CC stated she started with room 200 and passed meds to only a few residents but could not remember them all. She stated one of the rooms she entered to pass medications was R#1's room although the resident was not present at this time during the med pass. She further revealed that after passing medications she sat down at the nurses' station and began charting (update residents medical records with current activity performed by the nurse who enters documentation). RN CC revealed that she did not go back into R#1's room until 6:00 a.m. to administer her medication. She further revealed that she did not see R#1 in her bed or in her room. RN CC revealed that R#1's bathroom light was on, the door was slightly open, and she thought she heard water running therefore, she thought R#1 was in the bathroom. RN CC stated because she thought R#1 was in her bathroom she put her medication cup on her breakfast tray that was sitting on her table tray untouched. She continued to state after placing R#1's medication cup down on the breakfast tray, unattended, she continued with the medication pass on the unit. RN CC further stated it was normal and routine for her to leave R#1's medication for her to take on her own and she does not stay to witness R#1 taking her medication because she is very independent. RN CC revealed that LPN EE administered medication, and that she charted giving the medications, although she wasn't in the facility. RN CC continued to confirm she could not verify when the vitals were actually taken although she documented she was present and had taken R#1's vital information. RN CC further stated that at the end of her shift on Saturday 9/18/21that LPN EE helped her count the narcotic drawer. She continued to state that when she clocked out for the day she did not wait for the on-coming nurse, LPN AA. RN CC stated she started to receive phone calls from the DHS, LPN EE, and CNA JJ regarding R#1. She revealed receiving phone calls asking when the last time she saw R#1 and if she actually saw the resident when she administered medication pass which she reported the last time she saw R#1 was at midnight. An interview with the Administrator on 9/22/21 at 5:23 p.m. revealed she received a call on 9/18/21 at approximately 11:15 a.m. from Guest Services Manager (GSM), to advise a Code Pink (missing/eloped resident) has been called at the facility. She stated she began to question GSM as to the resident's name and room number, then gave instructions to search the entire facility twice, if resident is not found to expand the search to the outside grounds around the building, and if resident was not found outside to call 911 immediately. She further revealed that after phone call with GSM she checked her facility computer at home and then contacted the police department were the resident lived and ask for a welfare check after explaining the situation. The Administrator revealed that the local police department had responded to the facility, and she was advised that detectives will be taking over the investigation and will be onsite shortly. The Administrator stated she arrived at the facility at approximately noon on 9/18/21. When the Administrator arrived at the facility the family of R#1's was already present, talking with police officers and engaged in the search for R#1. The Administrator further revealed that she shared facility camera footage of the early morning hours with R#1's family which indicates R#1 was outside walking on the side of the building through the alley at 3:38 a.m. on 9/18/21. Review of the surveillance camera video revealed that the resident exited her room, walked down the hallway and entered room #209, which at the time was empty, and dislodged the base of the window in order to push the window open and remove the screen so she could climb out of the window with her personal belongings and leave the facility. The Administrator revealed that the Corporate Nurse Consultant (NC) arrived at the facility on 9/18/21, cannot recall time, and a head count of remaining residents on TSU and instructed maintenance to check all doors and windows for security. The Administrator revealed that phone calls were being made to the area hospitals for any recent admissions that fit R#1s description although no one fit the description. The Administrator revealed that R#1's purse and clothing were found in the trees and bushes just outside the facility property, but R#1's wallet and cell phone were missing among her personal items. The Administrator further stated the family and facility tried continuously to reach R#1 by phone until approximately 4:30 p.m. when it was determined the phone was turned off. The Administrator revealed that the Detectives advised the family to check the resident's bank records to determine if the resident had used her credit card. The family was able to gain access to R#1's bank account and was able to determine that R#1's credit card had been used at a drug store and a local hotel. The Detective contacted her stating the resident had been located and is safe and with her family. The Administrator further revealed that the investigation determined that CNA DD was the last person to see the resident and that RN CC charted giving medications to R#1 but did not and did not attempt to locate the resident. The Administrator revealed that RN CC should have waiting for LPN AA to give report and that the Administrator was not aware that RN CC had been 5.5 hours late for her shift. Observation of room 209 on 9/23/2021 at 5:35 p.m. revealed the window was repaired with the two (2) screws added at the top of the vertical window and the stud/stop at the base of the window. There was a [NAME] outside the window, approximately 4-feet high, which R#1 could have fallen into while climbing out of the window. The ground was covered in pine straw. Observation on 9/23/21 at 5:48 p.m. of the outside grounds on revealed a wooded area to the right of the driveway (moving away from the facility) which had a drop-off into which R#1 could have fallen if she lost her balance and/or became hypoxic without her oxygen. An interview with the Maintenance Director (MD) on 9/22/2021 at 10:00 a.m., revealed they discovered the window in room 209 and it appeared R#1 lifted the window from the base of the window seal, removed the screen and climbed out since the room was on the ground level. The MD stated he found the window screen on the ground outside the window. An interview with Licensed Practical Nurse (LPN) AA on 9/22/2021 at 2:50 p.m., she stated she did not work at the facility on Friday, 9/17/2021 but was scheduled for Saturday, 9/18/2021, 7:00 a.m. to 7:00 p.m. (7A-7P) shift, however she was late and did not report to work until 8:33 a.m. LPN AA stated she was supposed to relieve RN CC who worked the 7:00 p.m. to 7:00 a.m. (7P-7A) shift but RN CC had already left and did not leave a report concerning the residents on the 200 Hall. She stated she determined sometime after 9:00 a.m. that R#1 was not in her room, her belongings were gone, and her breakfast tray was on the bedside table untouched along with two pills in a cup which she determined were [MEDICATION(S)] (for nausea) and [MEDICATION(S)] (for gastroesophageal reflux disease-GERD). She stated she did not touch anything in the room and began to search for R#1 around the facility. She stated she was called to the front desk about 10:30 a.m. where R#1's RP and another family member were waiting to see R#1 and she informed them R#1 was missing from the facility. She stated she informed the Manager on Duty who was the Guest Services Manager (GSM) and she called the Administrator and the Director of Health Services (DHS). She stated the Administrator instructed her to call the local police and get the staff to help continue the search for R#1. An interview with Certified Nursing Assistant (CNA) BB on 9/22/21 at 2:30 p.m. revealed [NAME] she worked the 7:00 p.m.-7:00 a.m. shift on Friday, 9/17/2021. She stated she first saw R#1 in her room on 9/17/2021 at approximately 7:15 p.m. during shift change when she was counting all residents present on the 200 Hall/TCU. She revealed not seeing the resident again during her shift. She further revealed staying late after her shift on Saturday morning (9/18/21) to help out and passed out the breakfast trays when they came to the unit. She stated R#1 was not in her room and assumed she was nearby because she was able to self-ambulate, so she left the tray on her bedside table. An interview with LPN FF on 9/22/21 at 3:20 p.m. revealed she worked at the facility on Saturday 9/18/21, on the 7:00 a.m.-7:00 p.m. shift. She further revealed receiving the shift report from LPN EE although RN CC had already left for the day but left a written report which was uneventful. She stated she was familiar with R#1 but had little interaction with her. She stated when she did have the opportunity to speak to R#1, she never expressed wanting to go home or plans to go home. She stated R#1 was always pleasant, could make her needs known, and ambulated and toileted independently. An interview with the DHS on 9/22/2021 at 5:52 p.m. revealed that she did not work at the facility on Friday 9/17/2021 but was called to come in because of the Code Pink related to R#1 who was admitted on [DATE]. The DHS revealed that she expected all nursing staff to clock in on time, stay on duty until their relief arrives, call her if they expect to be late to work, call her two hours in advance if they can't come to woke, provide a complete shift report with walking rounds, and nurse should conduct a medication count. She stated she was aware the nurses assigned to R#1 did not meet her expectations from 9/17/2021 through 9/18/2021 as evidenced by leaving medications at the bedside then charting as giving the medications, and neither the RN nor the CNA had looked for the resident when she was in her room. An interview with LPN EE on 9/22/2021 at 7:05 p.m. revealed that he worked Friday, 9/17/2021, on the 7:00 p.m. to 7:00 a.m. shift and was working with CNA DD and CNA JJ. He revealed that R#1 was pleasant, quiet, didn't need much help, would take her medications, and had a cordial relationship with her roommate and did not express to him a desire to go home. He stated he heard later that R#1 wanted to go home but couldn't go home on Friday, 9/17/2021 because they couldn't set up her oxygen (O2) at home until Monday, 9/20/2021. He stated he last saw R#1 at 10:00 p.m. peeking out of the room into the hallway. He stated he did not recall seeing her anymore after that time. He revealed not hearing or seeing anything out of the ordinary that shift, particularly between the hours of 3:00 a.m. - 4:00 a.m. He stated, when he's not attending to residents directly, he mostly sits at the nurses' station to chart. He further revealed that if disoriented residents or those with nighttime confusion were wondering, he would try to redirect them and get them back to their rooms. He stated, if resident's gait is steady and they're cognitive, staff let them do their own thing as much as possible. He stated if a resident was up and about in the middle of the night, he would ask about their needs and engage with resident and redirect them back to their room. He stated the normal protocol for med pass, if the resident is not available, is to check the bathroom and try to locate the resident. He stated he would hold the meds and return them to the medication cart if the resident was unavailable. A telephone interview with CNA JJ on 9/23/21 at 9:35 a.m. revealed she did not work at the facility on Friday 9/17/21 but she did work at the facility on Saturday 9/18/21 from 7:00 a.m. to 3:00 p.m. CNA JJ stated after reporting to work Saturday morning she began to pass breakfast trays at approximately 7:15 a.m. and that CNA BB was responsible for passing breakfast trays for her residents that included R#1. CNA JJ further revealed that LPN AA reported to work late on 9/18/21 and reported to the at approximately 9:45 a.m. At approximately 10:00 a.m. she overheard LPN AA talking with LPN FF telling her that the family for R#1 was at the front desk and want to see her, but she is not in her room. CNA JJ revealed that staff began to look for the resident at that time. CNA JJ revealed that she went to R#1's room and noticed her breakfast tray on her tray table had been untouched. CNA JJ stated she asked CNA BB if she saw R#1 when she brought her breakfast tray to her room and CNA BB replied, no. A telephone interview with LPN KK, Unit Supervisor, on 9/23/21 at 9:45 a.m. revealed she was at the facility on Friday 9/17/21 and worked from 7:00 a.m. to 7:00 p.m. although she did not work on 9/18/21. LPN KK revealed being familiar with R#1 and that the resident did not like to be in isolation, was very alert, and cooperative in taking medication. She continued to state during her interactions with R#1 she never displayed signs and never voiced wanting to leave the facility. LPN KK stated she encountered R#1 twice during her shift on Friday, the first time the resident came to the Nurses' Station at approximately 3:00 p.m. without her oxygen on. LPN KK redirected the resident to her room and explained she could not be out of her room due to isolation status. She further revealed she last saw R#1 on Friday at approximately 4:30 p.m. during medication pass and she witnessed R#1 take her medication at that time. A telephone interview with CNA DD on 9/23/21 at 12:36 p.m. revealed that she worked at the facility on Friday 9/17/21 from 7:00 p.m. to 7:00 a.m. although she arrived late, 7:33 p.m., for her shift and was assigned to R#1. CNA DD further revealed that R#1 was independent and could ambulate independently. She revealed that she did see resident in her room during her rounds on Friday 9/ [TRUNCATED]