Every finding on record at Pruitthealth - Decatur

Based on observations and staff interviews, the facility failed to protect clean linen from cross-contamination. This deficient practice had the potential to affect two of two floors. The census was 135 residents.Findings include: Observation and interview on 03/02/2026 at 1:32 PM with Laundry Aide WW revealed Laundry Aid WW delivering clothes on a partially covered laundry cart. She confirmed that she was delivering to the first floor and acknowledged that she should be utilizing the transportation cart that was enclosed. However, she opted to use the laundry sorting cart due to concerns regarding her back, as it was difficult for her to push. Laundry Aid WW also noted that she should have had the cart covered. Interview on 03/04/202, at 6:11 PM with the Environment Manager revealed that the expectations for laundry were that it should be delivered in a timely manner, properly covered, and without any additional items on the cart. The Environment Manager explained that there were four laundry transportation units, with two assigned to each floor, and each unit has designated numbers for room identification. He confirmed that there was only one laundry staff member responsible for deliveries. The Environment Manager emphasized that it was not his expectation for clothes to be transported uncovered, as this posed an infection control issue and items were not isolated. Observation on 03/04/2026 at 5:10 AM revealed a cell phone in the clean linen cart. Interview on 03/04/2026 at 5:15 AM with Certified Nursing Assistant (CNA) RR confirmed her phone was in the linen cart and should not be there. When asked what the consequences were of having personal items in the clean linen cart, she stated cross contamination. Interview on 03/04/2026 at 5:45 PM with the Director of Health Services and Administrator revealed that personal items left on clean linen carts were not acceptable. Nothing personal should be in the clean linen cart, and a potential negative impact of personal items in a clean linen cart could impact infection control.

Based on observations and staff interviews, the facility failed to store potentially hazardous chemicals so that they were not accessible to cognitively impaired residents. Specifically, a can of cleanser powder was left on a handrail accessible to residents on the first floor.Findings include: Observation on 03/04/2026 at 5:28 AM of the second-floor hallway revealed a 21 ounce can of 'name brand' cleanser deodorizing powder placed on the handrail by a resident's room with no staff or housekeeping cart in sight. Interview on 03/04/2026 at 5:31 AM with Licensed Practical Nurse (LPN) SS confirmed the can of powder was in the hallway and that it should not be there. She stated she was not sure why it was left there. When asked about the consequences of leaving chemicals in the hallway, she stated that a resident could swallow it. Interview on 03/04/2026 at 5:45 PM with the Director of Health Services and the Administrator revealed that chemicals should not be left in the hallway and should be in a locked area for the health and safety of staff and residents. When asked about the situation regarding chemicals left in the hallway unsupervised, they stated that it should not have happened and possible negative outcomes were that the substance could be poisonous and could lead to death if a resident ingested it.

Based on observations, staff and resident interviews, record review, and review of the facility's policies titled Care Plans, the facility failed to add indwelling urinary catheter irrigation to the care plan for one of 50 sampled residents (R) (R51). This deficient practice had the potential to cause errors in care and omission of service ordered by the physician.Findings include:Review of the facility's policy titled Care Plan, revised 10/21/2025, Section 3 under the comprehensive care plan should describe the following: The services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Review of R51 care plan dated 12/10/2025 indicated a problem of an indwelling catheter related to neurogenic bladder, BPH, and urinary retention. Interventions included, but not limited to, R51's spouse prefers urinary catheter to be changed at the urologist's office monthly and not the facility. Administer cranberry supplement for UTI (urinary tract infection) prophylaxis as ordered. Keep the catheter tubing free of kinks. Keep the drainage bag below the bladder level. Prevent tension on the urinary meatus from the catheter. Provide catheter care per policy. There is no mention of irrigating the urinary catheter. Review of the Physician's Orders for R51 included, but was not limited to: Irrigate the suprapubic catheter with 50cc (cubic centimeters) of normal saline every shift.An interview on 03/04/2026 at 11:25 AM with the MDS Coordinator revealed that she communicated with the IDT (interdisciplinary team) in morning meetings about changes to orders or residents' status and she should have been informed of the urinary catheter irrigation order so she or one of the unit nurses could add it to the care plan.An interview on 03/04/2026 at 3:40 PM with the Director of Nursing (DON) revealed expectations for care plan changes were either the Charge Nurse, Unit Manager, or MDS Coordinator should make the changes as soon as ordered.An interview on 03/04/2026 at 7:10 PM with the Administrator revealed that the MDS department stated they were caught up with the MDS's and the care plans at the last morning meeting, but that was not accurate.

Based on observations, resident and staff interviews, and record review, the facility failed to ensure two of 50 sampled residents (R) (R13 and R38) received timely incontinence care and failed to provide sterile catheter irrigation and follow the irrigation procedure for one of 50 sampled residents (R) (R51). The deficient practices had the potential to affect resident's skin integrity and increase the potential for urinary tract infections (UTI).Findings include: A policy regarding incontinence care was requested but the facility did not submit one. Review of the facility's policy titled Clinical Procedure: Indwelling Catheter-Irrigation, revised 2025, printed from Relias education, Section Pre-Procedure: gather and set up supplies, clean and sterile gloves, Sterile irrigation set and syringe (60ml [milliliter]), Sterile normal saline, sterile protective cap for drainage tubing. 1. Review of the electronic medical record (EMR) revealed R13 was admitted to the with pertinent diagnoses including but not limited to Alzheimer's disease, encounter for palliative care, hypertensive heart and chronic kidney disease without heart failure, stage 4 chronic kidney disease, and dementia. Review of R13 annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score for R13 was not considered due to resident is rarely/never understood. Section GG, Functional Status, revealed R13 was dependent on assistance for activities of daily living (ADLs). Section H, Bladder and Bowel, revealed R13 is always incontinent of bladder and bowel. Review of R13's care plan indicated a problem regarding ADLs and R13 has self-care deficient of ADLs related to poor cognition/dementia, incontinence and generalized weakness. Goals included having all needs met with dignity. Interventions included but not limited to incontinent care after each incontinent episode. Further review of R13s care plan revealed a focus of pressure injuries. Goals included to minimize the risk of developing impaired skin. Interventions included but not limited to keep resident clean and dry as possible and to minimize exposure to moisture and provide incontinence care after each incontinent episode. Review of R13's care plan indicated a problem regarding urinary incontinence. Goals included R13 being kept clean and dry and dignity maintained. Interventions included but not limited to changing soiled clothes promptly and provide incontinent care after each episode. Observation on 03/01/2026 at 1:51 PM in R13's room revealed a smell of urine upon entering the room. Interview and observation on 03/01/2026 at 2:00 PM in R13's room with Certified Nursing Assistant (CNA) OO confirmed that R13 smelled of urine. When asked when R13's last change was, she stated 7:00 AM this morning and added that she was trying her best to get to everyone. When asked how many residents she was responsible for herself, she stated 14 residents. CNA OO left the room without addressing the smell of urine. Observation on 03/03/2026 at11:49 AM revealed R13 was asleep. There was an incontinence brief at the foot of the bed. Interview with CNA PP on 03/03/2026 at 12:00 PM revealed R13 was last changed between 7:30 AM and 8:00 AM. CNA PP did not change R13 after interview. Observation on 03/04/2026 at 5:20 AM in R13's room revealed a smell of urine. Interview on 03/04/2026 at 6:03 AM with CNA QQ revealed she was responsible for 18 residents and sometimes 24 if there were three CNAs working. She stated that it was hard to care for all the residents, but she did the best that she could and changed all her residents before she left her shift. She stated that she changed her residents every two hours. She confirmed R13 smelled of urine, and R13's brief was wet with urine. She stated that R13 was last changed around 3:00 AM. Interview on 03/04/2026 at 5:45 PM with the Director of Health Services and the Administrator revealed that if a resident smelled like urine, staff had to intervene and determine if they were being left in the urine for too long without being changed. They stated that residents should be checked on to be changed every two hours and as needed and a possible negative consequence of incontinence care not being provided timely could be affected skin integrity. Review of the EMR revealed R38 was admitted with pertinent diagnoses including but not limited to relapsing-remitting multiple sclerosis, muscle weaknesses, retention of urine, and unsteadiness on feet. Review of R38's annual MDS assessment dated [DATE] revealed a BIMS score of 15, which indicates R38 was cognitively intact. Section GG, Functional Status, revealed R38 requires substantial/maximal assistance for toileting/hygiene. Section H, Bladder and Bowel, revealed R38 is always incontinent of bladder and bowel. Review of R38's care plan indicated a problem regarding ADLs due to decline related to multiple sclerosis (MS). Goals included ADLs needs will be met and independence potential maximized within constraints of disease. Review of R38 care plan indicated a problem regarding urinary incontinence, that R38 has a diagnosis of MS and urinary retention with straight catheter use, and she is incontinent and needs assistance peri care (cleaning and maintenance of the genital and anal regions). Goals included assistance with toileting and for her skin to remain intact. Interventions include but not limited to offer peri care before leaving the room and getting in or out of bed as well as provide incontinent care after each incontinent episode. Review of Physician's Orders for R38 included but not limited to an order dated 12/05/2024 for cranberry extract 200 mg (milligram) capsule, once a day with instruction for urinary tract infection (UTI) prevention. Review of a Grievance Form dated 01/19/2026 revealed R38 stated to the Social Worker that on 12/26/2025 and 12/27/2025 she did not get changed at all from 11:00 PM to 7:00 AM and was finally changed at 9:00 AM. Review of a Grievance Form dated 02/13/2026 revealed R38 expressed concern that she was spoken to in a disrespectful manner when requesting care. A statement from CNA TT regarding this grievance revealed that R38 pressed her call light on at 11:20 PM and stated to CNA TT that she needed to be changed. The CNA responded to R38's request that the shift was changing to the11:00 PM to 7:00 AM shift, that there were only two CNAs on the hall/floor, and they were waiting for the other CNAs on schedule to arrive and they would assist once everyone arrived. CNA TT statement further documented that she explained to the CNA coming on the shift that R38's call light was on and she needed to be changed. Further review of the statement revealed the CNA started rounds at 1:00 AM on the other end of the hall and did not start with R38's need. Interview on 03/02/2026 at 2:00 PM with the resident council with five members who were cognitively intact in attendance revealed the following concerns: Staff did not always keep residents clean and healthy and residents did not receive attention needed due to lack of staff. Residents were not being taken out of room or gotten out of bed and there were delays in changing residents. Residents suffered due to lack of staff. They brought this to Administration and were told, We got the grievance, we're working on it. When asked if there had been any improvement, they stated there had only been improvement in staff attitudes; Call lights were not answered timely, one resident stated that she waited 1 hour and 15 minutes to be changed and also had to wait until the next shift to be changed. Another resident stated that he waited 3 hours to be changed. Wait times were worse on nights and weekends. Interview and observation on 03/04/2026 at 08:46 am with R38 revealed that she had not been changed since 3:00 AM. R38 stated that she was wet and would probably not be changed until 9:00 AM or 9:30 AM. 2. Review of the EMR revealed R51 was admitted to the facility with pertinent diagnoses including but not limited to multiple sclerosis, diabetes type 2, flacid hemiplegia affecting the left nondominant side, depression, muscle spasms, chronic pain, and neurogenic bladder. Review of R51's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated R51 was cognitively intact. Section GG, Functional Status, revealed R51 required extensive assistance for activities of daily living (ADLs) with two or more-person assistance. Section H, Bladder and Bowel, R51 has a suprapubic urinary catheter and is incontinent of bowel. Review of R51 care plan dated 12/10/2025 indicated a problem of an indwelling catheter related to neurogenic bladder, BPH (benign prostatic hyperplasia), and urinary retention. Interventions included, but not limited to, R51's spouse prefers urinary catheter to be changed at the urologist's office monthly and not the facility. Administer cranberry supplement for UTI prophylaxis as ordered. Keep the catheter tubing free of kinks. Keep the drainage bag below the bladder level. Prevent tension on the urinary meatus from the catheter. Provide catheter care per policy. Review of the Physician's Orders for R51 included but was not limited to: Irrigate the suprapubic catheter with 50cc (cubic centimeters) normal saline every shift. Foley catheter to be replaced monthly at MD (medical doctor) office except for emergencies on the 17th of the month. Observation and interview on 03/02/2026 at 2:15 PM with R51 revealed that he had a suprapubic urinary catheter, which was changed once a month at his urologist's office, and had missed appointments with his urologist due to transportation issues arranged by the facility. He and his spouse now pay out of pocket for non-emergency transportation. Observation on 03/02/2026 at 3:00 PM in R51's room revealed on the resident's nightstand: 2 catheter tip syringes in bags labeled tube feeding syringe, a large bottle, and a small bottle of normal saline, both opened. The syringes were not sterile, and there was no date indicating when or how old the normal saline or the syringes were. The resident stated that it was for irrigating his catheter every shift. Interview on 03/02/2026 at 3:30 PM with Licensed Practical Nurse (LPN) II confirmed that the catheter-tipped syringes and saline on R51's nightstand were for irrigating his catheter. She stated that was all they had to irrigate his catheter with. Then, at 3:45 PM, LPN II stopped me in the hall and showed me a 10ml (milliliter) prefilled sterile syringe of sterile normal saline, used to flush intravenous catheters, and stated that it was what she used to flush R51's catheter. The syringe has a Luer-Lok tip and would not fit a catheter. Interview on 03/04/2026 at 12:30 PM with the Director of Nursing (DON) revealed she expected that catheter irrigation be done in a sterile fashion. Interview on 03/04/2026 at 7:10 PM with the Administrator revealed that resident care comes first and that she expected procedures to be followed as policy. 2. Review of the EMR revealed R51 was admitted to the facility with pertinent diagnoses including but not limited to multiple sclerosis, diabetes type 2, flacid hemiplegia affecting the left nondominant side, depression, muscle spasms, chronic pain, and neurogenic bladder. Review of R51's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated R51 was cognitively intact. Section GG, Functional Status, revealed R51 required extensive assistance for activities of daily living (ADLs) with two or more-person assistance. Section H, Bladder and Bowel, R51 has a suprapubic urinary catheter and is incontinent of bowel. Review of R51 care plan dated 12/10/2025 indicated a problem of an indwelling catheter related to neurogenic bladder, BPH (benign prostatic hyperplasia), and urinary retention. Interventions included, but not limited to, R51's spouse prefers urinary catheter to be changed at the urologist's office monthly and not the facility. Administer cranberry supplement for UTI prophylaxis as ordered. Keep the catheter tubing free of kinks. Keep the drainage bag below the bladder level. Prevent tension on the urinary meatus from the catheter. Provide catheter care per policy. Review of the Physician's Orders for R51 included but was not limited to: Irrigate the suprapubic catheter with 50cc (cubic centimeters) normal saline every shift. Foley catheter to be replaced monthly at MD (medical doctor) office except for emergencies on the 17th of the month. Observation and interview on 03/02/2026 at 2:15 PM with R51 revealed that he had a suprapubic urinary catheter, which was changed once a month at his urologist's office, and had missed appointments with his urologist due to transportation issues arranged by the facility. He and his spouse now pay out of pocket for non-emergency transportation. Observation on 03/02/2026 at 3:00 PM in R51's room revealed on the resident's nightstand: 2 catheter tip syringes in bags labeled tube feeding syringe, a large bottle, and a small bottle of normal saline, both opened. The syringes were not sterile, and there was no date indicating when or how old the normal saline or the syringes were. The resident stated that it was for irrigating his catheter every shift. Interview on 03/02/2026 at 3:30 PM with Licensed Practical Nurse (LPN) II confirmed that the catheter-tipped syringes and saline on R51's nightstand were for irrigating his catheter. She stated that was all they had to irrigate his catheter with. Then, at 3:45 PM, LPN II stopped me in the hall and showed me a 10ml (milliliter) prefilled sterile syringe of sterile normal saline, used to flush intravenous catheters, and stated that it was what she used to flush R51's catheter. The syringe has a Luer-Lok tip and would not fit a catheter. Interview on 03/04/2026 at 12:30 PM with the Director of Nursing (DON) revealed she expected that catheter irrigation be done in a sterile fashion. Interview on 03/04/2026 at 7:10 PM with the Administrator revealed that resident care comes first and that she expected procedures to be followed as policy.

Based on observations, staff interviews, and review of the facility policy titled, Medication Storage in Healthcare Center, the facility failed to ensure one of two medication carts on the first floor was locked. The deficient practice had to potential for items in the unlocked medication cart to be accessible to residents, staff and visitors.Findings include:Review of the facility policy titled Medication Storage in Healthcare Centers revised 11/11/2025 revealed in the Policy Statement medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. Procedures revealed: .2. Only licensed nurses, certified medication aides, and the pharmacy personnel are allowed access to medications. Respiratory Therapists may access medications used in the provision of respiratory services. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 7. Potentially harmful substances (e.g., urine test reagent tablets, household poisons, cleaning supplies, disinfectants) are clearly identified and stored in a locked area and separated from medications.During a tour of the facility on 03/04/2026 at 5:05 am, it was observed that the door to a medication cart, situated on the first floor, was left unlocked and was not being directly monitored by authorized personnel. Several rolls of unidentifiable resident medication were found on top.Review of the in-services for the last 6 months revealed all staff, including housekeeping, were in-serviced on abuse/neglect/exploitation, Resident Rights, Dementia, Medications: Narcotic and Medication keys, as needed medication documentation, medication storage, and hazardous chemicals for those who were recently hired, annually, and as needed. Interview on 03/04/2026 at 5:08 AM with Licensed Practical Nurse (LPN) ZZ, she confirmed that it was her cart (Cart 2) that was left unattended. She explained that she had to rush to the bathroom due to an urgent need and her support staff was on break at the time. LPN ZZ also revealed there were wandering residents on the floor. Furthermore, she confirmed that she could have either completed the task of putting away medication or placed the medication in the cart until her return.Interview on 03/04/2026 at 5:03 PM with the Director of Nursing (DON) and the Administrator, the observation of an unlocked and unattended medication cart was confirmed. It was disclosed that in-service training has been completed, as it is deemed unacceptable to leave any medication unattended at any time. The DON confirmed the medication on top of the cart was called pizza roll and the medication was usually used for blood pressure, cholesterol, but it can vary based on each resident.

Based on observations, staff and resident interviews, and record review, the facility failed to provide dignity to one of two residents (R) (R88) with an indwelling catheter urinary bag. This deficient practice had the potential to cause emotional distress to R88.Findings include:The facility does not mention covering the indwelling urinary bag in either their resident rights policy or the indwelling catheter policy.Review of the electronic medical record (EMR) revealed R88 was admitted to the facility with pertinent diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, type 2 diabetes mellitus without complications, epilepsy, without status epilepticus, hyperlipidemia, contracture of the left hand, receptive-expressive language disorder, dysphagia (swallowing problems).A review of R88's Minimum Data Set (MDS) assessment revealed that one had not been completed for this current admission. Review of the Care Area Assessment (CAA) on the annual/significant change MDS dated [DATE] indicated R88 was identified with problems with communication, activities of daily living (ADLs), an indwelling catheter, dental care, and a pressure ulcer.Review of R88 care plan dated 01/05/2026 indicated a problem with an Indwelling Catheter and an antibiotic (ABT) for prophylaxis against urinary tract infection. Interventions included, but not limited to ABT, will be administered as prescribed, as ordered, and fluid will be encouraged as tolerated.Review of the Physician's Orders for R88 included, but was not limited to:Catheter care every shiftCatheter 16Fr. (French-catheter size) 10cc (cubic centimeter) bulbReview of the EMR revealed R88 had a suprapubic catheter insertion on 02/19/2026. Observation and interview on 03/01/2026 at 12:30 PM with R88 revealed that the resident had a brace for his left hand and arm, he denied knowing where it was, and he refused to wear it most of the time. His urinary catheter bag was visible from the hall and was not covered with a privacy cover.Observation on 03/01/2026 at 1:29 PM of R88's urinary catheter bag revealed that it lacked a privacy cover and was visible from the hall.Observation made on 03/01/2026 at 4:02 PM of R88 revealed his urinary catheter bag with what looked like an attempt to cover the bag, but the cover was just hanging on the bed frame, and the urine bag was not in it or covering the bag. The urinary bag was still visible from the hallway.An interview on 03/01/2026 at 4:10 PM with Certified Nursing Assistant (CNA) BB revealed /confirmed that R88's urinary catheter bag was not properly covered.An interview on 03/04/2026 at 12:30 PM with the Director of Nursing (DON) revealed/confirmed that R88's foley bag came from the hospital without a cover. We had to put a cover on it. The DON's expectations for resident rights and privacy were that residents' rights always be honored. An interview on 03/04/2026 at 7:10 PM with the Administrator revealed expectations were that resident rights always came first.

Based on resident, resident family and staff interviews, record review, and review of the facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to report an allegation of verbal abuse by a staff member to the State Survey Agency (SSA) for one of 50 sampled residents (R) (R144). The deficient practice had the potential for the alleged abuse to continue and to affect other residents.Findings include: Review of the facility policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revised 10/20/2025 revealed under Policy Statement: It is the policy of 'name of corporation' and its affiliated entities (collectively, the Organization) to comply with all applicable federal and state requirements regarding the reporting of patient abuse, neglect, exploitation, mistreatment, and misappropriation of property. Under Policy: 2. In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state agency (or agencies), the patient's attending physician, and the patient's designated representative of any allegation or incident described above and of the pending investigation. The state survey agency and the state agency for adult protective services should be notified in accordance with state law through established procedures of any allegations of abuse, neglect, exploitation or mistreatment, including injuries of an unknown source and misappropriation of patient property, within 2 hours after the allegation is made. If the events upon which the allegation is based involve abuse or result in serious bodily injury, report not later than 24 hours of being notified of the allegation. The Ombudsman should also be notified as required by state law. The Administrator or designee should direct an investigation into the allegation or incident.Interview on 03/1/2026 at 4:03 PM with Family of R144 revealed R144 was currently hospitalized . R144 telephoned her family member to report she overheard a Nurse comment an intent to slap someone as the Nurse was leaving R144's room following a request for her evening medications. R144's family member stated he came to the facility after hearing his mother's concerns and asked the facility staff why they had not notified the police regarding the alleged threat. The family member revealed that the Nurse who fielded his initial report did not act and told him he was getting ready to go home. The family member filed a police report on his mother's behalf the same evening. R144's family member further stated the facility would not release the name of the staff member who vocalized the threat nor provided any feedback regarding the abuse allegation, to date. R144 discharged from the facility in late December 2025.Review of a formal Grievance R144 filed on 12/15/2025 revealed the facility confirmed R144 reported a Nurse walked out after R144 requested evening medications and overheard the Nurse make a statement, I'm not going back in there. I may have to slap someone. On 12/17/2025, the facility documented the occurrence as a Customer Service matter and removed the Nurse from R144's assignment and listed an expectation for staff to attend inservices (training) for Good Customer Service. The facility did not file a report with the SSA nor completed an investigation to ensure R144 and other residents were free from abuse.Interview on 03/03/2026 at 12:31 PM with Certified Nursing Assistant (CNA) XX revealed the abuse reporting protocol of an alleged or real abuse occurrence; including verbalized threats included reporting of the allegation or incident occurrence to her supervisor and the facility Administrator, who was the Abuse Coordinator. The facility had two hours to report the occurrence to the SSA. CNA XX stated the facility held frequent educational trainings regarding abuse reporting including extensive online training and continuing education. Interview on 03/03/2026 at 12:38 PM with the Social Services Director (SSD) and Senior Care Coordinator confirmed the facility did make a police report on R144's behalf after verifying R144's concerns. Real or perceived allegations of abuse, including verbal threats, should be reported immediately, to include an abuse investigation.Interview on 03/03/2026 at 2:29 PM with the Administrator revealed the Administrator interpreted allegations of abuse, real or perceived, as reportable matters. If staff didn't report, they were culpable. The Administrator stated she always reported abuse occurrences, real or perceived to police and secured a case number from law enforcement. Additionally, a resident's Responsible Party and Physician, and the Long-Term Care Ombudsman were notified regarding occurrences.

Based on record review and staff interviews, the facility failed to ensure the need of a Level II Preadmission Screening and Resident Review (PASARR) for evaluation and determination for specialized services were offered to meet resident needs for one of 50 sampled residents (R)(R14). The deficient practice had the potential for R14's needs and services to go unmet.Findings include:PASARR/Level II policy requested but was not received as it was reported that the facility does not have a policy related to PASARR/Level II.Review of electronic medical record (EMR) for R14 revealed diagnoses of but not limited to bipolar disorder, current episode manic without psychotic features, unspecified, major depressive disorder, recurrent, unspecified, anxiety disorder, unspecified, post-traumatic stress disorder (PTSD), unspecified, accidental discharge from unspecified firearms or gun, sequela (a condition which is the consequence of a previous disease or injury). Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for R14 revealed he was admitted to the facility on [DATE]. Section A (Identification) revealed R14 had not been evaluated for a Level II PASARR. Further review of the MDS revealed section E (Behaviors): Behavior exhibited.Review of Care Plan dated 04/23/2024 for R14 revealed Problem: Resident is at risk for impaired Psychosocial wellbeing r/t (related to) difficulty expressing self due to hx (history) CVA (cerebral vascular accident-stroke). Approach: Assess for mood/behavior problems.Review of Georgia PASRR Level II referral cancellation notice dated 03/18/2025 revealed this member had been cancelled because the referring facility failed to provide Medication List Needed to Complete Level II Assessment.During an interview on 03/04/2026 at 9:40 AM, the Social Services Director (SSD) indicated that R14 was admitted with a level one PASARR. Considering the diagnoses of anxiety, schizophrenia, PTSD and bipolar disorder, it was concluded that a level two PASARR should have been performed within 30 days of admission. The SSD confirmed that R14 should have been screened for level two; however, his admission took place before she was onboarded at the facility. The SSD shared that she would reach out to the care line to check if a summary could be provided to determine whether the screening was completed prior to this date and/or to conduct a level two PASARR. Furthermore, the SSD mentioned that she had just completed a PASARR audit on Monday, and R14 was not included in the list. The SSD provided results indicating that R14's PASARR was denied because the previous SSD failed to submit the necessary documentation.An interview conducted on 03/04/2026 at 5:03 PM with the Director of Nursing (DON) and the Administrator disclosed that they assumed that R14's PASARR II was performed by the SSD. The DON indicated that upon reviewing R14's medical records, it was evident that R14 qualified; however, she was uncertain as to why he was screened. The DON confirmed that the assessment was carried out at the time of admission, with consent obtained from the family, and that 'name of mental health provider' was contacted.

Based on observations, record review, staff interviews, and review of the facility's policies titled, Infection Prevention-Hand Hygiene, Handwashing and Enhanced Barrier Precautions (EBP), the facility failed to place one of 19 residents (R) (R88) with wounds on EBP and failed to perform hand hygiene while serving meals in the dining room. The deficient practices had the potential to cause infection for R88 and other facility residents. The facility census was 130. Findings include: Review of the facility's policy titled Infection Prevention-Hand Hygiene revised 10/15/2024 documented under Policy Statement: [name of facility] partners will improve hand hygiene practices and reduce Healthcare Associated Infections (HAIs) . D. Indications Requiring Hand Wash or Hand Rub 1. Before and after contact with the resident. 8. After contact with inanimate objects (i.e., including medical equipment) in the immediate vicinity of the resident. 9. Passing meal trays to residents. Review of the facility's policy titled Handwashing reviewed 10/9/2023 documented under Policy Statement: It is the policy of [name of facility] that partners will clean their hands by either using soap and water or antiseptic hand sanitizer. Cleaning your hands reduces the spread of germs and decreases the spread of infections .under Procedure: When to perform Hand Hygiene: Before and after any direct patient skin contact, after any contact with objects/medical equipment in the vicinity of the patient. Review of the facility's policy titled Enhanced Barrier Precautions (EBP) documented under Policy Statement: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.2. Initiation of Enhanced Barrier Precautions: . i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) .even if the resident is not known to be infected or colonized with a Multi- Drug Resistant Organisms (MDRO).4. High-contact resident care activities include: . h. Wound care: any skin opening requiring a dressing. 1. Observation on 1/29/2025 at 12:30 pm revealed Licensed Practical Nurse (LPN) JJ was not practicing hand hygiene while assisting residents with their meals in the dining room. LPN JJ did not sanitize her hands after pushing a resident's wheelchair and before opening a condiment and sweetening coffee for another resident. Review of the facility's in-service signing sheets from January 2024 to December 2024 documented in-service was provided on hand washing in July 2024. Interview on 1/29/2025 at 1:28 pm with LPN JJ confirmed she did not sanitize her hands after pushing a resident's wheelchair and before opening a condiment and sweetening coffee for another resident. She stated she should have sanitized her hands after pushing the wheelchair and before assisting another resident with their meal. LPN JJ stated when she did not sanitize her hands, the residents could get infections, and they could get sick. Interview on 1/29/2025 at 2:00 pm with the Dietary Manager (DM) revealed she stated proper hand washing is to be performed when in contact with each resident and/or the residents' belongings, before serving meals to the residents and when going from one dining table to another to assist the residents. She stated the staff in the dining room were also to sanitize their hands before serving or assisting the residents and before attending to another resident. She stated if the staff did not perform proper hand hygiene the outcome could be cross contamination, and germs could be transmitted to the residents. Interview on 1/29/2025 at 2:22 pm with Dietary Supervisor KK revealed he stated staff should sanitize their hands before attending to the residents, before going to the residents' tables, and before assisting another resident. He stated if staff did not sanitize their hands, the residents could get sick from germs. Interview 1/29/2025 at 5:32 pm with the Clinical Competency Coordinator (CCC) revealed the staff received in-service on hand hygiene. Interview on 1/30/2025 at 8:45 am with Certified Nursing Assistant (CNA) MM, she stated hand sanitization should be done between contact with residents and during mealtimes. Interview on 1/30/2025 at 8:50 am with the Director of Nursing (DON) revealed her expectations were for the staff to sanitize their hands while serving meals and or assisting the residents with their meals. She stated if staff did not sanitize their hands the outcome would be the transmission of germs from one resident to another and the residents could get sick. 2. Review of the facility's electronic medical records (EMR) documented R88 was admitted to the facility with diagnosis included but not limited to stage 2 pressure ulcer of the sacral region. Review of R88's annual Minimum Data Set (MDS) dated [DATE] documented in Section C (Cognition) a Brief Interview for Mental Status (BIMS) score of 3, which indicated R88 had severely impaired cognition, and in Section M (Skin Condition) documented a Stage 2 pressure ulcer, required pressure reducing device for bed and pressure ulcer/injury care. Review of R88's care plan dated 12/2/2024 included but not limited to Problem area: sacral wound, pressure Injuries. Goal: Area to be decreased in size by next review. Approach: Treatment per medical doctor order, turn and position at intervals, incontinent care provided as needed by staff. Review of the Physician's Orders for R88 dated 12/2/2024 included but not limited to Treatments: Clean sacral wound with n/s (normal saline) or w/c (wound cleanser), pat dry then apply skin prep around peri (genital area) wound then apply honey then cover with a foam pad q (every) Monday and Thursday Once A Day on Mon (Monday), Thu (Thursday) 5:00 am - 11:00 pm. There was no order found for EBP for R88. Review of the Weekly Wound Observation Note dated 1/24/2025 for R88 documented Continue present treatment to open area to sacral [sic]. Area is old scar tissure [sic] that has reopened. Tissue is pink and moist. Edges open and attached. No odor or drainage, Resident is on a pressure reduction mattress to help relieve pressure. Turned and repositioned at intervals. Incontinent care provided by staff as needed. No distress noted. Hospice care continues. Observation on 1/30/2025 at 4:28 pm revealed Certified Nursing Assistant (CNA) LL performing peri-care to R88. CNA LL called Wound Care Nurse (WCN) DD to come and dress R88's sacral pressure ulcer wound because it was soiled and coming loose. Observation revealed CNA LL and WCN DD were not wearing gowns while performing peri-care and wound care to R88. Interview on 1/30/2025 at 4:52 pm with CNA LL revealed she stated R88 was not on EBP, so she was not wearing a gown while in contact with R88. Interview on 1/30/2025 at 4:56 pm with WCN DD revealed she stated R88 was not on EBP. She further stated that according to the infection control nurse, residents who were placed on EBP were at the discretion of the facility. Interview on 1/30/2025 at 7:09 pm with the Clinical Competency Coordinator (CCC) revealed she confirmed R88 had a stage two pressure ulcer wound and was not on EBP. She stated residents were placed on EBP at the discretion of the facility. She stated residents with wounds were also placed on EBP at the discretion of the facility. Interview on 1/30/2025 at 7:11 pm with Assistant Director of Nursing (ADON) revealed she confirmed R88 had a stage 2 pressure ulcer wound and was not on EBP. She further stated that residents were placed on EBP at the discretion of the facility and residents with wounds were placed on EBP at the discretion of the facility. The ADON stated if residents with wounds who needed to be on EBP and were not placed on EBP, the outcome would be the residents could get infections when staff do not wear appropriate PPE (personal protective equipment) and they could transfer germs from one resident to others.

Based on observations, record review, staff interviews, and review of the facility's policies titled, Labeling, Dating, and Storage and Foodborne Illness, the facility failed to dispose of expired food items in the kitchen. The deficient practice had the potential to affect the 124 residents (R) receiving food from the kitchen. The facility's census was 130. Findings include: Review of the facility's policy titled Labeling, Dating, and Storage revised [DATE] documented under Policy Statement: 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. Review of the facility's policy titled Foodborne Illness reviewed [DATE] documented under Procedure: 2. Foods will be used before the expiration date, use by date, best by date, and sell by date, indicated on the food item. Foods not used prior to the expiration date, use by date, best by date, or sell by date must be discarded. Observation on [DATE] at 9:20 am during initial tour of the dry storage pantry in the kitchen with the Dietary Manager (DM) revealed there were expired items in the dry storage pantry. The expired items included four one-gallon bottles of [name of water] water which expired [DATE], and 24 bottles of [name of water] distilled water which expired [DATE]. Observation on [DATE] at 9:35 am during the initial tour of the kitchen with the DM, the walk-in freezer was examined and there were four packs of [name of product] eight variety pack donuts which expired [DATE]. Observation on [DATE] at 9:45 am during the initial tour of the kitchen with the DM revealed there were expired items on a shelved area in the kitchen. The items were: One bottle ground thyme expired [DATE]. One bottle sesame seed expired [DATE]. One bottle sriracha seasoning expired [DATE]. One bottle poultry seasoning expired [DATE]. One bottle paprika seasoning expired [DATE]. One bottle crushed red pepper seasoning expired [DATE]. One bottle whole celery seed expired [DATE]. Interview on [DATE] at 1:40 pm with the DM revealed she confirmed there were expired food items in the kitchen. She stated there should not be expired food items in the kitchen. She further stated it was not good or proper to have expired food items in the kitchen. She stated she expected all expired food items in the kitchen be removed before they expire. The DM stated expired items must not be served to the residents and the outcome if expired food items were served to the residents would be the potential for the residents to get sick. Interview on [DATE] at 8:50 am with the Director of Nursing (DON) revealed she stated her expectations were for expired food items to be removed from the kitchen. She stated that audits were to be done and food items which were found in the kitchen should be removed and disposed of. She stated the outcome if expired supplies and food supplies were not disposed of and removed from the kitchen would be the residents could get sick and have a negative reaction from the expired food items.

Based on record review and staff interviews, the facility failed to assure the correct order was on file and medical records reflect the resident's choice per the Physician Orders for Life Sustaining Treatment (POLST) for two of four Resident (R) (R13 and R90) reviewed. The sample size was 55 residents. Findings include: 1. Review of the Electronic Medical Records (EMR) revealed, R13 was admitted to the facility with diagnoses that included but not limited to hypertensive heart, chronic kidney disease, heart failure, type 2 diabetes mellitus and dilated cardiomyopathy. Review of R13's POLST [a medical order form that helps persons who have serious illnesses make decisions about their care] dated 8/23/2024 revealed, POLST: Full Code. Review of R13's Physician's orders dated 2/28/2024 revealed, Code Status: Do Not Resuscitate (DNR). Review of R13's Face Sheet revealed, Advance directive: Full Code, Do Not Intubate (DNI). Interview on 1/30/2025 at 12:40 pm with the Social Services Director (SSD) CC confirmed R13's face sheet had both full code and DNI, her orders stated DNR, and the POLST stated full code. SSD CC stated, the physician's order for advance directive should be the same as the POLST, and the face sheet should align with the resident's wishes. She confirmed the advance directive for R13 was not reconciled with the physician orders. Interview on 1/30/2025 at 12:40 pm with the Director of Nursing (DON) confirmed R13's face sheet had both full code and DNI, her orders stated DNR, and her POLST stated full code. She stated her expectations were for the physician's order to match with the POLST documentation and the face sheet. The DON further stated if the advance directives were not reconciled the outcome would be the facility would not be honoring the residents' wishes, that orders would not be followed, and the residents would not receive the required care. 50170 2. Review of the EMR revealed, R90 was admitted to the facility with diagnoses that included but not limited to Alzheimer's disease and dementia in other diseases classified elsewhere, unspecified severity, with agitation. Review of R90's POLST dated 8/9/2024 revealed, POLST: Allow Natural Death (AND)- Do Not Attempt Resuscitation. Review of R90's Physician's orders dated 1/23/2024 revealed, Code Status: Full Code. Review of R90's Face Sheet revealed, Advance directive: DNR. Interview on 1/29/2025 at 12:23 pm with SSD CC revealed, that the nurses were responsible for putting orders in on admission. SSD CC revealed, residents have general orders to be placed on full code status until it has been determined whether or not the resident was a DNR. She revealed, when R90 was readmitted to the facility from the hospital, they may not have updated the order, but she could not be certain. She revealed, she was in the process of conducting an audit to ensure that everything in the system reflects as it should. She confirmed that the resident's code status should be a DNR because she has a POLST for a DNR.

Based on observations, record review, staff interviews, review of the facility policy titled, Clean Air Filters, review of manufacturer recommendations titled Amana- Packaged Terminal Air Conditioner (PTAC) Manual, and the facility policy titled, Infection Control-Housekeeping Services, the facility failed to maintain two of 67 resident rooms in a clean, sanitary manner. Specifically, the facility failed to ensure that the PTAC was maintained in a clean and sanitary manner for room [ROOM NUMBER] and failed to keep the bathroom in room [ROOM NUMBER] free of bodily fluids. These failures had the potential to compromise the health and safety of the residents sharing those rooms by increasing the risk of infection and negatively impacting their quality of life. The facility census was 130 residents. Findings include: Review of the facility policy titled, Clean Air Filters, documented under section titled, Building: Main Building revealed, 1. Remove or open access cover. 2. Remove air filter and inspect for cleanliness. If filter is dirty either wash or replace depending on type of filter. If clean, reinstall filter. 3. Re-install access cover. 4. Clean Grill on cover. 5. Close and make sure it is secure. 6. At minimum, air filters are to be replaced or thoroughly cleaned depending on type of filter every three months. 7. Clean evaporators coils if lint build-up is present. 8. Inspect electrical motors nad wires. Review of the manufacturer guidelines titled, Amana- PTAC Manual, documented under section titled Routine Scheduled Maintenance, documented, To achieve continuing top performance and high efficiency, establish a once a year cleaning/inspection schedule for the unit. Take the unit out of the sleeve and thoroughly clean and rinse. Be sure to include in the yearly cleaning the evaporator coils, and condenser coils, base pan, and drain passages. Scheduled maintenance can be accomplished by either qualified local maintenance staff or by an authorized servicer. They must follow the instructions described in this manual. Review of the facility policy titled, Infection Control-Housekeeping Services, revised 10/16/2023 revealed in the Policy Statement: It is the policy of this facility to ensure housekeeping services will be performed on a routine and consistent basis to ensure an orderly, sanitary, and comfortable environment. 1. Observation on 1/28/2025 at 9:34 am in room [ROOM NUMBER] revealed, the PTAC unit had visible debris inside the unit including a dead bug. Observation and interview on 1/30/2025 at 9:32 am with the Housekeeping Director (HD) and Maintenance Assistant (MA) AA revealed, that the PTAC units and filters were to be cleaned every four weeks, with housekeeping assisting in this process. Both the HD and MA AA confirmed that there was a significant number of debris present in the unit. Interview on 1/30/2025 at 9:38 am with the Maintenance Director (MD) revealed, that PTAC units were generally cleaned once a year, while the filters were cleaned monthly. MD stated that during these monthly cleanings, the entire cover was sometimes taken downstairs to be sprayed down. However, he noted that the PTAC units had not been cleaned recently. Interview on 1/30/2025 at 4:07 pm with the Administrator revealed, that the usual expectation was to follow the manufacturer's specifications for cleaning the units. The Administrator stated that Housekeeping was expected to clean the units when they enter the rooms. The Administrator also mentioned a potential negative outcome was if the PTAC unit is off and then turned back on, in such cases, airborne illness could be a risk, as the unit may blow debris into the room. 38154 2. Observation on 1/28/2025 at 11:53 am of the bathroom in room [ROOM NUMBER] revealed, a dark brown substance smeared on the inside door handle, both handrails and both door jams. Observation on 1/30/2025 at 9:15 am of the bathroom in room [ROOM NUMBER] revealed, the inside doorknob and both handrails were wiped down on the top surface, however the inner sides and door jams remained soiled. Interview on 1/30/2025 at 9:20 am with the Housekeeping Aide (HA) GG revealed, she was told the Certified Nursing Assistants (CNAs) should clean up body fluids and housekeeping should follow up and disinfect those area(s) afterward. She confirmed the presence of brown substance on the handrails, doorknob, and door jams. Interview on 1/30/2025 at 9:25 am with CNA HH revealed, the nursing staff should clean up body fluids and housekeeping should follow up to disinfect the area. Observation and interview on 1/30/2025 at 10:00 am with the Housekeeping Manager, confirmed the presence of brown substance on both inside surfaces of both handrails and doorknob as well as the door jams. He stated the nursing staff should clean up bodily fluids and his staff should follow up to disinfect the areas. He stated the housekeeping staff could wipe down the areas identified, and he considered that within their scope of duties. He stated he would attend to the areas identified. Observation and interview on 1/30/2025 at 3:57 pm with Licensed Practical Nurse (LPN) JJ, confirmed the presence of a brown substance on the right handrail in the room [ROOM NUMBER] bathroom. She also confirmed the nursing staff should clean the spillage of bodily fluids and call housekeeping to disinfect those surfaces. Interview on 1/30/2025 at 6:53 pm with the Director of Health Services (DHS) revealed, the nursing staff should clean up spills and leakage of bodily fluids as soon as possible and housekeeping should disinfect those areas when called.

Based on record review and staff interview, the facility failed to submit for a Preadmission Screening and Resident Review (PASARR) Level II after a new mental illness diagnosis was added for one of one resident (R) (R10) reviewed for PASARR. This deficient practice had the potential to affect the appropriate level of care and services provided for R10. Findings include: Review of R10's Electronic Medical Records (EMR) revealed, he admitted on [DATE] and received diagnoses that include but are not limited to bipolar disorder, current episode manic without psychotic features with diagnosed date of 6/30/2021; major depressive disorder, anxiety disorder, and post-traumatic stress disorder (PTSD) with diagnosed date of 4/22/2020. Review of R10's most recent Significant Change in Status Minimum Data Set (MDS) dated [DATE] revealed: Section A- Identification Information: no PASRR Level II; Section C-Cognitive Patterns: Brief Interview of Mental Status (BIMS) score of 99, indicating resident was unable to complete. Review of R10's care plans included but not limited to: Psychotropic Drug Use: Resident receives antidepressant medication (Sertraline once at bedtime) R/T (related to) dx (diagnosis) of Major Depression, Anxiety and PTSD with risk of adverse side effects with problem start date of 4/23/2020. Review of R10's medical record revealed a pending PASRR Level I dated 4/22/2020, however there was no primary diagnosis of serious mental illness, developmental disability, or related condition indicated. Interview on 1/29/2025 at 11:55 am with Social Service Director (SSD) CC confirmed R10 did not have a PASARR Level II completed. She verified R10 was admitted and received qualifying diagnoses in 2020. She stated that she was responsible for making the referrals to the appropriate state-designated authority when a resident was identified as having an evident or possible MD (mental disorder), ID (intellectual disability) or related condition. She revealed, once she is made aware that a resident was identified as having a newly evident or possible MD, ID or a related condition after admission, it was still her responsibility to refer the resident for PASARR Level II evaluation. She confirmed that the current diagnoses for R10 required a PASARR Level II to be completed.

Based on observations, staff interviews, and review of the facility's policy titled, Transmission-Based Isolation Precautions Policy, the facility failed to ensure infection control measures were appropriately implemented and maintained related to Transmission Based Precautions (TBP) for two out of two residents, Resident (R)44 and R84 who were reviewed for TBP. The facility also failed to ensure that the laundry facility kept clean laundry separated from dirty laundry. These failures had the potential to affect all 131 residents in the facility. Findings include: The facility's Transmission-Based Isolation Precautions Policy most recently dated 3/6/2019 read, Transmission-based precautions are used in combination with Standard Precautions for patients with documented or suspected infection or colonization with highly transmissible or epidemiologically important pathogens for which additional precautions are needed to prevent or to interrupt transmission of the suspected or confirm infectious agents. The appropriate isolation precaution signs should be placed in a readily visible location outside of the resident's room (i.e., resident's door/doorframe). Personal protective equipment (PPE) (e.g., gowns, gloves, masks) should be readily available outside the patient room either in a cart outside the patient's room door or in a designated cabinet outside the room door. Observation on 7/31/2023 at 12:43 p.m. located outside of R84's room revealed that Certified Nursing Assistant (CNA)8 went into a TBP room of a resident that had been exposed to Coronavirus disease (COVID) with no personal protective equipment (PPE) on. A sign was on the resident's door stating TBP and PPE was located outside the door. Interview on 7/31/2023 at 12:43 p.m. with CNA8 stated, I was told that R84 did not have COVID, and I thought the signage was wrong. When CNA8 entered the room, she had on a gown, gloves, face shield, but not an N95 mask. CNA8 stated I forgot my N95 in my pocket. Lunch trays arrived for R44, who was the COVID positive resident and for R84 who had been exposed to COVID. When CNA8 was asked if the meals for the two residents should be on paper and plastic, she reported she did not know. Interview on 7/31/2023 at 12:51 p.m. with the Unit Manager (UM1) stated, CNA8 should have known better and if they were not sure, then they should have asked. All PPE is to be worn for TBP rooms. Trays should be on paper and use plastic utensils, so they can just be thrown out. Interview on 8/3/2023 at 11:00 a.m. with the Director of Health Services (DHS) stated, Staff know how to use PPE when residents are on TBP. I guess because it is not happening often that they constantly have to be re-trained. 2. Observation and interview on 8/3/2023 at 12:33 p.m. with the Housekeeping Supervisor (HKS) revealed resident's dirty clothing was washed separately in a regular washing machine while all other laundry went in 65-pound washers to be cleaned. The laundry room was overflowing with dirty laundry. The resident's washing machine was broken, and resident's dirty clothing was laying all over the floor. There was clean and dirty laundry in the same small space. Clean laundry passed through the dirty laundry when being taken into the next room to be put in the dryers. The HKS stated, This room is a mess, and we need to hire a third shift. We are combining dirty laundry with clean laundry. There is just no room in here. Interview on 8/3/2023 at 12:49 p.m. with the Administrator stated, The facility laundry room needs refurbishing. It definitely needs work. Further interview on 8/3/2023 at 1:04 p.m. with the Administrator stated, My expectation for staff is that they are trained in policies and procedures, and they have to follow them. They need to be refreshed periodically.

Based on record review, staff interviews, family interview, and review of the facility policy titled, Involuntary Transfer and Discharges, the facility failed to ensure four of four residents and or their representatives (Resident (R) 24, R78, R115, and R119) reviewed for facility initiated emergent hospital transfer were provided with written transfer notice that contained all required information. This failure has the potential to affect the resident and/or their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: Review of the Involuntary Transfers and Discharges policy with a reviewed date of 3/30/2023 revealed, It is the policy of this healthcare center to permit each patient to remain in the healthcare center and not transfer or discharge them involuntarily unless it is necessary and for appropriate reasons. This policy applies to transfers or discharges initiated by the facility, not the patient. The healthcare center must provide notice to the patient representative in writing and language that they understand. The facility must send a copy of the notice to the Office of the State Long-Term Care Ombudsman. The facility must keep a copy of the notice in the medical record. 1. Review of Quarterly Minimum Data Set (MDS) located in the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 6/24/2023 revealed R24 was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating the resident was moderately cognitively impaired. Review of the Progress Notes from the Resident tab in the EMR dated 6/2/2023 revealed R24 was sent to the hospital for observation after being found on the floor of her room. There was no documentation of the resident or the resident's representative (RR) receiving a written transfer notice. Review of the Progress Notes from the Resident tab in the EMR dated 6/9/2023 revealed R24 was sent back to the hospital due to the resident arriving back at the facility with no discharge papers or orders. The note stated the bed hold policy was sent with R24. There was no documentation of a written transfer notice being given to the resident or RR was located. Interview attempt with Family Member (FM)7 of R24 on 8/3/2023 at 8:48 a.m. was not successful and no callback was received. 2. Review of R78's Face Sheet located in the EMR under the Resident tab showed a facility admitted [DATE], and a readmission on 12/15/2022. Review of R78's Progress Notes from the EMR Resident tab read in pertinent part, 12/10/2022 12:13 PM Resident noted falling on the floor while standing, hit and bruise left side of forehead. Call NP [Nurse Practitioner]. NP ordered to send resident to hospital for further evaluation and treat. RP [Resident Representative] made aware. Review of R78's EMR under the Observations, Events, Resident Documents, and Progress Notes from the Resident tab found nothing regarding the provision of the written transfer notice. 3. Review of R115's Face Sheet from the EMR Resident tab showed a facility admitted [DATE], and a readmission on 5/25/2023. Review of R115's Progress Notes from the EMR Resident tab read in pertinent part, 5/23/2023 2:24 p.m. Resident is A/O [alert and oriented]. no s/s [signs/symptoms] of distress noted. resident [sic] didn't have any behavior issues for shift went out appointment for cardiac F/U [follow up] escorted by CNA [Certified Nurse Aide], and facility transport. On 5/23/2023 5:28 p.m. CNA called from doctor's appointment with resident stating the doctor's office referred resident to got to ER [emergency room ] d/t [due to] blood clots. Review of R115's EMR under the Observations, Events, Resident Documents, and Progress Notes from the Resident tab found nothing regarding the provision of the written transfer notice. Review of the Bed Hold Acknowledgement Form: Georgia, dated 5/24/2023 signed by a facility representative revealed, R115's name and the RR's name was handwritten on the form, but the lines for those signatures was blank and no written transfer notice was attached. As evidence of provision a Progress Note dated 5/24/2023 12:02 p.m. that stated, Bed hold policy faxed to [hospital name and number] and also a note dated 5/23/2023 5:28 p.m. as noted above. In an interview on 8/2/2023 at 3:18 p.m., the Financial Counselor (FC) was asked about the mailing of the written bed hold notices, FC responded, Yes, I mail them out. Clarified, FC mails out the bed hold notice. When queried if FC also sends the transfer form, she stated, No, I don't send that. When clarified if FC sends anything written regarding the transfer, FC responded No, just the bed hold. 4. Review of the Admission MDS with an ARD of 5/17/2023 revealed R119 was admitted to the facility on [DATE] and had a BIMS score of zero out of 15 indicating the resident was severely cognitively impaired. Review of Progress Notes from the Resident tab in the EMR dated 6/13/2023 revealed R119 was sent to the hospital for tests and treatment due to rectal bleeding and R119's refusal to have labs drawn. The note revealed the RR was informed, but no documentation of a written transfer notice being supplied to the resident or RR was located. An interview on 8/3/2023 at 10:02 a.m. with FM6 of R119 revealed she was informed of the hospital transfer and understood the reason, but she did not receive written notice for the transfer on the subsequent days. An interview on 8/3/2023 at 1:45 p.m. with Licensed Practical Nurse (LPN)9 revealed a packet is given to the emergency medical technicians (EMTs) which contains a synopsis of the resident's current condition, a copy of the bed hold policy, and a face sheet. When asked if any forms are given to the resident or mailed to the RRs and not just sent to the hospital, LPN9 stated there were none. 46592

Based on staff interviews, record review, review of the Resident Assessment Instrument (RAI manual, and review of the facility policy titled, MDS Assessment Accuracy, the facility failed to ensure five of 16 residents (Resident (R) 19, R45, R66, R78, and R120) reviewed for a Minimum Data Set (MDS) assessment had a comprehensive admission/annual assessment completed within the allotted time frame. Findings include: Review of the October 2019 RAI Manual, page 2-16 (a timeline chart for assessments) showed: Annual (Comprehensive) Assessment Reference Date No later than: ARD of previous comprehensive assessment +366 calendar days AND ARD of previous Quarterly assessment + 92 calendar days MDS completion date No later than: ARD plus 14 calendar days CAA's [Care Area Assessment] completion date No later than: ARD + 14 calendar days Care Plan completion date No later than: CAA(s) Completion date +7 calendar days Transmission date No later than: Care Plan Completion Date + 14 calendar days Review of the facility policy titled, MDS Assessment Accuracy with a revised dated of 12/6/2022 revealed, Policy Statement: 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. The assessment will be scheduled to accurately account for the acuity and complexity of the patient/resident. Procedure: The 14-day MDS window for an ARD [Assessment Reference Date] includes days 13-18. Each patient/resident must be assessed individually to determine the most appropriate ARD to capture patient/resident's care needs. 1. Review of R120's Face Sheet located in the EMR under the Face Sheet tab revealed an admitted [DATE]. Review of the Admission MDS assessment with an ARD of 7/3/2023 was blank. The MDS was 19 days past due. During an interview on 8/3/2023 at 2:25 p.m., the Director of Health Services (DHS) was asked about the MDS for R120 not being completed within the 14 days of admission. The DHS stated, I did not realize they were that far behind. 2. Review of R45's Face Sheet from the EMR Resident tab showed an admitted [DATE]. Review of R45's EMR revealed an Annual MDS with an ARD of 6/23/2022 revealed Production Accepted, and an Annual MDS with an ARD of 6/23/2023 showed a status of In Process. 3. Review of R19's MDS 3.0 Assessment Summary located in the EMR under the MDS tab, revealed that on 6/9/2023 an Annual Review was finalized but never processed. 4. Review of R66's MDS 3.0 Assessment Summary located in the EMR under the MDS tab, revealed that on 6/9/2023 an Annual Review was in process. 5. Review of R78's Face Sheet from the EMR Resident tab showed a facility admitted [DATE], and a readmission on 12/15/2022. Review of R78's EMR MDS 3.0 Assessments tab showed an Annual MDS with an ARD of 6/22/2022 had a Production Accepted status and an Annual MDS with an ARD of 6/22/2023 showed a status of In Process. During an interview on 8/3/2023 at 9:59 AM regarding the incomplete and not transmitted Annual MDS assessments, the Case Mix Director (CMD) confirmed they were behind to about 6/22/2023. At 10:12 a.m. the CMD stated, We're out of compliance already [with those referenced] so we are trying to keep up with the current ones and then catch up on the late ones as we can. In an interview on 8/3/2023 at 3:03 p.m. regarding the incomplete MDS Annual assessments, the Director of Health Services (DHS) stated, I was aware the MDS's were behind but not the extent of the behind; but in morning meetings it was stated she was catching up. My expectation is that all MDS assessments are submitted on time. 18750

Based on staff interview, record review, review of the Resident Assessment Instrument (RAI)' manual, and review of the facility policy titled, MDS Assessment Accuracy, the facility failed to ensure nine of 16 residents (Resident (R) 2, R8, R35, R37, R72, R76, R77, R80, and R91) reviewed for Minimum Data Set (MDS) had assessments transmitted within the allotted time frame. Findings include: Review of the facility policy titled MDS Assessment Accuracy, revised 12/6/2022, showed: 6. All MDS Assessments must be completed following the guidance set forth in the RAI manual as directed by the Centers for Medicare and Medicaid Services (CMS). Review of the October 2019 RAI Manual, page 2-16 (a timeline chart for assessments) showed: Significant Change in Status Assessment (SCSA) (Comprehensive). Assessment Reference Date No Later than: 14th calendar day after determination that significant change in resident's status occurred (determination date + 14 calendar days). MDS completion date No later than: 14th calendar day after determination that significant change in resident's status occurred (determination date + 14 calendar days). CAA's [Care Area Assessment] completion date No later than: 14th calendar day after determination that significant change in resident's status occurred (determination date + 14 calendar days) Care Plan completion date No later than: CAA(s) Completion date +7 calendar days. Transmission date No later than: Care Plan Completion Date + 14 calendar days. 1. Review of R2's Face Sheet from the facility electronic medical record (EMR) Resident tab showed an admitted [DATE], and readmission on 6/20/2023. Review of R2's EMR MDS 3.0 Assessments tab showed an annual MDS with an assessment reference date (ARD) of 3/21/2023 with a status of Production Accepted, and a quarterly MDS with an ARD of 6/21/2023 that showed a status of Finalized but not yet transmitted. 2. Review of R8's Face Sheet from the EMR Resident tab showed an admitted [DATE], and readmission on 11/27/2018. Review of R8's EMR MDS 3.0 Assessments tab showed a Quarterly MDS with an ARD of 3/24/2023 with a Production Accepted status, and a quarterly MDS with an ARD 6/24/2023 that showed a status of Finalized but not yet transmitted. 3. Review of R35's MDS 3.0 Assessment Summary located in the EMR under the MDS tab, revealed that on 6/9/2023 a Quarterly Review was finalized but never transmitted. 4. Review of R37's MDS 3.0 Assessment Summary located in the EMR under the MDS tab, revealed that on 6/10/2023 a Quarterly Review was in process and not transmitted. 5. Review of R77's MDS 3.0 Assessment Summary located in the EMR under the MDS tab, revealed that on 6/11/2023 a Quarterly Review was in process and not transmitted. 6. Review of R80's MDS 3.0 Assessment Summary located in the EMR under the MDS tab, revealed that on 6/24/2023 a Quarterly Review was in process and not transmitted. 7. Review of R72's Face Sheet from the facility EMR Resident tab showed an admitted [DATE], and readmission on 7/18/2023. Review of R72's EMR MDS 3.0 Assessments tab showed a Quarterly MDS with an ARD of 3/20/2023 with a Production Accepted status; a quarterly MDS with an ARD of 6/20/2023 with a Finalized status but not yet transmitted; a discharge MDS with an ARD of 7/9/2023, and an entry MDS with an ARD of 7/18/2023 both with an In Process status and not transmitted. 8. Review of R76's Face Sheet from the facility EMR Resident tab showed an admitted [DATE], and readmission on 3/25/2022. Review of R76's EMR MDS 3.0 Assessments tab showed a Quarterly MDS with an ARD of 3/26/2023 with a Production Accepted status and a Quarterly MDS with an ARD of 6/6/2023 that showed a Finalized status but not transmitted. 9. Review of R91's Face Sheet from the EMR Resident tab showed an admitted [DATE]. Review of R91's EMR MDS 3.0 Assessments tab showed a Quarterly MDS with an ARD of 3/8/2023 with a Production Accepted status and a quarterly MDS with an ARD of 6/8/2023 with a Finalized status that was not yet transmitted. During an interview on 8/3/2023 at 9:59 a.m. regarding not transmitted MDS assessments, the Case Mix Director (CMD) confirmed they were behind to about 6/22/2023. At 10:12 a.m. the CMD stated, We're out of compliance already [with those referenced] so we are trying to keep up with the current ones and then catch up on the late ones as we can. In an interview on 8/3/2023 at 3:03 p.m. regarding the not transmitted MDS assessments, the Director of Health Services (DHS) stated, I was aware the MDS's were behind but not the extent of the behind; but in morning meetings it was stated she was catching up. My expectation is that all MDS [assessments] were transmitted on time. 43050

Based on observation, staff interview, record review, and review of the facility policies titled, Oxygen Administration and Respiratory Equipment Changeouts, the facility failed to clean the filter and/or the outside casing of the oxygen (O2) concentrator and failed to provide evidence the oxygen tubing was changed weekly for five of six residents (Residents (R)8, R34, R43, R118, and R120) sampled for respiratory services. Findings include: Review of the facility policy titled, Oxygen Administration with a revision date of 11/1/2019 revealed, Policy Statement: to provide oxygen safely and accurately to appropriate patients. Infection Control Policy of O2, 7. The large external, black filter should be washed with soap and water once each week and PRN. Dry with towel and reinsert. Do not discard unless it is damaged. 10. Clean exterior of concentrators weekly and between each patient use with bactericidal surface cleaner. Review of the facility policy titled, Respiratory Equipment Changeouts with a revision date of 1/25/2022 revealed, Policy Statement: To provide guidelines to help prevent infections associated with respiratory equipment and to prevent transmission of such infections to patients/residents and staff. Procedure: Oxygen Therapy Equipment: (Can be changed out by Charge Nurse or designee). Nasal Cannula (low flow) and tubing shall be changed weekly. 1. Review of R8's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab, revealed an admitted [DATE] with diagnosis including dementia, schizophrenia, shortness of breath, and wheezing. Review of R8's Orders located in the EMR under the Orders tab, revealed an order dated 7/11/2023, to Change respiratory circuit/supplies as needed. Review of R8's Medication Administration Review (MAR) revealed no documentation of oxygen supplies being replaced. Observation on 7/31/2023 at 3:11 p.m. revealed R8 had her eyes closed and had her oxygen on. The tubing had no date as to when it was last changed. Interview on 8/3/2023 at 8:46 a.m. with the Unit Manager (UM1) revealed the facility did not label and date oxygen tubing. It was their policy. I do see in the EMR that documentation is not being completed. Some residents have orders, and some are not on the MAR. We will have to find a system that all of nursing uses to document supply changes are made. Interview with the Director of Health Services (DHS) on 8/3/2023 at 9:02 a.m. revealed Oxygen tubing needs to be documented somewhere to show that it has been changed. 2. Review of R34's Face Sheet tab in the EMR revealed an undated Face Sheet which indicated the resident was admitted to the facility on [DATE] with diagnoses of obstructive sleep apnea. Further review of the EMR under Orders tab revealed a Physician Order dated 6/14/2023, Oxygen at 2 lpm [liters per minute] via nasal cannula as needed for obstructive sleep apnea. Also, an order dated for 12/8/2022 to change respiratory circuit/ supplies as needed. Review of R34's EMR under the Reports tab revealed the MAR dated July 2023 revealed no documentation that the respiratory supplies were changed under the area for Oxygen: Change respiratory supplies as needed. During an observation on 7/31/2023 at 2:23 p.m.; on 8/1/2023 at 3:40 p.m.; and on 8/220/23 at 9:12 a.m., R34 was in her bed with the nasal cannula attached to the oxygen concentrator. Observation of the concentrator casing revealed it was dusty. The cannula had no indication as to when it was changed. During an interview on 8/2/2023 at 8:59 a.m., Assistant Director of Nursing (ADON) was asked about the care of the concentrators and the changing of the tubing. The ADON stated, The concentrators should be wiped down weekly and kept dust free. Also, the tubing should be changed weekly. The ADON was asked how you know when the tubing is changed. The ADON stated, It was the facility policy not to date the tubing. It is tracked in the Medication Administration Record (MAR). Usually, the tubing is changed by the night shift on Mondays. 3. Review of R43's Face Sheet tab in the EMR revealed an undated Face Sheet which indicated the resident was admitted to the facility on [DATE] with diagnoses of shortness of breath. Further review of the EMR under Orders tab revealed a Physician Order dated 6/14/2023, Oxygen at 2 lpm via nasal cannula for shortness of breath. Also, an order dated for 12/08/22 to change respiratory circuit/ supplies as needed. During an observation on 7/31/2023 at 2:50 p.m. and 8/2/2023 at 8:45 a.m., R43 was in bed with the nasal cannula in her nose. The concentrator and the filter was dusty. During an observation and interview on 8/2/2023 at 8:59 a.m., with the ADON, she was shown the concentrator and the filter. The ADON stated, Yes. The filter and the machine are dusty. They should not look like that. The filter and the concentrator should be clean. 4. Review of R118's Face Sheet tab in the EMR revealed an undated Face Sheet which indicated the resident was admitted to the facility on [DATE] with diagnoses of hypertensive heart disease with heart failure. Further review of the EMR under Orders tab revealed a Physician Order dated 4/26/2023, Oxygen at 2 LPM via nasal cannula as to keep O2 Sats greater than 90%. During an observation on 8/1/2023 at 9:05 a.m.; and on 8/2/2023 8:28 a.m., R118 was in her bed with the nasal cannula attached to the oxygen concentrator. Observation of the concentrator casing revealed it was dusty around the inlet where the internal filter was located. During an interview on 8/2/2023 at 8:30 a.m., Licensed Practical Nurse (LPN)3 was asked to look at R118's concentrators. LPN3 stated, The concentrator was dusty. The concentrator comes from hospice, but ultimately we are responsible, and it should be wiped down. 5. Review of R120's Face Sheet tab in the EMR revealed an undated Face Sheet which indicated the resident was admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia. Further review of the EMR under Orders tab revealed a Physician Order dated 6/14/2023, Oxygen at 2 LPM via nasal cannula continuously for hypoxia. During an observation on 7/31/2023 at 3:05 p.m.; on 8/1/2023 at 9:00 a.m.; and on 8/2/2023 at 8:50 a.m., R120 was in his bed with the nasal cannula attached to the oxygen concentrator. Observation of the concentrator casing revealed it was dusty. The cannula had no indication as to when it was changed. Review of R120's EMR under the Reports tab revealed the MAR dated July 2023 revealed blanks under the area for Oxygen: Change respiratory supplies as needed. During an interview on 8/2/2023 at 8:59 a.m., ADON was asked to look at R120's concentrators. The ADON stated, I see what you mean. The machine is dirty. It should be dust free. During an interview on 8/3/2023 at 8:45 a.m., the Unit Manager (UM)1 was asked about the care of the care of the concentrators and the changing of the nasal cannulas. The UM1 stated, Not all of the cannulas were being tracked through the MAR. There is no evidence that the cannulas were changed on a weekly basis. The staff should be cleaning the concentrators and keep them dust free. During an interview on 8/3/2023 at 2:25 p.m., the Director of Health Services (DHS) was asked what the expectation was for cleaning the concentrators and the filters as well as changing the tubing. The DHS stated, Staff should be cleaning the concentrators and the filters if the filters aren't internal. The cannulas are changed by night shift weekly and should be documented in the MAR. If it is not documented, then it was not done. 28154

Based on staff interview, record review, and document review, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), CMS-10055, were signed and dated for two of three residents (Resident (R)132 and 133) reviewed for SNFABN. This deficient practice could potentially lead to uninformed decisions made by the resident or representative about their care. Findings include: Review of the undated facility form instruction titled Advance Beneficiary Notice of Noncoverage revealed, Overview: The ABN is a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case. 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 subject of the notice. The ABN must be verbally reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered before it is signed. 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. 1. Review of R132's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab indicated an admitted [DATE] with a diagnosis of cerebral vascular accident with hemiplegia (paralysis). Review of the SNFABN provided by the facility indicated Medicare Part A Skilled Services Episode Start date: 2/22/2023. Last covered day of Part A Services: 3/24/2023. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Review of the CMS-10055 for R132 furnished by the facility, revealed no signature of the resident or the representative or a date, and there was no option checked on the form. 2. Review of R133's Face Sheet located in the EMR under the Face Sheet tab indicated an admitted [DATE] with diagnosis of cancer. Review of the SNFABN provided by the facility indicated Medicare Part A Skilled Services Episode Start date: 4/26/2023. Last covered day of Part A Services: 6/7/2023. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Review of the CMS-10055 for R132 furnished by the facility, revealed no signature of the resident or the representative or a date, and there was no option checked on the form. During an interview on 8/2/2023 at 3:18 p.m., the Financial Counselor (FC) was asked about the forms not having a signature or date. The FC stated, The representatives were called by phone. The FC was asked why there was no option selected or a date of contact and who was contacted. The FC stated, I need to be more specific about who I talk to and yes it should be dated.

Based on observation, resident interview, staff interviews, record review, and review of the facility policy titled, Medication Administration: General Guidelines, the facility failed to ensure one of one (Resident (R)109) reviewed for self-administration of medications did not self-administer medications without first being assessed by the facility to determine if the practice was clinically appropriate. This deficient practice had the potential to allow the resident to administer the medication to not receive the correct dose of medication or receive it in an unsafe manner. Findings include: Review of the facility policy titled Medication Administration: General Guidelines, with a revision date of 4/10/2019, revealed: Policy Statement: Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Procedure: 3. Patients/residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. 4. Medications are administered at the time they are prepared. 9. Only the licensed or legally authorized personnel that prepare a medication may administer it. Review of R109's electronic medical record (EMR) revealed an undated Face Sheet located under the Face Sheet tab which revealed the resident was admitted to the facility on [DATE] with diagnoses of cerebral infarction (stroke), benign prostatic hyperplasia without lower urinary tract symptoms, pain disorder, and hypertension. Review of R109's EMR under the Order tab revealed the following current medications ordered for morning administration; [NAME] chewable aspirin 81mg (milligram) one tablet orally once a day for blood thinner, ferrous sulfate tablet 325mg one tablet orally once a day for anemia, finasteride tablet 5mg one tablet orally once a day for enlarged prostate, furosemide tablet 20mg one tablet orally once a day for hypertension, metformin tablet 500 mg one tablet orally twice a day for diabetes, nifedipine tablet 30mg one tablet orally once a day for hypertension, potassium chloride 10 mEq (milliequivalents) one capsule orally once a day for supplement, and Tradjenta tablet 5mg one tablet orally once a day for diabetes. Further review of the EMR under the Observation tab or Resident Documents revealed there was no evidence of an assessment for self- administration of medication. During an observation and interview on 7/31/2023 at 11:57 a.m., in R109's room, a cup of pills was observed to be on the bedside table. R109 was asked if those were his medications. R109 stated, You are very observant. Yes, those are my meds from this morning, and I better take them. The resident took the medications. R109 was asked if the pills were his morning medications and he stated, Yes. They bring them in to me and I am supposed to take them when they bring them in. They are not supposed to leave them. Sometimes I have some swallowing problems and just wasn't ready to take them when they brought them in this morning. During an interview on 8/3/2023 at 8:56 a.m., the Unit Manager (UM)1 was asked about R109 self-administration of medication. UM1 stated, There is no resident assessed to give themselves medication. I have instructed the staff not to leave meds at the bedside for residents to take themselves. I don't like that. During an interview on 8/3/2023 at 9:00 a.m., the Assistant Director of Nursing (ADON) was asked about medications being left at the bed side. The ADON stated. No medication should be left at the bedside. There are no residents that have been assessed to take the medication on their own. During an interview on 8/3/2023 at 2:29 p.m., the Director of Health Services (DHS) was asked about residents taking medications. The DHS replied, We recently did an in-service on this. There should not be any meds left at the bedside for residents to self- administer. I have no residents that have been assessed to self-administer medications.

Based on record reviews, interviews with staff and review of the facility policies, facility administration failed to ensure residents identified at elopement risk did not exit the facility unsupervised. The sample was 17 residents. The census was 138 residents. On 10/4/17, a determination was made that a situation in which the facility's noncompliance with one or more requirement of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Health Services (DHS) where informed of the immediate jeopardy on 10/4/17 at 4:33 p.m. The noncompliance related to the immediate jeopardy was identified to exist on 8/22/17 when R#1 exited the building. The Immediate Jeopardy was identified when one resident (R#1), who was an elopement risk, exited the facility in a wheel chair on 8/22/17, following staff who exited the building to the parking lot and the door remained open, resulting in the resident traveling approximately 90 feet, then crashing into a retaining wall. The resident was transferred to the hospital with an admitting [DIAGNOSES REDACTED]. On 10/5/17, the facility provided a Credible Allegation of Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediacy on 10/6/17. Based on validation of the A[NAME], the State Survey Agency (SSA) determined the Immediate Jeopardy was removed on 10/6//17. The Scope and Severity were lowered to a D level while the facility develops and implements a Plan of Correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. The immediate jeopardy is outline as follows: 483.20(k)(3)(ii)--Services By Qualified Person/per Care Plan (F282, Scope and Severity (S/S): J) the facility failed to follow the care plan for R#1 to place the resident in area where constant observation is possible. 483.25(h)--Free of Accident Hazards/supervision/devices (F 323, S/S: J) the facility failed to ensure that R#1, a wandering risk, did not leave the facility unattended on 8/22/17 resulting in injury and hospitalization after elopement from the facility. 483.75--Effective Administration/resident Well-Being (F490, S/S: J) the facility Administrator failed to ensure that all exit doors were safe to prevent residents, specifically R#1, from exiting unattended which resulted in elopement with injury and hospitalization after elopement from the facility. In addition, Substandard Quality of Care was identified at F323-S/S: J-Free of Accident Hazard/Supervision/Devises. Findings include: Review of the Administrator's job description revealed Job Purpose: Directs 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 Vice President, to provide appropriate care for our patients/residents. Key responsibilities: 5. Ability to apply standards of professional practice to operations of nursing facility and to establish criteria to assure that care provided meets established standards of quality. 7. Ability to develop and implement administrative policies and procedures that reflect the center's philosophy and mission in compliance with federal and state laws and regulations. During an interview, on 9/09/17 at 6:36 p.m., the Administrator revealed that R#1 was sitting in the holding area after breakfast waiting to be transported back to her unit on the elevator, when she followed staff out the side exit door. Staff was unaware that the resident was behind them. The Administrator further revealed that residents at risk for elopement had not previously been assigned specific staff to transport them from the dining area, since all employees including administrative staff had previously assisted with this task. Continued interview at this time with the Administrator revealed that she did not know how the resident was able to get out of the building unsupervised by staff. Interview on 9/25/17 at 10:30 a.m. with the Maintenance Director revealed that the door alarms will shut off in two minutes and that the monitors around that door was tested that morning with no problems.He revealed that he reviewed the campus video which revealed that two staff went out the side door. He revealed that R#1 was beside the bulletin board and door, and that as the door started closing, it closed on R#1. He revealed that R#1 pushed on through the doors. He revealed that there was no audio available with the video and that he did not have a copy of it. He revealed that the Wanderguard monitor around the doors are tested daily. An interview with the Maintenance Director on 10/4/17 at 2:30 p.m. revealed the video is no longer available as the video is rewritten every 3-4 days. An interview with the Administrator on 10/4/17 at 4:33 p.m. revealed that she and her staff were not certain how best to prevent this from occurring again. She revealed that both staff and visitors had used this door to enter and exit the building although a resident leaving unattended had not occurred before 8/22/17. She had suggested changing the code for the door, closest to the elevators, and allowing only a few management staff to have the code preventing staff and visitors from utilizing this door. She revealed that when deliveries are made to the facility this door is used. She revealed that a bench has been placed beside the door and someone must sit at the location until the delivery is completed and the door has been locked again. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On (MONTH) 22, (YEAR), RN II stated that she exited out of the facility through the secured doors adjacent to the elevators on the ground floor. RN II stated that she was not aware that R#l followed her out of the doors. RN II back was to the building as she walked towards her car in the parking lot. RN II stated that it wasn't until she got to her car, she turned around and faced the building and noted R#l rolling downhill on the sidewalk at a fast pace. RN II stated that she ran to catch R#l but she reached the bottom of the sidewalk crossed the driveway and fell outside of laundry department. R#l along with her wheel chair fell to the left side where she sustained serious injury. RN II, Nurse ZZ and CNA JJ rendered immediate care and assisted resident to wheelchair and into the facility. 2. MD and family was notified of the incident. State report sent in. 3. 8/22/2017 DHS made the request of the Maintenance Director to change the code immediately to prevent use of the side door in question 8/22/2017 Signs were placed on both sides of the door requesting all visitors and partners to use the front door to enter and exit the building. Partners were educated and in-serviced by our DHS and Clinical Competency Coordinator, Unit Managers of changes (MONTH) 22- 25th .In¿ services were initiated immediately and included all three shifts. Staff has been in¿ serviced on - 'No staff is permitted to Enter or Exit Coded Door Located near Ground Floor Elevators' and on 'Elopement Prevention Policy'. 146/157 partners. No partners will be allowed to work until they have received and understand the in-services . 4. System failure: when staff members exited the facility for a personal break, she failed to observe the location of the elopement risk resident. 5. Resident admitted to hospital secondary to fall with significant injury. 6. 10/4/2017 all residents were assessed by our Senior Nurse Consultant using the Elopement Risk Observations form. Residents identified with Elopement Risk Observation score of 11 or more have interventions in place if indicated. Residents with moderate risk scores of 5-10, have been assessed on individual basis for elopement risk with interventions initiated as indicated. Completed 10/5/2017. 7. 10/4/2017 all residents' wander guard bracelets are checked daily times 7 days a week by Restorative CNAs for signal and proper functioning. - on going 8. 10/4/2017 all residents with wander guard devices will have placement checked q shift by the nurse and documented on the MAR. on going. 9. 10/4/2017 all doors with wander guard system were checked by the Maintenance Director, maintenance assistance or a member of nursing staff if the director is not on duty. Daily times 7 days a week and ongoing. 10. 10/4/2017 Wander guard books updated with current residents at risk completed 10/5/17. 11. 10/4/2017 Additional wander guard books added to new secured locations to provide privacy but easy access: behind the front receptionist desk, locked in the meal service closet in main dining room, therapy department. Books were already maintained at both nursing station, unit 1 and 2, and at the front receptionist's desk. Done 10/4/2017 12. 10/4/2017 in-services were held by Clinical Competency Coordinator, OHS, ADHS and Senior Nurse Consultant and Administrator for all staff- clinical and nonclinical, regarding location of wander guard books, identification of elopement risk residents by Pink tape or ribbon on wheel chairs or other assistive devices. Pink tape on name outside of resident room. Code Pink (missing resident), supervision of elopement risk residents to and from the ground level, and other topics regarding elopement procedures. 146 out of 157 partners. To include RNs- 11/12, LPN's 27/30,CNAs 59/62, Administrative department 7/7, Dietary 9/11,Housekeeping 11/14, Laundry 4/5, Maintenance department 1/1,Admissions 1/1,Social Services 1/1,Activity department 1/1,therapy 12/15 Medical records 1/1 and 3 Corporate partners. The reminder of the partners have been notified that they must complete their in- services with Clinical Competency Coordinator or OHS prior to returning to work. Done 10/5/17 13. All admissions/readmissions completed by the nurse. Those who have been identified with the potential to be affected and will have the Elopement Risk Observation form completed and interventions put in place as indicated by the admission nurse. Completed 10/5/17 and ongoing. 14. All new admission records within last 7 days completed by OHS/ADHS to be reviewed to ensure appropriate interventions are in place and care plans updated as indicated. Completed 10/5/17 15. All current elopement risk residents had their nursing care plans and behavioral management communication sheet form updated by Senior Nurse Consultant. The wander guard books' pictures and descriptions were also updated at this time. Completed 10/5/17. 16. Reviewed with 32 out of 37 nurses the expectation of giving shift reports to include Elopement risk patients. The other 7 nurses will not be allowed to work until in-serviced. Done 10/5/17 17. The elopement risk residents are now being listed on the nursing shift report on both nursing units. Done 10/4/17. 18. Wander guard book will be brought to Daily Clinical meeting and will review all new admission charts for Elopement risk that need to have immediate interventions and wander guard book updates. Done 10/5/17. 19. When resident enters building with score of 11 or more on the Elopement risk observation form, OHS, ADHS or Unit Manager will be notified to assess for appropriate interventions to reduce risk of elopement. Ongoing 20. Restorative CNAs and CNAs from unit 1 and unit 2 have been assigned to supervise the ground floor holding area and dining room daily during meals and activity assistants will monitor and document daily on elopement risk residents returned to their designated areas safely. Using the supervision tool each meal and activities. 21. Restorative Aides and Activity Aides have been assigned to escort elopement risk resident back to their designated areas after meals and activity first. Ongoing 22. Wander guard books has be updated as indicated with changes. Done 10/5/2017. 23. Administrator will review all allegations of abuse, neglect and falls with serious injury to ensure accurate investigation was comp completed and reporting was completed per current policy ongoing. 24. Case Mix Director will ensure patient centered care interventions are incorporated on the Elopement risk care plan during the patient assessment period upon admission, quarterly, annual and with significant changes. This will be Ongoing 25. Ongoing review of the elopement procedures is added to the staff's monthly Town Hall meeting presented by Administrator. Elopement and safety topic will be added to the quarterly family night agenda to raise awareness. Ongoing quarterly. 26. Door adjunct to the elevators remain out of use. Only key personal to include Administrator, Maintenance Director, OHS and RN supervisors evening and night shifts and the Receptionist will have the code not to share with anyone. The code will be changed monthly. Done 10/4/2017 27. The doors are no longer on an automatic opener. After using the key pad the door will open manual and sensors have been installed on right and left door to allow wander guard to alarm if near the door. Done 10/5/2017 28. Alarm sound adjusted louder for the wander guard system 10/5/2017 29. 10/4/2017 if the door must be used to allow delivery or ambulance in an emergency Only key personal to include Administrator, Maintenance Director, DHS and RN supervisors evening and night shifts and the Receptionist must remain at the door to ensure the door latch and locks. Ongoing 30. Daily Review every new admission/readmission's Elopement Risk Observation Form for compliance and timeliness of interventions ongoing in the morning clinical meetings. Ongoing 31. Updated the nursing 24 hour report form changes to the elopement risk list. This our tool used as a guide for our morning clinical meetings to follow up from previous day activity. 10/4/2017 32. Audit tool and paper test created and utilized for the DHS, Clinical Competency Coordinator to verify all staff awareness of Elopement at risk procedures and identifiers. Individual education was rendered to all partners with a score less than 100 to further educate that partner after which the partner was allowed to correct their wrong answers with the right one. Done 10/5/2017. 33. New partner orientation will have written test administered to all partners prior to completing orientation by the Clinical Competency Coordinator. 10/4/2017 34. Completed chart check form to be given to DHS within 24 hours of resident admission/readmission. Weekend admissions/readmissions' forms will be given to DHS the following Monday for follow up DHS or ADHS will be notified on the weekends by nurse of new or readmissions elopement risk score of 11 or more to ensure appropriate interventions have been put in place. DHS or ADHS will notify Administrator of the newly identified patient. This will be Ongoing 35. Elopement risk residents will continued to be reviewed in Behavioral Management Program week weekly if indicated. Ongoing. 36. Daily Random audit of elopement risk patients are being assisted to and from the ground floor after meals or activities. Started on 10/4/2017 and ongoing 37. Findings will be included in monthly/quarterly Quality Assurance meetings ongoing 38. Administrator will be responsible for overseeing the A[NAME] to ensure compliance through daily rounding 5 days a week. DHS or ADHS will notify Administrator of the newly identified patients at risk for Elopement on the weekends. This will be Ongoing 39. Area Vice President have reviewed with me my job description and in serviced me on my role as Administrator to carry out my responsibilities. Done 10/5/2017 The State Survey Agency (SSA) validated the facility's Credible Allegation of Immediate Jeopardy Removal as follows: 1 and 2. Confirmed during survey. 3. 10/4/17 at 2:00 p.m. sign noted on both sides of the side exit door where R#1 eloped for Visitors and partners to use front entrance door. Review of in-service sign in sheets dated 8/22/17 through 8/25/17 titled no staff is permitted to enter or exit coded door located near ground floor elevators and Elopement Prevention. Sign in sheet reveals that all staff have been educated as of 10/6/17. 6. Review of the residents records revealed that all resident's had been assessed for wandering/elopement behaviors and based upon their score were placed on the resident wandering list. (ten residents were included on the wandering list: (R#3, R#9, R#10, R#17, R#14, R#13, R#12, R#2, R#15 and R#16). 7. Review of the Restorative Certified Nursing Assistant (CNA) check list for the residents on the wandering list, the Wanderguard bracelets are checked daily for signal and proper functioning. 8. Review of the Medication Administration Record (MAR) for residents on the wandering list revealed that the Wanderguards are checked per shift for placement, by the nurses, and recorded on the MAR. 9. Review of the Maintenance Director 's Wanderguard audit tool that doors equipped with a wanderguard are checked and recorded daily, 7 days per week. 10 and 11. Review of the Wanderguard books which are located at the nurses' stations, front desk and in a locked area of the dining room where reviewed at all locations. 12. Review of the new policy Wandering/Elopement confirmed changes to include: Residents who are a Wandering/Elopement Risk have Pink tape or ribbon on their wheel chairs or other assistive devices and on the door name plate. Code Pink would indicate a missing resident. Review of the in-service sheets 10/4/17 revealed that 146 staff members have been in-serviced to date on the new Wandering/Elopement policy including how to identify a resident as risk. 13. R#17 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident is ambulatory. Record review revealed the resident was assessed for Wandering/Elopement behaviors on 10/6/17 with a score of 11 indicating the resident is a risk. The resident has a Wanderguard bracelet on his left wrist and a pink ribbon on his left wrist. Observation on 10/6/17 at 5:27 p.m. of resident walking on the unit near the elevator, with a bag in his hand, when the elevator door opened he attempted to enter. Staff was near by and distracted the resident until the elevator door closed. The resident was aggressive towards the staff and difficult to distract. Another staff member contacted the Assistant Director of Health Services (ADHS) at this time who was able to get the resident to move to another area of the unit. An interview with the ADHS at this time, revealed the resident is always saying he needs to catch the train and always walks around with a bag of popcorn. He further stated that the resident can be very aggressive towards the female staff members but does respond when he speaks with the resident. 14. Review of R#17's, admitted on [DATE], care plan revealed he is care plan was updated on 10/2/17 for Wandering/Elopement behaviors with interventions for distracting the resident. 15. Record review, on 10/6/17, of the resident's on the Wandering/Elopement list (R#3, R#9, R#10, R#17, R#14, R#13, R#12, R#2, R#15 and R#16) revealed that the resident's assessments and care plans were updated to reflect their risk and behaviors and were included in the Wanderguard books with photographs and descriptions. 16 and 17. Review of the 24 hour reports and nursing interviews confirmed that shift reports and 24 hour reports include Wandering/Elopement behaviors for the on-coming shift. 18. An interview with the DHS on 10/6/17 at 6:00 p.m. confirms that the Wanderguard book and new Admissions are discussed in the Daily Clinical meeting. 19. There had been no new admissions since 10/4/17 to confirm this portion of the A[NAME]. 20 and 21. Review of the Supervision tool utilized for each meal and activities confirms that restorative aides are assigned to supervise and return the wandering residents to their units. This tool is hanging in the dining room area and signed off by the restorative aides at the end of meals and activities. 22. Review of the Wanderguard books revealed they are current as of 10/6/17. 23. An interview with the Administrator on 10/6/17 at 2:00 p.m. confirmed there have been no allegations of abuse or neglect since 10/4/17. The Administrator is notified of any falls that take place. 24. Review of the patient assessments and care plans revealed they were updated and would be re-assessed upon admission, quarterly, annual and with significant changes per an interview with the DHS on 10/6/17 at 6:00 p.m. 25. Review of the Town hall meeting which was held on 9/29/17 and discussed elopement. They have not held a Family night meeting yet. 26. 27 and 28. An interview and observation with the Maintenance Director on 10/6/17 at 3:57 p.m. revealed the door can only be opened with a code that only two people in the building have access to at this time. All doors with Wanderguards were checked for functioning at this time utilizing a Wanderguard. During interviews with staff they confirmed that they did not have the code for this door. The Administrator does have the code. The Maintenance Director did confirm that in case of a fire the door would automatically unlock, as would all exit doors in the facility. The Maintenance Director demonstrated at this time that the door would alarm if a resident with a Wanderguard was near this door. Per the Maintenance Director the Wanderguard alarm sound has been increased for all doors armed with a Wanderguard system. 29. Observation and interview with the Administrator on 10/6/17 at 4:30 p.m. revealed that a bench has been placed beside the side exit door and that when a delivery is made that administrative staff must be sitting at the bench until the delivery is complete and ensure that the door is locked again. She states that it is usually her that has this duty. 30. An interview with the DHS on 10/6/17 at 6:00 p.m. confirms that the Wanderguard book and new Admissions are discussed in the Daily Clinical meeting. 31. Review of a 24-hour report dated 10/6/17 confirms that Elopement risk list is discussed and included on the 24-hour report. 32. Review of the Audit tool and paper test that were given to the staff. Staff persons who did score less than 100 percent were given further education and re-tested to ensure complete understanding and a 100 percent score. 33. There were no new staff since 10/4/17 to confirm this portion of the A[NAME] although the policy does reflect this will occur. 34. There were no new admission at risk for elopement at this time. During an interview with the Administrator, DHS and ADHS on 10/6/17 at 2:00 p.m. confirmed this finding. 35. An interview with the ADHS on 10/6/17 at 5:27 p.m. confirmed while reviewing R#17 record that the resident was being assessed for his behaviors on the weekly Behavioral Management Program. 36. Review of the Audit tool dated 10/4/17 documents random elopement resident being assisted to and from the ground floor daily. 37 and 38. An interview with the Administrator on 10/6/17 at 6:15 p.m. that the last QA meeting was 9/28/17 which included Elopement and falls. The Quality Assurance (QA) committee meets monthly and includes the Medical Director. The Administrator revealed that she is responsible for the QA meetings and is responsible for overseeing the A[NAME] to ensure that the facility is in compliance. 39. Review of the Position Description Acknowledgement agreement and in-service dated 10/5/17 and signed by the Administrator and the Corporate Leader. Interviews with Licensed Practical Nurses (LPN) on 10/6/17, LPN AE at 2:21 p.m., LPN AB at 2:55 p.m., LPN RR at 4:26 p.m., LPN MM at 4:45 p.m., LPN AG at 5:09 p.m., LPN AH at 5:20 p.m. and LPN AI at 5:35 p.m. and Registered Nurse KK at 4:36 p.m., revealed they had participated in multiple in-services specific to wandering/elopement, monitoring placement of Wanderguards and recording on the MAR, assessing new admissions for wandering/elopement risk, restorative aide assignments for dining and activities for resident's with wandering/elopement risk, including wandering/elopement behaviors on the 24-hour report, updating care plans for wandering/elopement behaviors, notifying the DHS of new admissions with wandering/elopement risk and the new Wandering/Elopement Policy that includes Code Pink and using pink ribbons, tape on devices and on the resident door name tag to identify residents at risk . They also revealed being in-serviced on not using the side door, by the elevator, for entrance or exit and to always check behind you for residents when exiting an exit door. Interviews with Certified Nursing Assistants (CNA) on 10/6/17, CNA PP at 1:53 p.m., CNA AF at 2:28 p.m., CNA AC at 2:36 p.m., CNA AD at 2:42 p.m., CNA YY at 3:04 p.m., CNA QQ at 4:20 p.m., and CNA SS at 4:31 p.m. revealed they had participated in multiple in-services related to the new Wandering/Elopement Policy, identifying residents at risk with pink ribbons, pink tape on their wheelchairs, assistive devices or their person and on the resident's room name tags, notifying the nurses if a resident has wandering/elopement behaviors, use of the side door by the elevator and assignments for dining and activities to ensure residents at risk are not left alone off their units. An interview with the Rehabilitation Manager OO on 10/6/17 at 1:41 p.m. revealed that she sits at the Rehabilitation door entrance during the day as the facility does outpatient rehab as well. If no one is at their exit door then the door is locked. She has been in-serviced on wandering/elopement residents, the new Wandering/Elopement Policy-Code Pink for a missing resident and that wandering/elopement risk residents had pink ribbons or tape on their wheel chairs or assistive devices. She is aware that the side door, nearest the elevators, cannot be used be staff or visitors. Interviews with the Rehabilitation Staff on 10/6/17 at 3:37 p.m., DPT TT, ST UU, OT VV, Rehab Tech WW revealed that they had been in-serviced on wandering/elopement residents, the new Wandering/Elopement Policy-Code Pink for a missing resident and that wandering/elopement risk residents had pink ribbons or tape on their wheel chairs or assistive devices. They are aware that the side door, nearest the elevators, cannot be used be staff or visitors. They confirmed that they cannot see the area outside of the doors near the elevators although it is beside that area. Observation and interview at this time revealed that the Physical Therapy (PT) windows are covered preventing anyone in PT from seeing the outside area. An interview on 10/6/17 at 2:45 p.m. with housekeeper ZZ revealed that she has been in-serviced on the new Wandering/Elopement Policy-Code Pink indicating a missing resident. She is aware that staff cannot use the side door, nearest the elevators any longer. She confirms that only a few management staff have the code. An interview with Laundry Aide XX on 10/6/17 at 3:01 p.m. revealed that she has been in-serviced on the new Wandering/Elopement Policy-Code Pink indicating a missing resident. She is aware that staff cannot use the side door, nearest the elevators any longer. She confirms that only a few management staff have the code. An interview with the Interim Dietary Manager LL on 10/6/17 at 4:41 p.m. revealed that she is new but has been in-serviced on the new Wandering/Elopement Policy-Code Pink which would be used for a missing resident. She is aware of the monitoring of wandering/elopement resident by the restorative aides and that a wandering/elopement book is kept in the a secured location in the dining room. She is aware that resident's at risk for wandering/elopement have pink ribbon or tape on their wheel chairs or other assistive devices and if they are ambulatory on their person. She is aware that only a few management staff have the code for the side door, nearest to the elevator, and that all staff and visitors should use the front entrance. Staff should ensure that residents are not following them when they enter or exit the building. An interview with the Activity Director NN on 10/6/17 at 4:49 p.m. revealed that she has been in-serviced on the new Wandering/Elopement Policy. She is aware that restorative aides must accompany residents at risk to and from their units during meal service and activities. Residents are not to be placed in front of the elevators any longer.

Based on observations, record review, review of Elopement Prevention Policy, and staff interviews, the facility failed to provide an environment that was free of accident hazards for one resident (R#1) who was identified as an elopement risk. R#1 was care planned for the use of a wanderguard to prevent the resident from exiting the facility unsupervised. On 8/22/17 R#1 exited the facility falling out of the wheelchair and sustained a major injury that resulted in hospitalization . The sample was 17 residents. On 10/4/17, a determination was made that a situation in which the facility's noncompliance with one or more requirement of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Health Services where informed of the immediate jeopardy on 10/4/17 at 4:33 p.m. The noncompliance related to the immediate jeopardy was identified to exist on 8/22/17 when R#1 exited the building. The Immediate Jeopardy was identified when one resident (R#1), who was an elopement risk, exited the facility in a wheel chair on 8/22/17, following staff who exited the building to the parking lot as the door remained open, resulting in the resident traveling approximately 90 feet, then crashing into a retaining wall. The resident was transferred to the hospital with an admitting [DIAGNOSES REDACTED]. On 10/5/17, the facility provided a Credible Allegation of Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediacy on 10/6/17. Based on validation of the A[NAME], the State Survey Agency (SSA) determined the Immediate Jeopardy was removed on 10/6//17. The Scope and Severity were lowered to a D level while the facility develops and implements a Plan of Correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. Findings include: Review of the facility policy titled Elopement Prevention revised 2/99 revealed Policy: In order to prevent residents/patients from wandering away from the healthcare center, procedures have been developed to be taken when a resident/patient has a recent history of elopement or leaves the healthcare center premises unsupervised. Prevention of elopements is an integral part of the Incident Prevention Program. All residents/patients will be assessed, during admission or annual review process be reviewed for elopement history or potential. The Admission Log for Incident Prevention will be utilized to identify wandering behaviors. Residents/patients who are at risk will be cared for by consideration of room placement, formulation of individual care plan including Social Service and Recreation Service intervention, education of direct care staff and closer monitoring. High risk residents/patients will be provided a bracelet for the door monitoring system, if one is utilized in the healthcare center. They will also be placed on the Behavior Management Program. A record review for R#1 provided documentation to show that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for R#1 documented a Brief Interview for Mental Status (BIMS) score of 99 indicating the resident was severely impaired with regard to cognitive skills for daily decision making. Record review of the care plan for R#1 identified the resident as an elopement risk, with the onset of the problem documented as 3/20/14, and was updated on 1/15/17, 4/20/17, and 7/14/17. Goals included: Will not elope from the facility by next review. Approaches included: Place resident in area where constant observation is possible PRN (as needed), Do not allow resident to leave facility alone without s/o (The Director of Nursing confirmed via telephone on 9/28/17 at 10:44 a.m. that s/o means someone) or supervision, Monitor/document resident location in the facility as indicated, Maintain locks on doors are in proper working order, Apply Wanderguard; keep Wanderguard bracelet (sic) in proper working order, Notify MD (medical doctor) as warranted. Record review revealed a Physician's order for a Wanderguard device was obtained on 3/20/14. A review of the facility's Incident Log dated 8/22/17 at 9:30 a.m. revealed that R#1 sustained a fall with significant injury in the parking lot and was transported to the emergency room . The facility's Fall Risk Observation Form noted that R#1 was sent to the hospital on [DATE] for evaluation and treatment r/t (related to) hematoma left forehead. Pain medications were given and ice pack applied. During an interview on 9/9/07 at 9:37 a.m., the family member stated that the resident was now at another nursing facility recovering after her fall. He also said that R#1 had never gotten out of the facility before and he was disappointed that this accident was allowed to happen. During an interview on 9/9/17 at 5:41 p.m., Certified Nursing Assistant (CNA) JJ revealed that she and another employee, Registered Nurse (RN) II left the facility using the side exit door, after punching in the code to open the exit door which was armed with the Wanderguard monitoring system. CNA JJ reported that RN II was behind her, and that CNA JJ was unaware that R#1 was following them. CNA JJ also revealed that she did not hear the Wanderguard alarm go off when she exited the door. CNA JJ stated that as she was opening the door of her car, she saw R#1's wheelchair start to roll down the incline leading from the door to the parking lot. She further revealed that she started to run toward the resident to stop the wheelchair but the resident fell out of the wheelchair onto the ground before she could get to her. During an interview on 9/9/17 at 6:36 p.m., the Administrator revealed that R#1 was sitting in the holding area after breakfast waiting to be transported back to her unit on the elevator, when she followed staff out the side exit door. Staff was unaware that the resident was behind them. The Administrator further revealed that residents at risk for elopement had not previously been assigned specific staff to transport them from the dining area, since all employees including administrative staff had previously assisted with this task. Continued interview at this time with the Administrator revealed that she did not know how the resident was able to get out of the building unsupervised by staff. During an interview and observation of the retaining wall on 9/15/17 at 3:05 p.m., with RN II revealed that she and CNA JJ left the facility via the side exit door to access the parking lot. RN II further stated that she opened her car door and heard a family member screaming for help. When she looked up, she saw R#1's wheelchair coming down the incline from the side exit door, cross the driveway and crash into a retaining wall and the resident fell to the ground. At this time RN II identified the retaining wall where R#1's wheel chair came to a stop causing the resident to fall face forward to the ground which was across a large sloping parking lot to the retaining wall. During an interview on 9/16/17 at 3:16 p.m. the DHS stated that at the time of the incident, staff was assisting with the residents on the elevator and another staff was monitoring residents in the dining area, on the main floor. Interview on 9/25/17 at 10:30 a.m. with the Maintenance Director revealed that the door alarms will shut off in two minutes and that the monitors around that door was tested that morning with no problems.He revealed that he reviewed the campus video which revealed that two staff went out the side door. He revealed that R#1 was beside the bulletin board and door, and that as the door started closing, it closed on R#1. He revealed that R#1 pushed on through the doors. He revealed that there was no audio available with the video and that he did not have a copy of it. He revealed that the Wanderguard monitor around the doors are tested daily. A follow up interview with the Maintenance Director on 10/4/17 at 2:30 p.m., revealed the video is no longer available as the video is rewritten every 3-4 days. Interview on 9/25/17 at 11:20 a.m. with Registered Nurse (RN) II revealed that she was going to her car to get her badge and some water. She revealed that the residents were being taken back to their room after breakfast. She revealed that she did not recall seeing (R#1) down in the area, she revealed she was in a hurry to get to her car and back. She revealed that the CNA's were getting residents from dining, they could only take two (2) residents at a time in the elevators. She revealed CNA JJ came out also with her at the same time. She revealed that she had just opened her car door to get her badge and water when she heard someone scream help, someone is going down the hill. She revealed that it was two family members that were yelling for help for the resident. She revealed that she tried to run and catch (R#1); but, the wheelchair was going too fast. She revealed that it went down the hill and came to a stop, (R#1) fell out of wheelchair and hit the ground on her face. She revealed that she did not hear the wander guard alarm sounding. She revealed that there were two (2) CNA's assigned to the dining room that day. She revealed that (R#1) was able to propel herself. Interview on 9/25/17 at 11:25 a.m. with CNA JJ revealed that she was headed to her car and that she went out with another nurse. She revealed that the RN II punched in the code into the door because she did not know it. She revealed that she did not hear an alarm. She revealed that she saw the (R#1) sitting on the side of the building, and that her wheel chair was not rolling at that time. She revealed that she went on to her car to get her [NAME]et; then, she saw (R#1) rolling, but, she could not catch her. She revealed that she did not know that (R#1) was not supposed to be outside. She revealed that by the time she got to (R#1) she had impacted the ground. She revealed a nurse coming to work and RN EE assisted (R#1) back into the wheel chair. She revealed that the CNA's in the dining room would not have been able to see the (R#1) on the side of the building. She revealed that she worked on the second (2nd) floor and was not familiar with (R#1). Interview on 9/25/17 at 11:27 a.m. with the Administrative Assistant KK revealed that she heard the wander guard alarm sounding. She revealed that she checked the front door and did not see anyone. She revealed that she saw the red light on the side door, she revealed that she unlocked the door and saw R#1 lying down and that the nurses were with her. A review of medical records obtained from the hospital provided documentation to show that R#1 was admitted to the hospital on [DATE] with multiple diagnose including: left frontal scalp hematoma, non-displaced acute fractures of the posterior left first and second ribs, and left acromioclavicular shoulder displacement. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On (MONTH) 22, (YEAR), RN II stated that she exited out of the facility through the secured doors adjacent to the elevators on the ground floor. RN II stated that she was not aware that R#l followed her out of the doors. RN II back was to the building as she walked towards her car in the parking lot. RN II stated that it wasn't until she got to her car, she turned around and faced the building and noted R#l rolling downhill on the sidewalk at a fast pace. RN II stated that she ran to catch R#l but she reached the bottom of the sidewalk crossed the driveway and fell outside of laundry department. R#l along with her wheel chair fell to the left side where she sustained serious injury. RN II, Nurse ZZ and CNA JJ rendered immediate care and assisted resident to wheelchair and into the facility. 2. MD and family was notified of the incident. State report sent in. 3. 8/22/2017 DHS made the request of the Maintenance Director to change the code immediately to prevent use of the side door in question 8/22/2017 Signs were placed on both sides of the door requesting all visitors and partners to use the front door to enter and exit the building. Partners were educated and in-serviced by our DHS and Clinical Competency Coordinator, Unit Managers of changes (MONTH) 22- 25th .In¿ services were initiated immediately and included all three shifts. Staff has been in¿ serviced on - 'No staff is permitted to Enter or Exit Coded Door Located near Ground Floor Elevators' and on 'Elopement Prevention Policy'. 146/157 partners. No partners will be allowed to work until they have received and understand the in-services . 4. System failure: when staff members exited the facility for a personal break, she failed to observe the location of the elopement risk resident. 5. Resident admitted to hospital secondary to fall with significant injury. 6. 10/4/2017 all residents were assessed by our Senior Nurse Consultant using the Elopement Risk Observations form. Residents identified with Elopement Risk Observation score of 11 or more have interventions in place if indicated. Residents with moderate risk scores of 5-10, have been assessed on individual basis for elopement risk with interventions initiated as indicated. Completed 10/5/2017. 7. 10/4/2017 all residents' wander guard bracelets are checked daily times 7 days a week by Restorative CNAs for signal and proper functioning. - on going 8. 10/4/2017 all residents with wander guard devices will have placement checked q shift by the nurse and documented on the MAR. on going. 9. 10/4/2017 all doors with wander guard system were checked by the Maintenance Director, maintenance assistance or a member of nursing staff if the director is not on duty. Daily times 7 days a week and ongoing. 10. 10/4/2017 Wander guard books updated with current residents at risk completed 10/5/17. 11. 10/4/2017 Additional wander guard books added to new secured locations to provide privacy but easy access: behind the front receptionist desk, locked in the meal service closet in main dining room, therapy department. Books were already maintained at both nursing station, unit 1 and 2, and at the front receptionist's desk. Done 10/4/2017 12. 10/4/2017 in-services were held by Clinical Competency Coordinator, OHS, ADHS and Senior Nurse Consultant and Administrator for all staff- clinical and nonclinical, regarding location of wander guard books, identification of elopement risk residents by Pink tape or ribbon on wheel chairs or other assistive devices. Pink tape on name outside of resident room. Code Pink (missing resident), supervision of elopement risk residents to and from the ground level, and other topics regarding elopement procedures. 146 out of 157 partners. To include RNs- 11/12, LPN's 27/30,CNAs 59/62, Administrative department 7/7, Dietary 9/11,Housekeeping 11/14, Laundry 4/5, Maintenance department 1/1,Admissions 1/1,Social Services 1/1,Activity department 1/1,therapy 12/15 Medical records 1/1 and 3 Corporate partners. The reminder of the partners have been notified that they must complete their in- services with Clinical Competency Coordinator or OHS prior to returning to work. Done 10/5/17 13. All admissions/readmissions completed by the nurse. Those who have been identified with the potential to be affected and will have the Elopement Risk Observation form completed and interventions put in place as indicated by the admission nurse. Completed 10/5/17 and ongoing. 14. All new admission records within last 7 days completed by OHS/ADHS to be reviewed to ensure appropriate interventions are in place and care plans updated as indicated. Completed 10/5/17 15. All current elopement risk residents had their nursing care plans and behavioral management communication sheet form updated by Senior Nurse Consultant. The wander guard books' pictures and descriptions were also updated at this time. Completed 10/5/17. 16. Reviewed with 32 out of 37 nurses the expectation of giving shift reports to include Elopement risk patients. The other 7 nurses will not be allowed to work until in-serviced. Done 10/5/17 17. The elopement risk residents are now being listed on the nursing shift report on both nursing units. Done 10/4/17. 18. Wander guard book will be brought to Daily Clinical meeting and will review all new admission charts for Elopement risk that need to have immediate interventions and wander guard book updates. Done 10/5/17. 19. When resident enters building with score of 11 or more on the Elopement risk observation form, OHS, ADHS or Unit Manager will be notified to assess for appropriate interventions to reduce risk of elopement. Ongoing 20. Restorative CNAs and CNAs from unit 1 and unit 2 have been assigned to supervise the ground floor holding area and dining room daily during meals and activity assistants will monitor and document daily on elopement risk residents returned to their designated areas safely. Using the supervision tool each meal and activities. 21. Restorative Aides and Activity Aides have been assigned to escort elopement risk resident back to their designated areas after meals and activity first. Ongoing 22. Wander guard books has be updated as indicated with changes. Done 10/5/2017. 23. Administrator will review all allegations of abuse, neglect and falls with serious injury to ensure accurate investigation was comp completed and reporting was completed per current policy ongoing. 24. Case Mix Director will ensure patient centered care interventions are incorporated on the Elopement risk care plan during the patient assessment period upon admission, quarterly, annual and with significant changes. This will be Ongoing 25. Ongoing review of the elopement procedures is added to the staff's monthly Town Hall meeting presented by Administrator. Elopement and safety topic will be added to the quarterly family night agenda to raise awareness. Ongoing quarterly. 26. Door adjunct to the elevators remain out of use. Only key personal to include Administrator, Maintenance Director, OHS and RN supervisors evening and night shifts and the Receptionist will have the code not to share with anyone. The code will be changed monthly. Done 10/4/2017 27. The doors are no longer on an automatic opener. After using the key pad the door will open manual and sensors have been installed on right and left door to allow wander guard to alarm if near the door. Done 10/5/2017 28. Alarm sound adjusted louder for the wander guard system 10/5/2017 29. 10/4/2017 if the door must be used to allow delivery or ambulance in an emergency Only key personal to include Administrator, Maintenance Director, DHS and RN supervisors evening and night shifts and the Receptionist must remain at the door to ensure the door latch and locks. Ongoing 30. Daily Review every new admission/readmission's Elopement Risk Observation Form for compliance and timeliness of interventions ongoing in the morning clinical meetings. Ongoing 31. Updated the nursing 24 hour report form changes to the elopement risk list. This our tool used as a guide for our morning clinical meetings to follow up from previous day activity. 10/4/2017 32. Audit tool and paper test created and utilized for the DHS, Clinical Competency Coordinator to verify all staff awareness of Elopement at risk procedures and identifiers. Individual education was rendered to all partners with a score less than 100 to further educate that partner after which the partner was allowed to correct their wrong answers with the right one. Done 10/5/2017. 33. New partner orientation will have written test administered to all partners prior to completing orientation by the Clinical Competency Coordinator. 10/4/2017 34. Completed chart check form to be given to DHS within 24 hours of resident admission/readmission. Weekend admissions/readmissions' forms will be given to DHS the following Monday for follow up DHS or ADHS will be notified on the weekends by nurse of new or readmissions elopement risk score of 11 or more to ensure appropriate interventions have been put in place. DHS or ADHS will notify Administrator of the newly identified patient. This will be Ongoing 35. Elopement risk residents will continued to be reviewed in Behavioral Management Program week weekly if indicated. Ongoing. 36. Daily Random audit of elopement risk patients are being assisted to and from the ground floor after meals or activities. Started on 10/4/2017 and ongoing 37. Findings will be included in monthly/quarterly Quality Assurance meetings ongoing 38. Administrator will be responsible for overseeing the A[NAME] to ensure compliance through daily rounding 5 days a week. DHS or ADHS will notify Administrator of the newly identified patients at risk for Elopement on the weekends. This will be Ongoing 39. Area Vice President have reviewed with me my job description and in serviced me on my role as Administrator to carry out my responsibilities. Done 10/5/2017 The State Survey Agency (SSA) validated the facility's Credible Allegation of Immediate Jeopardy Removal as follows: 1 and 2. Confirmed during survey. 3. 10/4/17 at 2:00 p.m. sign noted on both sides of the side exit door where R#1 eloped for Visitors and partners to use front entrance door. Review of in-service sign in sheets dated 8/22/17 through 8/25/17 titled no staff is permitted to enter or exit coded door located near ground floor elevators and Elopement Prevention. Sign in sheet reveals that all staff have been educated as of 10/6/17. 6. Review of the residents records revealed that all resident's had been assessed for wandering/elopement behaviors and based upon their score were placed on the resident wandering list. (ten residents were included on the wandering list: (R#3, R#9, R#10, R#17, R#14, R#13, R#12, R#2, R#15 and R#16). 7. Review of the Restorative Certified Nursing Assistant (CNA) check list for the residents on the wandering list, the Wanderguard bracelets are checked daily for signal and proper functioning. 8. Review of the Medication Administration Record (MAR) for residents on the wandering list revealed that the Wanderguards are checked per shift for placement, by the nurses, and recorded on the MAR. 9. Review of the Maintenance Director 's Wanderguard audit tool that doors equipped with a wanderguard are checked and recorded daily, 7 days per week. 10 and 11. Review of the Wanderguard books which are located at the nurses' stations, front desk and in a locked area of the dining room where reviewed at all locations. 12. Review of the new policy Wandering/Elopement confirmed changes to include: Residents who are a Wandering/Elopement Risk have Pink tape or ribbon on their wheel chairs or other assistive devices and on the door name plate. Code Pink would indicate a missing resident. Review of the in-service sheets 10/4/17 revealed that 146 staff members have been in-serviced to date on the new Wandering/Elopement policy including how to identify a resident as risk. 13. R#17 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident is ambulatory. Record review revealed the resident was assessed for Wandering/Elopement behaviors on 10/6/17 with a score of 11 indicating the resident is a risk. The resident has a Wanderguard bracelet on his left wrist and a pink ribbon on his left wrist. Observation on 10/6/17 at 5:27 p.m. of resident walking on the unit near the elevator, with a bag in his hand, when the elevator door opened he attempted to enter. Staff was near by and distracted the resident until the elevator door closed. The resident was aggressive towards the staff and difficult to distract. Another staff member contacted the Assistant Director of Health Services (ADHS) at this time who was able to get the resident to move to another area of the unit. An interview with the ADHS at this time, revealed the resident is always saying he needs to catch the train and always walks around with a bag of popcorn. He further stated that the resident can be very aggressive towards the female staff members but does respond when he speaks with the resident. 14. Review of R#17's, admitted on [DATE], care plan revealed he is care plan was updated on 10/2/17 for Wandering/Elopement behaviors with interventions for distracting the resident. 15. Record review, on 10/6/17, of the resident's on the Wandering/Elopement list (R#3, R#9, R#10, R#17, R#14, R#13, R#12, R#2, R#15 and R#16) revealed that the resident's assessments and care plans were updated to reflect their risk and behaviors and were included in the Wanderguard books with photographs and descriptions. 16 and 17. Review of the 24 hour reports and nursing interviews confirmed that shift reports and 24 hour reports include Wandering/Elopement behaviors for the on-coming shift. 18. An interview with the DHS on 10/6/17 at 6:00 p.m. confirms that the Wanderguard book and new Admissions are discussed in the Daily Clinical meeting. 19. There had been no new admissions since 10/4/17 to confirm this portion of the A[NAME]. 20 and 21. Review of the Supervision tool utilized for each meal and activities confirms that restorative aides are assigned to supervise and return the wandering residents to their units. This tool is hanging in the dining room area and signed off by the restorative aides at the end of meals and activities. 22. Review of the Wanderguard books revealed they are current as of 10/6/17. 23. An interview with the Administrator on 10/6/17 at 2:00 p.m. confirmed there have been no allegations of abuse or neglect since 10/4/17. The Administrator is notified of any falls that take place. 24. Review of the patient assessments and care plans revealed they were updated and would be re-assessed upon admission, quarterly, annual and with significant changes per an interview with the DHS on 10/6/17 at 6:00 p.m. 25. Review of the Town hall meeting which was held on 9/29/17 and discussed elopement. They have not held a Family night meeting yet. 26. 27 and 28. An interview and observation with the Maintenance Director on 10/6/17 at 3:57 p.m. revealed the door can only be opened with a code that only two people in the building have access to at this time. All doors with Wanderguards were checked for functioning at this time utilizing a Wanderguard. During interviews with staff they confirmed that they did not have the code for this door. The Administrator does have the code. The Maintenance Director did confirm that in case of a fire the door would automatically unlock, as would all exit doors in the facility. The Maintenance Director demonstrated at this time that the door would alarm if a resident with a Wanderguard was near this door. Per the Maintenance Director the Wanderguard alarm sound has been increased for all doors armed with a Wanderguard system. 29. Observation and interview with the Administrator on 10/6/17 at 4:30 p.m. revealed that a bench has been placed beside the side exit door and that when a delivery is made that administrative staff must be sitting at the bench until the delivery is complete and ensure that the door is locked again. She states that it is usually her that has this duty. 30. An interview with the DHS on 10/6/17 at 6:00 p.m. confirms that the Wanderguard book and new Admissions are discussed in the Daily Clinical meeting. 31. Review of a 24-hour report dated 10/6/17 confirms that Elopement risk list is discussed and included on the 24-hour report. 32. Review of the Audit tool and paper test that were given to the staff. Staff persons who did score less than 100 percent were given further education and re-tested to ensure complete understanding and a 100 percent score. 33. There were no new staff since 10/4/17 to confirm this portion of the A[NAME] although the policy does reflect this will occur. 34. There were no new admission at risk for elopement at this time. During an interview with the Administrator, DHS and ADHS on 10/6/17 at 2:00 p.m. confirmed this finding. 35. An interview with the ADHS on 10/6/17 at 5:27 p.m. confirmed while reviewing R#17 record that the resident was being assessed for his behaviors on the weekly Behavioral Management Program. 36. Review of the Audit tool dated 10/4/17 documents random elopement resident being assisted to and from the ground floor daily. 37 and 38. An interview with the Administrator on 10/6/17 at 6:15 p.m. that the last QA meeting was 9/28/17 which included Elopement and falls. The Quality Assurance (QA) committee meets monthly and includes the Medical Director. The Administrator revealed that she is responsible for the QA meetings and is responsible for overseeing the A[NAME] to ensure that the facility is in compliance. 39. Review of the Position Description Acknowledgement agreement and in-service dated 10/5/17 and signed by the Administrator and the Corporate Leader. Interviews with Licensed Practical Nurses (LPN) on 10/6/17, LPN AE at 2:21 p.m., LPN AB at 2:55 p.m., LPN RR at 4:26 p.m., LPN MM at 4:45 p.m., LPN AG at 5:09 p.m., LPN AH at 5:20 p.m. and LPN AI at 5:35 p.m. and Registered Nurse KK at 4:36 p.m., revealed they had participated in multiple in-services specific to wandering/elopement, monitoring placement of Wanderguards and recording on the MAR, assessing new admissions for wandering/elopement risk, restorative aide assignments for dining and activities for resident's with wandering/elopement risk, including wandering/elopement behaviors on the 24-hour report, updating care plans for wandering/elopement behaviors, notifying the DHS of new admissions with wandering/elopement risk and the new Wandering/Elopement Policy that includes Code Pink and using pink ribbons, tape on devices and on the resident door name tag to identify residents at risk . They also revealed being in-serviced on not using the side door, by the elevator, for entrance or exit and to always check behind you for residents when exiting an exit door. Interviews with Certified Nursing Assistants (CNA) on 10/6/17, CNA PP at 1:53 p.m., CNA AF at 2:28 p.m., CNA AC at 2:36 p.m., CNA AD at 2:42 p.m., CNA YY at 3:04 p.m., CNA QQ at 4:20 p.m., and CNA SS at 4:31 p.m. revealed they had participated in multiple in-services related to the new Wandering/Elopement Policy, identifying residents at risk with pink ribbons, pink tape on their wheelchairs, assistive devices or their person and on the resident's room name tags, notifying the nurses if a resident has wandering/elopement behaviors, use of the side door by the elevator and assignments for dining and activities to ensure residents at risk are not left alone off their units. An interview with the Rehabilitation Manager OO on 10/6/17 at 1:41 p.m. revealed that she sits at the Rehabilitation door entrance during the day as the facility does outpatient rehab as well. If no one is at their exit door then the door is locked. She has been in-serviced on wandering/elopement residents, the new Wandering/Elopement Policy-Code Pink for a missing resident and that wandering/elopement risk residents had pink ribbons or tape on their wheel chairs or assistive devices. She is aware that the side door, nearest the elevators, cannot be used be staff or visitors. Interviews with the Rehabilitation Staff on 10/6/17 at 3:37 p.m., DPT TT, ST UU, OT VV, Rehab Tech WW revealed that they had been in-serviced on wandering/elopement residents, the new Wandering/Elopemen

Based on record review and staff interviews, the facility failed to ensure that one resident (R#1) who was care planned for elopement risk was supervised to prevent R#1 from exiting the building unsupervised and sustaining serious injury after a fall resulting in hospitalization . The sample was 17 residents. On 10/4/17, a determination was made that a situation in which the facility's noncompliance with one or more requirement of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Health Services (DHS) where informed of the immediate jeopardy on 10/4/17 at 4:33 p.m. The noncompliance related to the immediate jeopardy was identified to exist on 8/22/17 when R#1 exited the building. The Immediate Jeopardy was identified when one resident (R#1), who was an elopement risk, exited the facility in a wheelchair on 8/22/17, following staff who exited the building to the parking lot and the door remained open, resulting in the resident traveling approximately 90 feet, then crashing into a retaining wall. The resident was transferred to the hospital with an admitting [DIAGNOSES REDACTED]. On 10/5/17, the facility provided a Credible Allegation of Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediacy on 10/6/17. Based on validation of the A[NAME], the State Survey Agency (SSA) determined the Immediate Jeopardy was removed on 10/6/17. The Scope and Severity were lowered to a D level while the facility develops and implements a Plan of Correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. Findings include: Record Review for R#1 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for R#1 documented a Brief Interview for Mental Status (BIMS) score of 99 indicating the resident was severely impaired with regard to cognitive skills for daily decision making. Review of the care plan for R#1 identified the resident as an elopement risk, with the onset of the problem documented as 3/20/14, and was updated on 1/15/17, 4/20/17, and 7/14/17. Goals included: Will not elope from the facility by next review. Approaches included: Place resident in area where constant observation is possible PRN (as needed), Do not allow resident to leave facility alone without s/o (The Director of Health Services confirmed via telephone on 9/28/17 at 10:44 a.m. that s/o means someone) or supervision, Monitor/document resident location in the facility as indicated, Maintain locks on doors are in proper working order, Apply Wanderguard; keep Wanderguard bracelet (sic) in proper working order, Notify MD (medical doctor) as warranted. Record review revealed a physician's orders [REDACTED]. A review of the facility's Incident Log provided documentation to show that on 8/22/17 at 9:30 a.m., R#1 sustained a fall with significant injury in the parking lot and was transported to the emergency room . The facility's Fall Risk Observation Form noted that R#1 sustained a hematoma on left forehead. Review of medical records obtained from the hospital provided documentation to show that R#1 was admitted to the hospital on [DATE] with the following [DIAGNOSES REDACTED]. During an interview, on 9/9/17 at 5:30 p.m. the Administrator revealed that R#1 was sitting in the holding area after breakfast waiting to be transported back to her unit when she followed staff out the side exit door. Staff was unaware that R#1 was behind them. The Administrator also revealed that residents, at risk for elopement, had not previously been assigned specific staff to transport them from the dining area and back to their unit. During an interview on 9/16/17 the DHS revealed that at the time of the incident/elopement of R#1, that one staff person was assisting with the residents on the elevator, and another staff was monitoring residents in the dining room. She confirmed that the resident was not under constant observation while waiting for the elevator. Interview on 9/25/17 at 10:30 a.m. with the Maintenance Director revealed that the door alarms will shut off in two minutes and that the monitors around that door was tested that morning with no problems.He revealed that he reviewed the campus video which revealed that two staff went out the side door. He revealed that (R#1) was beside the bulletin board and door, and that as the door started closing, it closed on (R#1). He revealed that (R#1) pushed on through the doors. Cross reference to Tag 0323 The facility implemented the following actions to remove the Immediate Jeopardy: 1. On (MONTH) 22, (YEAR), RN II stated that she exited out of the facility through the secured doors adjacent to the elevators on the ground floor. RN II stated that she was not aware that R#l followed her out of the doors. RN II back was to the building as she walked towards her car in the parking lot. RN II stated that it wasn't until she got to her car, she turned around and faced the building and noted R#l rolling downhill on the sidewalk at a fast pace. RN II stated that she ran to catch R#l but she reached the bottom of the sidewalk crossed the driveway and fell outside of laundry department. R#l along with her wheel chair fell to the left side where she sustained serious injury. RN II, Nurse ZZ and CNA JJ rendered immediate care and assisted resident to wheelchair and into the facility. 2. MD and family was notified of the incident. State report sent in. 3. 8/22/2017 DHS made the request of the Maintenance Director to change the code immediately to prevent use of the side door in question 8/22/2017 Signs were placed on both sides of the door requesting all visitors and partners to use the front door to enter and exit the building. Partners were educated and in-serviced by our DHS and Clinical Competency Coordinator, Unit Managers of changes (MONTH) 22- 25th .In¿ services were initiated immediately and included all three shifts. Staff has been in¿ serviced on - 'No staff is permitted to Enter or Exit Coded Door Located near Ground Floor Elevators' and on 'Elopement Prevention Policy'. 146/157 partners. No partners will be allowed to work until they have received and understand the in-services . 4. System failure: when staff members exited the facility for a personal break, she failed to observe the location of the elopement risk resident. 5. Resident admitted to hospital secondary to fall with significant injury. 6. 10/4/2017 all residents were assessed by our Senior Nurse Consultant using the Elopement Risk Observations form. Residents identified with Elopement Risk Observation score of 11 or more have interventions in place if indicated. Residents with moderate risk scores of 5-10, have been assessed on individual basis for elopement risk with interventions initiated as indicated. Completed 10/5/2017. 7. 10/4/2017 all residents' wander guard bracelets are checked daily times 7 days a week by Restorative CNAs for signal and proper functioning. - on going 8. 10/4/2017 all residents with wander guard devices will have placement checked q shift by the nurse and documented on the MAR. on going. 9. 10/4/2017 all doors with wander guard system were checked by the Maintenance Director, maintenance assistance or a member of nursing staff if the director is not on duty. Daily times 7 days a week and ongoing. 10. 10/4/2017 Wander guard books updated with current residents at risk completed 10/5/17. 11. 10/4/2017 Additional wander guard books added to new secured locations to provide privacy but easy access: behind the front receptionist desk, locked in the meal service closet in main dining room, therapy department. Books were already maintained at both nursing station, unit 1 and 2, and at the front receptionist's desk. Done 10/4/2017 12. 10/4/2017 in-services were held by Clinical Competency Coordinator, OHS, ADHS and Senior Nurse Consultant and Administrator for all staff- clinical and nonclinical, regarding location of wander guard books, identification of elopement risk residents by Pink tape or ribbon on wheel chairs or other assistive devices. Pink tape on name outside of resident room. Code Pink (missing resident), supervision of elopement risk residents to and from the ground level, and other topics regarding elopement procedures. 146 out of 157 partners. To include RNs- 11/12, LPN's 27/30,CNAs 59/62, Administrative department 7/7, Dietary 9/11,Housekeeping 11/14, Laundry 4/5, Maintenance department 1/1,Admissions 1/1,Social Services 1/1,Activity department 1/1,therapy 12/15 Medical records 1/1 and 3 Corporate partners. The reminder of the partners have been notified that they must complete their in- services with Clinical Competency Coordinator or OHS prior to returning to work. Done 10/5/17 13. All admissions/readmissions completed by the nurse. Those who have been identified with the potential to be affected and will have the Elopement Risk Observation form completed and interventions put in place as indicated by the admission nurse. Completed 10/5/17 and ongoing. 14. All new admission records within last 7 days completed by OHS/ADHS to be reviewed to ensure appropriate interventions are in place and care plans updated as indicated. Completed 10/5/17 15. All current elopement risk residents had their nursing care plans and behavioral management communication sheet form updated by Senior Nurse Consultant. The wander guard books' pictures and descriptions were also updated at this time. Completed 10/5/17. 16. Reviewed with 32 out of 37 nurses the expectation of giving shift reports to include Elopement risk patients. The other 7 nurses will not be allowed to work until in-serviced. Done 10/5/17 17. The elopement risk residents are now being listed on the nursing shift report on both nursing units. Done 10/4/17. 18. Wander guard book will be brought to Daily Clinical meeting and will review all new admission charts for Elopement risk that need to have immediate interventions and wander guard book updates. Done 10/5/17. 19. When resident enters building with score of 11 or more on the Elopement risk observation form, OHS, ADHS or Unit Manager will be notified to assess for appropriate interventions to reduce risk of elopement. Ongoing 20. Restorative CNAs and CNAs from unit 1 and unit 2 have been assigned to supervise the ground floor holding area and dining room daily during meals and activity assistants will monitor and document daily on elopement risk residents returned to their designated areas safely. Using the supervision tool each meal and activities. 21. Restorative Aides and Activity Aides have been assigned to escort elopement risk resident back to their designated areas after meals and activity first. Ongoing 22. Wander guard books has be updated as indicated with changes. Done 10/5/2017. 23. Administrator will review all allegations of abuse, neglect and falls with serious injury to ensure accurate investigation was comp completed and reporting was completed per current policy ongoing. 24. Case Mix Director will ensure patient centered care interventions are incorporated on the Elopement risk care plan during the patient assessment period upon admission, quarterly, annual and with significant changes. This will be Ongoing 25. Ongoing review of the elopement procedures is added to the staff's monthly Town Hall meeting presented by Administrator. Elopement and safety topic will be added to the quarterly family night agenda to raise awareness. Ongoing quarterly. 26. Door adjunct to the elevators remain out of use. Only key personal to include Administrator, Maintenance Director, OHS and RN supervisors evening and night shifts and the Receptionist will have the code not to share with anyone. The code will be changed monthly. Done 10/4/2017 27. The doors are no longer on an automatic opener. After using the key pad the door will open manual and sensors have been installed on right and left door to allow wander guard to alarm if near the door. Done 10/5/2017 28. Alarm sound adjusted louder for the wander guard system 10/5/2017 29. 10/4/2017 if the door must be used to allow delivery or ambulance in an emergency Only key personal to include Administrator, Maintenance Director, DHS and RN supervisors evening and night shifts and the Receptionist must remain at the door to ensure the door latch and locks. Ongoing 30. Daily Review every new admission/readmission's Elopement Risk Observation Form for compliance and timeliness of interventions ongoing in the morning clinical meetings. Ongoing 31. Updated the nursing 24 hour report form changes to the elopement risk list. This our tool used as a guide for our morning clinical meetings to follow up from previous day activity. 10/4/2017 32. Audit tool and paper test created and utilized for the DHS, Clinical Competency Coordinator to verify all staff awareness of Elopement at risk procedures and identifiers. Individual education was rendered to all partners with a score less than 100 to further educate that partner after which the partner was allowed to correct their wrong answers with the right one. Done 10/5/2017. 33. New partner orientation will have written test administered to all partners prior to completing orientation by the Clinical Competency Coordinator. 10/4/2017 34. Completed chart check form to be given to DHS within 24 hours of resident admission/readmission. Weekend admissions/readmissions' forms will be given to DHS the following Monday for follow up DHS or ADHS will be notified on the weekends by nurse of new or readmissions elopement risk score of 11 or more to ensure appropriate interventions have been put in place. DHS or ADHS will notify Administrator of the newly identified patient. This will be Ongoing 35. Elopement risk residents will continued to be reviewed in Behavioral Management Program week weekly if indicated. Ongoing. 36. Daily Random audit of elopement risk patients are being assisted to and from the ground floor after meals or activities. Started on 10/4/2017 and ongoing 37. Findings will be included in monthly/quarterly Quality Assurance meetings ongoing 38. Administrator will be responsible for overseeing the A[NAME] to ensure compliance through daily rounding 5 days a week. DHS or ADHS will notify Administrator of the newly identified patients at risk for Elopement on the weekends. This will be Ongoing 39. Area Vice President have reviewed with me my job description and in serviced me on my role as Administrator to carry out my responsibilities. Done 10/5/2017 The State Survey Agency (SSA) validated the facility's Credible Allegation of Immediate Jeopardy Removal as follows: 1 and 2. Confirmed during survey. 3. 10/4/17 at 2:00 p.m. sign noted on both sides of the side exit door where R#1 eloped for Visitors and partners to use front entrance door. Review of in-service sign in sheets dated 8/22/17 through 8/25/17 titled no staff is permitted to enter or exit coded door located near ground floor elevators and Elopement Prevention. Sign in sheet reveals that all staff have been educated as of 10/6/17. 6. Review of the residents records revealed that all resident's had been assessed for wandering/elopement behaviors and based upon their score were placed on the resident wandering list. (ten residents were included on the wandering list: (R#3, R#9, R#10, R#17, R#14, R#13, R#12, R#2, R#15 and R#16). 7. Review of the Restorative Certified Nursing Assistant (CNA) check list for the residents on the wandering list, the Wanderguard bracelets are checked daily for signal and proper functioning. 8. Review of the Medication Administration Record (MAR) for residents on the wandering list revealed that the Wanderguards are checked per shift for placement, by the nurses, and recorded on the MAR. 9. Review of the Maintenance Director 's Wanderguard audit tool that doors equipped with a wanderguard are checked and recorded daily, 7 days per week. 10 and 11. Review of the Wanderguard books which are located at the nurses' stations, front desk and in a locked area of the dining room where reviewed at all locations. 12. Review of the new policy Wandering/Elopement confirmed changes to include: Residents who are a Wandering/Elopement Risk have Pink tape or ribbon on their wheel chairs or other assistive devices and on the door name plate. Code Pink would indicate a missing resident. Review of the in-service sheets 10/4/17 revealed that 146 staff members have been in-serviced to date on the new Wandering/Elopement policy including how to identify a resident as risk. 13. R#17 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident is ambulatory. Record review revealed the resident was assessed for Wandering/Elopement behaviors on 10/6/17 with a score of 11 indicating the resident is a risk. The resident has a Wanderguard bracelet on his left wrist and a pink ribbon on his left wrist. Observation on 10/6/17 at 5:27 p.m. of resident walking on the unit near the elevator, with a bag in his hand, when the elevator door opened he attempted to enter. Staff was near by and distracted the resident until the elevator door closed. The resident was aggressive towards the staff and difficult to distract. Another staff member contacted the Assistant Director of Health Services (ADHS) at this time who was able to get the resident to move to another area of the unit. An interview with the ADHS at this time, revealed the resident is always saying he needs to catch the train and always walks around with a bag of popcorn. He further stated that the resident can be very aggressive towards the female staff members but does respond when he speaks with the resident. 14. Review of R#17's, admitted on [DATE], care plan revealed he is care plan was updated on 10/2/17 for Wandering/Elopement behaviors with interventions for distracting the resident. 15. Record review, on 10/6/17, of the resident's on the Wandering/Elopement list (R#3, R#9, R#10, R#17, R#14, R#13, R#12, R#2, R#15 and R#16) revealed that the resident's assessments and care plans were updated to reflect their risk and behaviors and were included in the Wanderguard books with photographs and descriptions. 16 and 17. Review of the 24 hour reports and nursing interviews confirmed that shift reports and 24 hour reports include Wandering/Elopement behaviors for the on-coming shift. 18. An interview with the DHS on 10/6/17 at 6:00 p.m. confirms that the Wanderguard book and new Admissions are discussed in the Daily Clinical meeting. 19. There had been no new admissions since 10/4/17 to confirm this portion of the A[NAME]. 20 and 21. Review of the Supervision tool utilized for each meal and activities confirms that restorative aides are assigned to supervise and return the wandering residents to their units. This tool is hanging in the dining room area and signed off by the restorative aides at the end of meals and activities. 22. Review of the Wanderguard books revealed they are current as of 10/6/17. 23. An interview with the Administrator on 10/6/17 at 2:00 p.m. confirmed there have been no allegations of abuse or neglect since 10/4/17. The Administrator is notified of any falls that take place. 24. Review of the patient assessments and care plans revealed they were updated and would be re-assessed upon admission, quarterly, annual and with significant changes per an interview with the DHS on 10/6/17 at 6:00 p.m. 25. Review of the Town hall meeting which was held on 9/29/17 and discussed elopement. They have not held a Family night meeting yet. 26. 27 and 28. An interview and observation with the Maintenance Director on 10/6/17 at 3:57 p.m. revealed the door can only be opened with a code that only two people in the building have access to at this time. All doors with Wanderguards were checked for functioning at this time utilizing a Wanderguard. During interviews with staff they confirmed that they did not have the code for this door. The Administrator does have the code. The Maintenance Director did confirm that in case of a fire the door would automatically unlock, as would all exit doors in the facility. The Maintenance Director demonstrated at this time that the door would alarm if a resident with a Wanderguard was near this door. Per the Maintenance Director the Wanderguard alarm sound has been increased for all doors armed with a Wanderguard system. 29. Observation and interview with the Administrator on 10/6/17 at 4:30 p.m. revealed that a bench has been placed beside the side exit door and that when a delivery is made that administrative staff must be sitting at the bench until the delivery is complete and ensure that the door is locked again. She states that it is usually her that has this duty. 30. An interview with the DHS on 10/6/17 at 6:00 p.m. confirms that the Wanderguard book and new Admissions are discussed in the Daily Clinical meeting. 31. Review of a 24-hour report dated 10/6/17 confirms that Elopement risk list is discussed and included on the 24-hour report. 32. Review of the Audit tool and paper test that were given to the staff. Staff persons who did score less than 100 percent were given further education and re-tested to ensure complete understanding and a 100 percent score. 33. There were no new staff since 10/4/17 to confirm this portion of the A[NAME] although the policy does reflect this will occur. 34. There were no new admission at risk for elopement at this time. During an interview with the Administrator, DHS and ADHS on 10/6/17 at 2:00 p.m. confirmed this finding. 35. An interview with the ADHS on 10/6/17 at 5:27 p.m. confirmed while reviewing R#17 record that the resident was being assessed for his behaviors on the weekly Behavioral Management Program. 36. Review of the Audit tool dated 10/4/17 documents random elopement resident being assisted to and from the ground floor daily. 37 and 38. An interview with the Administrator on 10/6/17 at 6:15 p.m. that the last QA meeting was 9/28/17 which included Elopement and falls. The Quality Assurance (QA) committee meets monthly and includes the Medical Director. The Administrator revealed that she is responsible for the QA meetings and is responsible for overseeing the A[NAME] to ensure that the facility is in compliance. 39. Review of the Position Description Acknowledgement agreement and in-service dated 10/5/17 and signed by the Administrator and the Corporate Leader. Interviews with Licensed Practical Nurses (LPN) on 10/6/17, LPN AE at 2:21 p.m., LPN AB at 2:55 p.m., LPN RR at 4:26 p.m., LPN MM at 4:45 p.m., LPN AG at 5:09 p.m., LPN AH at 5:20 p.m. and LPN AI at 5:35 p.m. and Registered Nurse KK at 4:36 p.m., revealed they had participated in multiple in-services specific to wandering/elopement, monitoring placement of Wanderguards and recording on the MAR, assessing new admissions for wandering/elopement risk, restorative aide assignments for dining and activities for resident's with wandering/elopement risk, including wandering/elopement behaviors on the 24-hour report, updating care plans for wandering/elopement behaviors, notifying the DHS of new admissions with wandering/elopement risk and the new Wandering/Elopement Policy that includes Code Pink and using pink ribbons, tape on devices and on the resident door name tag to identify residents at risk . They also revealed being in-serviced on not using the side door, by the elevator, for entrance or exit and to always check behind you for residents when exiting an exit door. Interviews with Certified Nursing Assistants (CNA) on 10/6/17, CNA PP at 1:53 p.m., CNA AF at 2:28 p.m., CNA AC at 2:36 p.m., CNA AD at 2:42 p.m., CNA YY at 3:04 p.m., CNA QQ at 4:20 p.m., and CNA SS at 4:31 p.m. revealed they had participated in multiple in-services related to the new Wandering/Elopement Policy, identifying residents at risk with pink ribbons, pink tape on their wheelchairs, assistive devices or their person and on the resident's room name tags, notifying the nurses if a resident has wandering/elopement behaviors, use of the side door by the elevator and assignments for dining and activities to ensure residents at risk are not left alone off their units. An interview with the Rehabilitation Manager OO on 10/6/17 at 1:41 p.m. revealed that she sits at the Rehabilitation door entrance during the day as the facility does outpatient rehab as well. If no one is at their exit door then the door is locked. She has been in-serviced on wandering/elopement residents, the new Wandering/Elopement Policy-Code Pink for a missing resident and that wandering/elopement risk residents had pink ribbons or tape on their wheel chairs or assistive devices. She is aware that the side door, nearest the elevators, cannot be used be staff or visitors. Interviews with the Rehabilitation Staff on 10/6/17 at 3:37 p.m., DPT TT, ST UU, OT VV, Rehab Tech WW revealed that they had been in-serviced on wandering/elopement residents, the new Wandering/Elopement Policy-Code Pink for a missing resident and that wandering/elopement risk residents had pink ribbons or tape on their wheel chairs or assistive devices. They are aware that the side door, nearest the elevators, cannot be used be staff or visitors. They confirmed that they cannot see the area outside of the doors near the elevators although it is beside that area. Observation and interview at this time revealed that the Physical Therapy (PT) windows are covered preventing anyone in PT from seeing the outside area. An interview on 10/6/17 at 2:45 p.m. with housekeeper ZZ revealed that she has been in-serviced on the new Wandering/Elopement Policy-Code Pink indicating a missing resident. She is aware that staff cannot use the side door, nearest the elevators any longer. She confirms that only a few management staff have the code. An interview with Laundry Aide XX on 10/6/17 at 3:01 p.m. revealed that she has been in-serviced on the new Wandering/Elopement Policy-Code Pink indicating a missing resident. She is aware that staff cannot use the side door, nearest the elevators any longer. She confirms that only a few management staff have the code. An interview with the Interim Dietary Manager LL on 10/6/17 at 4:41 p.m. revealed that she is new but has been in-serviced on the new Wandering/Elopement Policy-Code Pink which would be used for a missing resident. She is aware of the monitoring of wandering/elopement resident by the restorative aides and that a wandering/elopement book is kept in the a secured location in the dining room. She is aware that resident's at risk for wandering/elopement have pink ribbon or tape on their wheel chairs or other assistive devices and if they are ambulatory on their person. She is aware that only a few management staff have the code for the side door, nearest to the elevator, and that all staff and visitors should use the front entrance. Staff should ensure that residents are not following them when they enter or exit the building. An interview with the Activity Director NN on 10/6/17 at 4:49 p.m. revealed that she has been in-serviced on the new Wandering/Elopement Policy. She is aware that restorative aides must accompany residents at risk to and from their units during meal service and activities. Residents are not to be placed in front of the elevators any longer.

Based on observations, record review, and staff interview the facility failed to ensure medication required to manage a resident 's pain was available and administered as ordered for one (1) resident (#118) from a sample of forty-four (44) residents. This failure resulted in actual harm for resident #118 that was not immediate jeopardy. Findings include: Review of the clinical record for resident #118 revealed that the resident was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan developed 3/16/11 and updated quarterly, revealed the resident had pain related to sacral decubitus. Review of the resident's physician's orders [REDACTED]. Interview with staff Licensed Practice Nurse (LPN) " NN " on 3/14/13 at 10:32 a.m. revealed the resident had not received any pain medication that morning. She further revealed that the resident was scheduled to receive a pain medication every 12 hours but did not receive the medication that morning due to having none on hand, as there was no current signed prescription for the narcotic. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She did receive Tylenol 650 mg at 9 p.m. on 3/13/13. Interview with unit manager (UM) " AA " on 3/15/13 at 9:02 a.m. revealed that medications are delivered once daily, on night shift, unless an emergency medication needs to come from the back-up pharmacy. When there are 5 to 6 doses left, the nurse pulls the re-order sticker off the medication card, and the medication is re-ordered. If a nurse orders medications and they do not come, the nurse calls the pharmacy to find out why the medication did not come. If the medication needs a re-certification, the pharmacy will let the physician know to send a new prescription. Review of the Medication Reorder form with UM " AA " revealed the resident's Vicodin was re-ordered (faxed to the pharmacy) on 3/5/13 but had not been received yet. Cross Refer to F309

Based on observation, staff interview, and record review, the facility failed to address signs of pain and provide pain management during the provision of wound care for one (1) resident (#118) from a sample of forty-four (44) residents. This failure resulted in actual harm for resident #118 that was not immediate jeopardy. Findings include: Review of the clinical record for resident #118 revealed that the resident was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan developed 3/16/11 and updated quarterly, revealed the resident had pain related to sacral decubitus. Review of the physician's orders [REDACTED].m and 9:00 p.m. Observation of the resident during the dressing change on 3/14/13 at 10:25 a.m. by staff Registered Nurse (RN) "II" revealed the resident was exclaiming in a loud voice that something was burning and repeatedly stated that this thing was burning her. The resident was attempting to physically pull away from the treatment nurse during the procedure. Interview on 3/14/13 at 10:29 a.m. with RN "II" and Certified Nursing Assistant "LL " revealed that both confirmed that the resident was in pain during wound care. Interview with RN "II" on 3/14/13 at 10:30 a.m. revealed that she sometimes medicates residents before a dressing change. She was not aware of what pain medications resident #118 was on or when she had received them last. Continued interview revealed the treatment nurse was not aware that she should have stopped the treatment when the resident complained of pain. Interview with the medication nurse, Licensed Practical Nurse (LPN) " NN " on 3/14/13 at 10:32 a.m. revealed the resident had not received any pain medication that morning. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She did receive Tylenol 650 mg at 9 p.m. on 3/13/13. Interview with the Assistant Director of Health Services (ADHS) and unit manager on 3/13/13 at 10:55 a.m. revealed the ADHS was not aware the treatment nurse should have stopped the treatment due to the resident's pain, as the pain medication would have taken 45 minutes to take effect. Interview on 3/15/13 at 9:54 a.m. with RN " II " revealed the resident does sometimes respond to wound treatment as she did on 3/14/13. She re-confirmed that the resident was in pain during the dressing change on 3/14/13.

Based on observation, record review, staff interviews and review of the Georgia Registered Nurse and Practical Nurse Practice Acts, the facility failed to ensure that services provided met professional standards of quality for one (1) resident (#118) from a sample of forty-four (44) residents. This failure resulted in actual harm for resident #118 that was not immediate jeopardy. Findings include: Review of the clinical record for resident #118 revealed that the resident was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan developed 3/16/11 and updated quarterly, revealed the resident had pain related to sacral decubitus. Review of the physician's orders [REDACTED].m and 9:00 p.m. Observation of the resident during the dressing change on 3/14/13 at 10:25 a.m. by staff Registered Nurse (RN) "II" revealed the resident was exclaiming in a loud voice that something was burning and repeatedly stated that this thing was burning her. The resident was attempting to physically pull away from the treatment nurse during the procedure but the nurse continued with the dressing change. Interview on 3/14/13 at 10:29 a.m. with RN "II" and Certified Nursing Assistant "LL " revealed that both confirmed that the resident was in pain during wound care. Interview with RN "II" on 3/14/13 at 10:30 a.m. revealed that she sometimes medicates residents before a dressing change. She was not aware of what pain medications resident #118 was on or when she had received them last. Continued interview revealed the treatment nurse was not aware that she should have stopped the treatment when the resident complained of pain. Interview with the medication nurse, Licensed Practical Nurse (LPN) " NN " on 3/14/13 at 10:32 a.m. revealed the resident had not received any pain medication that morning. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She did receive Tylenol 650 mg at 9 p.m. on 3/13/13. Interview with the Assistant Director of Health Services (ADHS) and unit manager on 3/13/13 at 10:55 a.m. revealed the ADHS was not aware the treatment nurse should have stopped the treatment due to the resident's pain, as the pain medication would have taken 45 minutes to take effect. Interview on 3/15/13 at 9:54 a.m. with RN " II " revealed the resident does sometimes respond to wound treatment as she did on 3/14/13. She re-confirmed that the resident was in pain during the dressing change on 3/14/13. Review of the Georgia Registered Professional Nurse Practice Act revealed that to practice nursing as a registered professional nurse means to perform for compensation acts which shall include but not be limited to: -Chapter 2-Standards of Nursing Practice-Section 2.2.2-Standards related to Registered Nurse responsibility for nursing practice implementation, Section K-evaluates the impact of nursing care, the client's response to therapy, the need for alternative interventions and the need to communicate and consult with other health professionals -Section M-Intervenes on the behalf of the client when problems are identified and revises the care plan as needed Review of the Georgia Practical Nurses Practice Act revealed that the practice of licensed practical nursing means the provision of care for compensation acts which shall include but not be limited to: -Chapter 2-Standards of Nursing Practice-Section 2.3.2-Standards related to Licensed Practical Nurse responsibilities for Nursing practice implementation- Section D-Assists in identification of client needs Section G-Assists in evaluation of the impact of nursing care, contributes to the evaluation of client care Section J-Implements appropriate aspects of client care in a timely manner, #3-Administers medication accurately Section L-Communicates relevant and timely client information with other health team members,#2 Client response or lack of response to therapies. Cross refer to F309

Based on record review and staff interview, the facility failed to ensure that one (1) resident (#1) who had been assessed to need the assistance of a Sit-to-Stand Lift for safe transfer, on the survey sample of eight (8) residents, was transferred utilizing the lift. This resulted in Resident #1 sustaining a fall and a femur fracture. Findings include: Record review for Resident #1 revealed a Minimum Data Set (MDS) assessment of 09/29/2010 which indicated that the resident had medical [DIAGNOSES REDACTED]. The resident's Care Plan, which documented the resident's original date of admission as 04/04/2009, also documented a problem of the resident being at risk for falls. This Care Plan specified, as an approach to address this resident's risk for falls, to assist with transfers as indicated. An assessment by the physical therapist, documented in the Therapy Notes and dated 01/07/2010, recommended the use of a Sara Lift (Sit-to-Stand Lift) for daily transfers. A Lift/Transfer Assessment Form, originally dated 12/29/2009 and dated as having been reviewed on 03/22/2010, 07/07/2010 and 10/01/2010, also indicated that a Sit-to-Stand Lift was required. Additionally, the resident's current ADL Care Plan record specified the use of a Sit-to-Stand Lift for mobility. A Nurse's Note dated 10/25/2010 documented that a Certified Nursing Assistant (CNA) had informed the nurse that she had to lower Resident #1 to the restroom floor while attempting to toilet the resident. This Note documented that the resident was assessed and complained of discomfort in the right leg, that the physician was made aware of the fall, and that an order was received to X-ray the resident's tibia, fibula and femur. The Radiological Consultation X-Ray report dated 10/25/2010 at 7:43 p.m. documented a moderately displaced fracture of the proximal femur. A Nurse's Note of 10/25/2010 at 10:45 p.m. documented that the resident was transferred to the hospital for further evaluation. During interviews with the Director of Nursing (DON) conducted on 11/05/2010 at 10:15 a.m. and 2:00 p.m., the DON stated that at the time Resident #1 had sustained the fall referenced above, CNA "AA" had not used the Sit-to-Stand lift during the resident's transfer, as specified on the resident's ADL Care Plan record. The DON further acknowledged that Resident #1 had been evaluated by the physical therapist to need a Sit-to-Stand lift during transfer. During interviews with CNAs "BB" and "CC" conducted on 11/05/2010 at 11:15 a.m. and 11:30 a.m., respectively, both CNAs stated that the Sit-to-Stand Lift was necessary to safely transfer Resident #1.