Every finding on record at Pruitthealth - Lafayette

Based on observations, staff interviews, and review of facility policy titled, Food Ordering, Receiving, and Storage, the facility failed to store food off the floor and failed to remove dented canned food item from the storage rack. The deficient practice had the potential to affect 70 of 73 residents receiving an oral diet. Findings include: Review of the facility policy titled Food Ordering, Receiving, and Storage revealed under Procedure: . 9. Dented cans should be kept in a separate designated area with a dented can sign, and away from regular stock. The policy also stated under Storage and Rotation Guidelines: . Food should be stored six inches from the floor. 1. Observation on 3/14/2025 at 8:00 am of the nursing staff break room revealed 29 cases of emergency water stored directly on the floor. Observation on 3/14/2025 at 8:22 am of the walk-in freezer revealed a case of sliced yellow squash and a case of split top white bread directly on the floor. During an interview on 3/14/2025 at 8:22 am the Dietary Manager (DM) revealed that they could use more food storage shelves for the freezer, but it had not been requested. Observation on 3/15/2025 at 7:45 am of the nursing staff break room revealed that the 29 cases of emergency water remained stored directly on the floor. Observation on 3/15/2025 at 8:25 am of the walk-in freezer revealed that the case of sliced yellow squash and case of spit top white bread remained directly on the floor. During an interview on 3/15/2025 at 8:25 am, the DM confirmed that the two cases of food were stored on the floor. The DM stated that the cases had been stacked, and the stack tipped over causing the two cases to be directly on the floor. The DM revealed that all food items should be stored off the floor. During an interview on 3/15/2025 at 2:30 pm, the Administrator confirmed that the cases of emergency water were stored directly on the floor in the nursing staff break room. The Administrator revealed he approved for staff to store the emergency water in the break room to prevent them from freezing in the outside storage shed. When asked why the cases were not stored off the floor and stored on empty crates or pallets, he stated that he could have but did not. During an interview on 3/16/2025 at 9:05 am, the Administrator revealed that he expected all food items not to be stored on the floor. 2. Observation on 3/14/2025 at 8:25 am of the dry storage area revealed a large can of sliced beets in the can rack that had a large dent to the side. During an interview on 3/14/2025 at 8:25 am, the DM confirmed that the can of sliced beets were stored in the can rack and that the can had a large dent on the side. The DM revealed that all dietary staff were responsible for assisting with putting groceries away when they were delivered and if any can(s) had a dent, dietary staff were to place them by the back door. The DM stated that dietary staff should not have put the can in the storage rack.

Based on observations, record reviews, staff interviews, and review of the facility's policy titled, Care Plans, the facility failed to implement the care plan related to oxygen (O2) therapy for one of 17 residents (R) (R21) receiving oxygen. The deficient practice had the potential for R21 not to receive treatment and/or care according to their needs. Findings include: Review of the facility's policy titled Care Plans revised 7/27/2023 revealed under Admission Comprehensive Plan of Care: . 4. The goal is an expected outcome the patients/residents should achieve by implementing specific interventions. Review of the 12/27/2024 quarterly Minimum Data Set (MDS) for R21 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition and is on oxygen therapy. Review of the care plan dated 5/24/2024 revealed R21 has oxygen use related to failure to maintain oxygen saturation above 90 percent and has shortness of breath when lying flat. Interventions include but is not limited to oxygen as ordered. Review of physician orders for R21 revealed an order on 12/11/2024 for Oxygen at 2 Liters Per Minute (LPM) via nasal cannula (NC) to keep O2 Saturations (Sats) greater than 90 percent. Observation on 3/14/2025 at 8:23 am revealed R21 resting in bed. She was clean with no odors present. O2 was in place via NC. O2 was set at a flow rate of 1.5 LPM. Interview during this time with R21 revealed she received 2 liters of O2. Observation on 3/15/2025 at 7:31 am revealed R21 resting in bed. She was clean with no odors present. O2 in place via NC. O2 remained at 1.5 LPM. A joint interview on 3/15/2025 at 9:05 am with MDS Coordinator AA and MDS Coordinator BB revealed it was the responsibility of the nurse to ensure new care plans were put into place or that new interventions were put into place on current care plans. They revealed they were made aware of any changes or newly added interventions to care plans during the morning meeting and by reviewing resident charts. MDS Coordinators AA and BB revealed that the staff were very good about letting them know when changes had been made to the care plans and stated that it was the responsibility of the Unit Managers (UM) to ensure staff were educated on what was on the care plan and that they understood the care plan was how they would know the care needs of a particular resident as each care plan was person centered. Interview on 3/15/2025 at 9:17 am with UM CC with UM DD present revealed that during the orientation process and periodic in-services she taught how staff should look at the resident profile and the care plan to understand care needs for an individual resident. She stated for O2 therapy she taught the staff to bend down at eye level with the O2 gauge to ensure the resident was on the ordered LPM and it was her expectation that staff were looking at the care plan, and following those directions to ensure the care plan was being followed based on the physician ordered LPM.

Based on observations, record review, staff and resident interviews, and review of the facility's policy titled, Oxygen (O2) Administration, the facility failed to ensure that (O2) concentrators were clean, and O2 orders were followed for two of 17 residents (R) (R21 and R6) receiving O2. The deficient practice had the potential to place the residents at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility's policy titled Oxygen Administration revised 8/20/2023 revealed a Policy Statement: It is the policy of this facility to provide oxygen safely and accurately to appropriate patients/residents. Under Safety revealed: . 10. Clean exterior of concentrators weekly and between each patient/resident use with bactericidal surface cleaner. 1. Review of the 12/27/2024 quarterly Minimum Data Set (MDS) for R21 revealed a Brief Interview for Mental Status score (BIMS) of 13, indicating intact cognition and is on oxygen therapy. Review of the care plan dated 5/24/2024 revealed R21 has oxygen use related to failure to maintain oxygen saturation above 90 percent and has shortness of breath when lying flat. Interventions include but is not limited to oxygen as ordered. Review of physician orders for R21 revealed an order on 12/11/2024 of Oxygen at 2 Liters Per Minute (LPM) via nasal cannula (NC) to keep oxygen (O2) Saturations (Sats) greater than 90 percent. Observation on 3/14/2025 at 8:23 am revealed R21 resting in bed. She was clean with no odors present. O2 was in place via NC. The vent on the back of the O2 concentrator had gray, dusty debris noted. O2 was set at 1.5 LPM. Interview during this time with R21 revealed she received 2 liters of O2. Observation on 3/15/2025 at 7:31 am revealed R21 resting in bed. She was clean with no odors present. O2 in place via NC. The vent on the back of the O2 concentrator continued to have gray, dusty debris noted. O2 remained at 1.5 LPM. 2. Review of the 1/9/2025 quarterly MDS for R6 revealed a BIMS score of 15, indicating intact cognition and is on oxygen therapy. Review of the care plan dated 5/30/2024 revealed R6 has oxygen and is short of breath lying flat with an intervention of Oxygen to maintain O2 at 92 percent. Review of physician orders for R6 revealed an order on 2/7/2025 for Oxygen at 2 Liters Per Minute (LPM) continuously. Observation on 3/14/2025 at 8:30 am revealed R6 resting in bed. She was clean with no odors present. O2 was in place via NC. The vent on the back of th eO2 concentrator had gray, dusty debris noted. O2 was at 1.5 LPM. Interview during this time with R6 revealed she was on 2 LPM of O2. Observation on 3/15/2025 at 7:40 am revealed R6 resting in bed. She was clean with no odors present. O2 was in place via NC. The vent on the back of the O2 concentrator continued to have gray, dusty debris noted. O2 remained at 1.5 LPM. Observation and interview on 3/15/2025 at 7:50 am with Registered Nurse (RN) EE revealed it was the responsibility of housekeeping to clean the O2 concentrators. He stated he ensured the humidifiers were filled and would change out tubing when needed. During this time the weekend supervisor verified that the side vent on the O2 concentrator for R21 and R6 had gray, dusty debris and that the Physician order for R21 and R6 was for O2 at 2 LPM and that R21 and R6's concentrators were set on 1.5 LPM.

Based on observations, staff interviews, and review of the facility policy titled, Cleaning Schedules and Labeling, Dating and Storage, the facility failed to ensure that kitchen equipment was kept clean and sanitary and the dating and labeling of food items. Specifically, the facility failed to ensure routine cleaning of the oven, ice machine, fish basket and food items in the freezer were not dated and labeled. Also, pureed food was not prepared using a recipe. These deficient practices had the potential to affect 81 of 82 residents receiving an oral diet. Findings include: Review of the facility policy titled, Cleaning Schedules dated September 2022, under Policy revealed . It is the Dietary manager's responsibility to develop and enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks to promote a sanitary environment . Under Guidelines number 4. The Dietary Manger will conduct routine sanitation checks and maintains a file of completed checks. Review of the facility policy titled, Labeling, Dating, and Storage dated November 2022, revealed all partners who assist in handling, preparing, serving, and storing food and beverage items to follow the proper procedures for labeling, dating, and storage to ensure proper food safety. Under Guidelines number 1. Food and beverage items will have an identifying label as well as a received date and open date, as applicable; for items prepared onsite, a 'use by' date will also be indicated. Initial walk thru 12/12/2023 at 8:50 am with the Dietary Manager (DM) revealed the ice machine lid was dirty, three bins that contained various cereal were not dated or labeled, and three other bins next to the compartment sink containing corn meal, flour and sugar were not dated or labeled. Continued observation also revealed cold foods in the freezer were not labeled or dated including a box of sausage patties in a plastic bag that was opened, but was not dated, and the plastic bag was left open, which could cause freezer burn. Further observation revealed the shelves where the dishwasher baskets were stored were rusted, the fish fry basket sitting on the fryer was covered with food debris, and the oven was covered with food stains and burned debris. A follow up walk through on 12/13/2023 at 8:30 am of the main kitchen revealed all previous observations including the dishwasher basket stored on a rusty shelf by the dish washer machine. All observations were confirmed with the DM during the walk through. During the observation of puree preparation on 12/13/2023 at 2:20 pm, Cook II pureed ham and melted butter for six residents and mixed vegetables with melted butter for six residents. Cook II did not follow the proper procedure to use the recipe book for pureed foods. Cook II revealed she did not use the recipe book and could not explain the amount, or the quantity used by measurement. Interview on 12/13/2023 at 9:00 am with the DM revealed her expectation of the dietary staff was to conduct daily cleaning of the kitchen equipment after their shift. Further interview revealed that there was currently no cleaning schedule in place for the kitchen. Interview on 12/13/2023 at 9:10 a.m. with the Administrator revealed his expectation of the dietary staff was to keep the kitchen equipment clean daily and for foods to be labeled and dated when opened and including the discard date. He revealed that there should be a schedule of tasks to be completed. Interview on 12/13/2023 at 2:44 pm with the DM revealed her expectation from dietary staff during puree preparation was to ask questions if they weren't sure of what to do.

Based on resident and staff interviews, record review, and review of the facility policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to protect the resident's right to be free from mental/emotional abuse by a staff member for one of three residents (R) (R56) reviewed for abuse. Specifically, Certified Nursing Assistant (CNA) NN engaged in a personal relationship with R56 which he understood to be intimate. He suffered emotional distress when he alleged CNA NN told him she was not in love with him. Findings include: Review of the facility policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, reviewed 12/7/2022, revealed the following: Policy Statement: It is the policy of Pruitthealth and its affiliated entities (collectively, the Organization) to actively preserve each patient's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation, mistreatment, and misappropriation of patient property, (referred to collectively in this policy as abuse, neglect, mistreatment, and exploitation). Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish. Review of the electronic medical record (EMR) for R56 revealed he was admitted to the facility with diagnoses to include unspecified paraplegia, generalized muscle weakness, neuromuscular dysfunction of bladder, generalized anxiety disorder, recurrent major depressive disorder, and acute kidney failure. Review of the quarterly Minimum Data Set (MDS) assessment for R56 dated 10/19/2023, documented a Brief Interview for Mental Status (BIMS) score of 15, indicating little to no cognitive impairment; a Mood score of zero, indicating no depression; and no behaviors exhibited during the seven-day assessment period. Section GG documented functional status/ activities of daily living (ADL) as needing setup assistance for eating and oral hygiene, but substantial to dependent assistance for all other ADLs. In addition, Section N documented R56 received antianxiety and antidepressant medications. Review of the Facility Reported Incident (FRI) dated 11/11/2023 revealed R56 reported to staff and filed a formal grievance related to a personal relationship with CNA NN, which he understood to be intimate, and gave her money for her rent. The FRI investigation could not substantiate exploitation as there was no proof of money exchange, however, R56 gave permission to nursing management to review the text messages on his phone which exchanged messages with CNA NN and were documented to be of an intimate, sexual nature. Review of the local police report documented an interview with CNA NN on 11/16/2023 in which she admitted to being in a relationship with R56, asking for money but not taking it, sending intimate text messages, nude photographs and videos to his phone, and allowing R56 to touch her body over her clothing while she was on duty. Local police arrested CNA NN on 11/27/2023 for sexual assault against a person in custody. Interview on 12/13/2023 3:04 pm with R56 in his room, he stated he thought CNA NN was his girlfriend; she said they were a couple, boyfriend and girlfriend. He stated he later found out she was doing the same with other men in the facility. He stated money changed hands, approximately $780 which he neither expected to get back nor did he ask for it back from CNA NN or the facility. He stated he gave her cash which she didn't push for, but stated she needed it, so he gave it to her. He stated he wound up in the same room with the other [NAME]. He stated he did not expect her to get arrested but thought she would only be fired because she was playing people for money. R56 said you should not play with people for money. He stated CNA NN did not perform any sexual favors, but they kissed almost daily when she worked. He finally stated there was no proof that he gave her money because it was in cash. Interview on 12/13/2023 at 3:45 pm with the Medical Director revealed he did not know of any exploitation efforts against R56 until the facility notified him. He stated, as a result, he needed to increase the frequency of R56's antianxiety medications, which he hoped to wean back to baseline within six months. He stated, other than that, he hadn't made any other changes to R56's plan of care and found him to be stable so far. Review of the Physician's Orders documented an order dated 9/20/2023 for alprazolam one (1) milligram (mg) orally BID (twice daily) related to anxiety. The order was discontinued on 11/15/2023 and a new order was placed for an increase in frequency of the same medication every eight hours. Interview on 12/13/2023 4:40 pm with the Area [NAME] President (AVP), she stated the company terminated CNA NN on 11/17/2023 for violating the company's code of conduct policy and resident rights. She stated there was enough information in the resident's phone to confirm inappropriate interactions between staff and resident. She stated R56's mother informed the facility that her son had a history of attaching to female staff at another facility. She stated the staff followed up with residents for psychosocial support. Interview on 12/14/2023 at 1:54 pm with the Administrator, he stated the facility and corporate office launched an immediate investigation when notified of the allegations. He stated R56's mother called to tell of R56's history of connecting with staff. He stated he had not seen any changes in R56's behavior or condition so far. He stated during staff interviews he was told that R56 and his roommate were known to instigate inappropriate conversations with staff. He stated he advised staff to team up to care for those residents and not care for either of them alone.

Based on record review and staff interviews, the facility failed to apply for Level two (2) preadmission screening and resident review (PASARR) for evaluation and determination of specialized services for one of one resident (R) (R11) reviewed for positive Level I PASARR for mental illness and diagnoses of post traumatic stress disorder (PTSD), generalized anxiety disorder, and major depressive disorder prior to and on admission to the facility. This deficient practice had the potential for R11 to be denied specialized services for psychological, psychiatric, and functional needs. Findings Include: The facility's Nurse Consultant informed the surveyor it does not have a PASARR policy in place and follows state guidelines. Review of the Resident Face Sheet for R11 located in the electronic medical record (EMR) revealed the following diagnoses but not limited to PTSD, generalized anxiety disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for R11 revealed in section C- Cognitive Patterns-Brief Interview for Mental Status (BIMS) score of 15, indicating R11 was cognitively intact, section E-Behaviors-no behaviors exhibited, I-Active Diagnoses-anxiety, PTSD, and major depressive disorder, section N-Medication-on an antidepressant medication 7 days, section O-Special Treatments, Procedures, and Programs-no therapies noted. Review of the care plan dated 8/14/2023 for R11 located in the EMR revealed: address emotional and psychosocial needs of resident. Assess and monitor mood and behavior. Identify any triggers that prompt behaviors or re-experiencing of stressful event. Encourage social support. Review of the Physician's Orders for R11 located in the EMR revealed an order: Trazadone 50mg (milligram) give half tablet at bedtime. Interview on 12/14/2023 at 3:25 pm with the RN Nurse consultant revealed Social Services did not do a PASARR level II because nothing triggered in the system to indicate it was necessary and the PASARR committee stated, Because he had not had a triggered behavior or new onset issues associated with PTSD, a PASARR level II was not needed.

Based on staff interview, record review, and review of the facility policy titled, Care Plans, the facility failed to ensure that the care plans included interventions for a diagnosis of post-traumatic stress disorder (PTSD) for one of two residents (R) (R2). This failure had the potential to prevent R2 from receiving the comprehensive care he required. Findings include: Review of the facility policy titled Care Plans last revised on 7/27/2023 revealed on page 6, Comprehensive care plans updates/reviews will be performed within 7 days of each quarterly assessment, each acute change in condition and as needed following each hospital stay. Review of the electronic medical record (EMR) revealed R2's last quarterly Minimum Data Set (MDS) assessment completed on 9/22/2023 revealed a Brief Interview for Mental Status (BIMS) score of nine, which indicates moderate cognitive impairment. Pertinent diagnoses included unspecified dementia, senile degeneration of brain, schizophrenia, and PTSD. The diagnosis of PTSD was first noted on the annual MDS assessment dated [DATE]. An active diagnosis of PTSD was first notated in R2's medical record on 6/30/2022. Record review revealed R2 has been receiving psychiatric services since 4/19/2023 with a diagnosis of PTSD indicated in the psychiatric notes dated 4/24/2023. Review of the EMR revealed R2's care plan did not include any mention of or interventions for his diagnosis of PTSD. Interview on 12/14/2023 at 9:03 am with Registered Nurse (RN) MDS Director BB confirmed R2 had a diagnosis of PTSD, but care for this diagnosis had not been addressed in his current care plan. She stated that he may be the only resident at the facility at the time with PTSD, but he needed to have PTSD addressed on his care plan.

Based on observations, staff interviews, and review of the facility policy titled, Infection Control: Glucometer Cleaning and Disinfecting, the facility failed to ensure disinfecting the glucometer per facility policy between residents requiring fingerstick blood sugars checks for two of 18 sampled residents (R) (R4, R36). The deficient practice had the potential to cause an unclean environment for R4 and R36 and increase the potential for infections caused by cross contamination between residents. Findings include: Review of the facility policy titled Infection Control: Glucometer Cleaning and Disinfecting last revised on 6/29/2023, page 2, section E. Cleaning and Disinfection revealed, NOTE: The Glucose Meter must be cleaned and disinfected after each patient/resident use to minimize the risk of transmission of blood-borne pathogens between patient/residents and healthcare professionals. To ensure proper disinfection, it is important to clean the meter prior to disinfecting the meter (Step 4). 4. Clean and disinfect the meter by using the EPA approved wipes [sic] Germicidal and Disinfectant Wipes. Wipe all external areas of the meter including both the front and back surfaces until visibly clean. 5. Ensure that the surface of the meter remains wet at room temperature for the contact time listed on the wipe's directions for use. Allow to air dry. Page 3, section E. revealed: 7. Glucose meters used in a clinical setting for testing multiple persons must be cleaned and disinfected between patients. Observation on 12/13/2023 at 7:58 am revealed Licensed Practical Nurse (LPN) DD checked a fingerstick glucose level on R4. LPN DD stated that the glucose machine had just been cleaned, so did not reclean prior to performing the fingerstick blood glucose check. After obtaining the blood sugar result, LPN DD placed the used glucometer on a paper towel on top of the medication cart and cleaned it with an alcohol swab. An interview after the fingerstick with LPN DD revealed that she always sanitized the glucometer with an alcohol wipe unless they have beach wipes. She stated that last time she asked, she was told it was ok to use alcohol wipes to clean it. Observation on 12/13/2023 at 11:28 am revealed LPN EE performed a fingerstick blood glucose check on R36. Following obtaining the fingerstick blood glucose result, LPN EE was observed cleaning the glucometer with an alcohol wipe. An interview after the fingerstick with LPN EE revealed that she always uses alcohol wipes to sanitize the glucometer. She revealed she was taught to use an alcohol swab to clean the glucometer. Interview on 12/14/2023 at 8:33 am with the Director of Nursing revealed that her expectation was that staff sanitize the glucose machine after each resident with the purple wipes (germicidal/disinfectant wipes) and not alcohol swabs. She confirmed the facility policy and that disinfection of the glucometer using just an alcohol swab was not adequate for proper disinfection. She revealed she was not aware nurses were using alcohol wipes to clean the glucometers. Interview on 12/14/2023 at 4:59 pm with LPN HH, LPN FF and LPN GG revealed they had had education on the proper process for cleaning the glucometer a couple of times this year, including during the mandatory skills lab held in October 2023. These LPNs confirmed that disinfecting the glucometer included using the purple top disinfectant wipes to clean and to make sure the dwell time is several minutes between uses. LPN HH, LPN FF and LPN GG revealed they had received education on how to clean the glucometer during the required nursing staff skills lab in October 2023. An interview on 12/14/2023 at 5:19 pm with the LPN Nurse Manager revealed the skills lab held October 2023 was mandatory and had personally seen LPN DD and LPN EE attend and complete the skills lab.

Based on observation, interviews, and policy review entitled Cleaning Procedures: Kitchen Area, the facility failed to ensure the walk-in cooler was operating properly and failed to store food in the kitchen under sanitary conditions. The deficient practice had the potential to affect 70 of 72 residents receiving an oral diet. Findings include: During the initial tour of the kitchen on 7/17/22 at 9:00 a.m., revealed the following: * The floor in the main kitchen was in the process of being mopped. The walk-in cooler was observed to have a leak somewhere from the ceiling dripping from the seams onto the overflow food in the cooler. The floor was observed having a thick black substance and water standing on the floor of the cooler. The ceiling was actively dripping water during surveyors' observation. The temperature was observed to be 38 degrees Fahrenheit. The food observed in the walk-in cooler exposed was strawberries, cucumbers, and potatoes. There were several items wrapped in plastic such as muffins and cucumber salad and these items are unconfirmed for contamination from the leak in the ceiling. * The walls in the dishwasher room were observed to have a yellow substance that was dried and appeared in a streaking motion. * Observation of the cooking area revealed the stove eyes were black with debris noted and the oven, when opened, was observed to have a thick black, caked on substance, on the oven racks and inside the oven and on the inside of the oven doors. * The fryer was observed to have a thick yellow grease for frying food and the surface had a yellow substance on the outside of the fryer. Next to the fryer was a double oven that was observed to have a black and brown substance that was dried. The inside of the double oven was observed to have a thick, black substance, on the oven racks and all inside the oven and on the inside of the oven doors. The wall behind the stove/oven observed to have a thick, black substance that was dried and appeared in a streaking motion. * The ceiling tiles in the back of the kitchen were observed and there were yellow stains. The ice machine was observed to have a thick yellow film substance on the inner lip and underneath. Behind the ice scooper was a blackish splattered film across the ice machine. A review of policy entitled Cleaning Procedures: Kitchen Area created 9/2001 and revised 4/2016, revealed, the policy of (the facility) is to maintain a clean and sanitary environment to prepare patient/resident meals. The policy applies to all dietary, housekeeping, and maintenance partners scheduled to assist in cleaning/sanitizing procedures. Splashes and spills should be wiped off surfaces as soon as they occur. Monthly wash the walls, ceilings, doors and vents with hot water and detergent. Heavily soiled surfaces need to be cleaned more often. Mop spills as they occur. All soiled, dirty, dusty, surfaces and/or areas within the kitchen should be cleaned and/or sanitized (as needed) immediately upon identification. Observation on 7/18/22 at 2:00 p.m. of the facility kitchen cleaning schedule revealed the last documented cleaning was on 8/15/21 by a staff member. No further cleaning schedules were provided during the survey and the surveyor was given a book with blank copies of cleaning schedules. During an interview on 7/17/22 at 3:30 p.mm. with the Area Vice President, she revealed the areas of concern in the kitchen were being addressed promptly by a crew coming from another facility to assist in cleaning. The facility was in contact with a company for an afterhours service on the walk-in cooler. During an interview on 7/17/22 at 5:30 p.m. with the Dietary Manager (DM), she revealed the cooler has been leaking for approximately a year. The DM stated she has reported the issue to the Maintenance Director (DM) by phone and spoke with the Administrator several times with no resolution. She further revealed not being aware of reporting issue to a work order system. The DM stated she has always reported issues involving the kitchen by phone and maintenance comes to fix the problem. The DM stated she has been with the facility for one year and is still getting the kitchen in order. She does give the staff areas to clean daily but is still working on getting cleaning schedules made up and put together. During an interview with the Maintenance Director on 7/17/22 at 11:00 a.m., he stated this was the first time seeing the cooler leaking, and he was not informed of the leaking cooler by phone or work order. He was under the impression the door may have been left open to long causing condensation in the room. Observation on 7/18/22 at 9:30 a.m. of the kitchen revealed all initial areas of concern during walkthrough were addressed and sanitized. The walls and ice machine were clean along with the ceiling tiles and double oven. The fryer and the area beside the fryer had no sanitation issues. The walk-in cooler had plastic tubs with lids to prevent any leaking water to spill on food. All food previously exposed were discarded. The floors in the cooler were dry and without a black substance buildup. A floor mat is in the dishwasher area. The stove is clean and without black residue. During an interview on 7/18/22 at 10:00 a.m. with the Regional Dietician she revealed her last visit in June found no issues with the kitchen cleaning schedules or the kitchen itself. She further revealed not seeing the leak in the cooler upon observation and feels the kitchen is in good condition today and sees no concern. During an interview with the Administrator on 7/18/22 at 3:00 p.m., he revealed being unaware of the cooler having a leak in the ceiling, and it was brought to his attention by the MD upon the arrival by the surveyors. The Administrator provided an invoice from (name) Commercial Refrigeration Inc. who looked at the cooler and stated the cooler needs to be replaced.

Based on observation, resident/staff interview, and record review the facility failed to provide baths/showers for five residents (R) (R#62, R#49, R#4, R#48, and R#276) of 10 residents reviewed for Activities of Daily Living (ADL). Findings include: 1. R#62 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 7/1/22 Quarterly Minimum Data Set (MDS) for R#62 revealed in section (C) Cognitive Patterns a Brief Interview for Mental Status Score of 7 indicating severe cognitive impairment. Section (E) Behaviors, none identified. Section (G) Functional Status (G0120) Bathing - A. Self Performance - 8. Activity itself did not occur during the entire period. B. Support Provided: One person physical assist. Section (H) Bowel and Bladder, R#62 is frequently incontinent of bladder and occasionally incontinent of bowel. Section (N) Medication revealed R#63 receives a diuretic 7 out of 7 days a week. Review of the Point of Care History, Certified Nursing Assistant (CNA) documentation, related to bathing for R#62 revealed from 5/1/22 through 7/18/22 the resident received a documented total of 10 baths/showers, 67 times it is documented that the activity did not occur, and one documented refusal. The last documented shower/bath for R#62 is 6/22/22, 3 weeks and 5 days ago. During an interview and observation, with R#62 on 7/17/22 at 2:17 p.m. revealed a strong smell of urine. The pads were bunched up under him and partially out from under the resident and was observed to have yellow stains. During this time the resident began to cry, and he stated that he had not had a bath in weeks and added that he stunk so bad that it was no wonder no one wanted to be around him. During an interview on 7/18/22 at 1:31 p.m. with the DON she revealed the facility does not have a shower/bathing policy/procedure. She stated showers/baths are given by resident preference and stated CNAs have a list they go by. Review of the Master Shower List updated 6/1/22 revealed R#62 is scheduled to receive baths/showers on Mondays, Wednesdays, and Fridays. During an interview and observation on 7/18/22 at 1:45 p.m. of R#63 he was in clean clothes, and his bed was observed to be clean. During this time R#63 revealed he got a shower this afternoon and stated he is so grateful to be clean. There were no unpleasant odors noted. During an interview on 7/19/22 at 10:47 a.m. with CNA GG she revealed she has worked in the facility for 3 years. She revealed she is the only full time CNA on day shift working in the facility. She revealed there is no bath team and added that the residents do not get their baths as they should and that the residents do have body odor. She revealed there is not enough staff to get all the baths done and revealed on Tuesdays, sometimes, the extra part time CNA will do as many baths as she can, but she cannot get to everyone. CNA GG revealed she has spoken to the Director of Nursing (DON) related to the facility being short staffed of CNAs and how this affects resident Quality of Care in a negative way and revealed the DON told her they are working on it. During an interview on 7/19/22 at 11:18 a.m. with Wound Care Nurse (WCN) EE she revealed the residents are not getting their baths. She revealed there is not enough staff to give baths as they should be given. During an interview on 7/19/22 at 11:56 a.m. with the Staffing Coordinator she confirmed residents are not receiving their baths as they should and stated staffing is an issue. During an interview on 7/21/22 at 11:00 a.m. with the Administrator he revealed his role in the facility is overseeing the facility, ensuring the best resident care, and listening to staff, family, and residents' concerns. The Administrator stated he provides feedback to the corporate team concerning staffing, hospitalization s, ADLs, and therapy. He further revealed that his goal for this facility is to continue improving and providing optimum care to the residents. He revealed his only concerns have been call light response time, customer service, and the need for more therapy and stated there were occasions staff brought concerns about showers, but usually, that issue is taken up with the charge nurse. He stated the staff does not typically run down the hall chasing him about showers and changing people. The Administrator further revealed the facility has a morning meeting where they discuss tasks for the day and any major daily concerns. Administrator revealed he ensures concerns are assigned to the appropriate person if significant issues are brought up during the morning meeting. 2. R#49 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 6/17/22 Quarterly MDS Assessment for R#49 revealed in Section (C) Cognitive Patterns a BIMS score of 00 indicating severe cognitive impairment. Section (E) Behaviors revealed R #49 exhibited no behaviors. Section (G) Functional Status revealed R#49 is a 2 or more-person physical, extensive assist, for bed mobility. (G0120 - Bathing) revealed the resident is totally dependent for bathing. Section (H) Bowel and Bladder revealed R#49 is always incontinent. Review of the Master Shower List updated 6/1/22 revealed R#49 is listed on the Saturday/Sunday column only. Review of the shower sheets for R#49 revealed beginning 4/20/22 through 7/22/22 he received a total of 7 baths/showers. During an observation on 7/17/22 at 1:15 p.m. of R#49 revealed he was resting in bed with his eyes closed. A strong odor of urine was noted, and the resident appeared unkept with greasy hair noted. During an observation on 7/18/22 at 11:00 a.m. of R #49 revealed he was resting in bed with eyes open. He was covered with a sheet. During this time R#49 revealed he has not had a bath or been cleaned up in a long while. A strong odor of urine continued to be present and appeared unkept with greasy hair noted. During an observation on 7/19/22 at 1:28 p.m. of R#49 revealed he was resting in bed with eyes closed. Again, he was covered with a sheet. An odor of urine remained and the resident appeared unkept with greasy hair noted. During an interview on 7/20/22 at 9:05 a.m. with WCN EE she revealed she has worked in the facility since March 2022 and since that time there has been a serious staffing issue related specifically to CNAs. She revealed the residents do not receive their baths and are not provided the care they need. During an interview on 7/22/22 at 12:30 p.m. with CNA DD, she revealed R#49 can make his needs known and stated he has not gotten showers as he has asked due to the facility being so short staffed. She stated when she works at this facility the skin of R#49 is dry from not having lotion applied. CNA EE revealed R#49 has been asking for a full bath, and she believes he finally had a bed bath today. 3. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#4 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment indicated R#4 had a brief interview for mental status (BIMS) score of 15, indicating no cognitive impairment. The resident was assessed in Activities of Daily Living (ADL) functional status to require the total dependence of two staff with toileting and personal hygiene requires the extensive assistance of one staff. R#4 was assessed have an indwelling catheter of bladder. The resident was assessed to always be always incontinent of bowel. The resident was assessed to have one stage three pressure ulcer present on admission. A review of bathing/shower sheets from 5/1/22 through 7/20/22 revealed R#4 received six baths/showers during this period. During an observation on 7/17/22 at 10:30 a.m. and 2:00 p.m., R#4 was observed lying in bed and was not dressed for the day. During an interview on 7/17/22 at 10:35 with R#4, she revealed being lucky if she gets a bath once in two weeks. She stated the facility has no staff and she lays in her brief for at least an hour waiting for someone to change the soiled brief for bowel movements. During an interview on 7/17/22 at 1:45 p.m. with Licensed Practical Nurse (LPN) AA, she revealed being at the facility is sometimes a challenge with the lack of staffing to take care of the residents every day needs. She stated trying to help the CNA's with changing briefs, turning, and refilling water cups but there are more residents than the CNA staff can handle at one time. 4. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#48 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment indicated R#4 had a brief interview for mental status (BIMS) score of 15, indicating no cognitive impairment in cognitive skills for daily decision making. The resident was assessed in Activities of Daily Living (ADL) functional status to require the extensive assistance of one staff with toileting and personal hygiene. R#4 was assessed to be frequently incontinent of bladder. The resident was assessed to always be frequently incontinent of bowel. A review of bathing/shower sheets from 5/1/22 through 7/20/22 revealed R#48 received five baths/showers during this period. An observation and interview on 7/17/22 at 4:06 p.m., R#48 stated she has not received a bath in several weeks and is placed in her electric wheelchair only once a week. The resident appears with dirty gown, greasy hair and unkept facial hair. The smell of urine is present in the room. An observation on 7/18/22 at 10:00 a.m., R#48 is lying in bed with dirty gown, no bath as of this morning, and continued to appear with greasy hair and unkept facial hair. The smell of urine is present at bedside. During an interview on 7/18/22 at 9:45 a.m. with a Certified Nursing Assistant (CNA) EE, she revealed the facility is short staffed with CNA's and typically the facility does not bring in other CNA's from sister facilities. She stated normally she works on the A hall and these residents need the most care, but it is impossible to get everyone turned every two hours and changed appropriately. The CNA EE further revealed working alone on the A hall multiple days and she does her best to get each residents need met but they do have to wait until she can get to each person. Bathing residents is difficult and right now they are mostly getting bed baths. She stated the nurse does help any way she can and tries to give out water during medication pass. The CNA EE stated management continues to say they are bringing over help from sister facilities, but it is very inconsistent with the needs we have here in this facility. The CNA EE further stating taking care of both R#4 and R#48 every day she works since she only works the A hall, and the two residents are located on this hall. The residents are not known to refuse showers or baths when she is working and do want to have their clothes and linens changed several times a week. An interview on 7/22/22 at 11:00 a.m. with Certified Nursing Assistant (CNA) DD revealed having shower sheets in the shower room along with a Master shower list with the names of residents due for showers. The CNA DD stated she documents the resident's name, room, and whether a bath or shower was given to the resident on the shower sheet. She would include on the shower sheet if hair, nails, or shaving was completed. The CNA DD further revealed the charge nurse signs off on the shower sheet, and the sheet is picked up at the end of the week. 5. R#276 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident has a BIMs of 15 meaning cognition intact. R#276 has a functional status that requires one person supervision with ADL's. During an interview on 7/17/22 at 4:38 p.m. R#276 stated that he did not get a shower last week and none today. He revealed that he asked for a shower 3 times a week but is only getting once a week. Review of the Point of Care History related to bathing for R#276 revealed from 5/1/22 through 7/18/22 the resident received a documented total of six baths/showers, 67 times it is documented that the activity did not occur, and no documented refusal. The last documented shower/bath for R#276 is 7/10/22, eight days ago. Review of the Progress Notes for the above time period revealed that there was no documentation indicating resident's refusing shower. During an interview on 7/18/22 at 12:17 p.m. with the DON regarding facility policy for showers, she revealed that the facility does not have a policy for showers. When asked her expectations from CNAs regarding providing showers for the residents, she revealed that showers are provided per resident preference. She revealed that CNAs are encouraged to provide showers to the residents according to their preference and if they refuse to notify the charge nurse who will document the refusal.

Based on observation, staff interview, and record review the facility failed to provide adequate staff to ensure baths/showers were provided as scheduled for five residents (R) (R#62, R#49, R#4, R#48, and R#276) of 10 residents reviewed for Activities of Daily Living (ADL). Findings include: The following residents were affected due to lack of staffing: 1. Review of the Master Shower List updated 6/1/22 revealed R#62 is scheduled to receive baths/showers on Mondays, Wednesdays, and Fridays. During an interview and observation, with R#62 on 7/17/22 at 2:17 p.m. revealed a strong smell of urine. The pads were bunched up under him and partially out from under the resident and was observed to have yellow stains. During this time the resident began to cry, and he stated that he had not had a bath in weeks and added that he stunk so bad that it was no wonder no one wanted to be around him. During an interview on 7/19/22 at 10:47 a.m. with CNA GG she revealed she has worked in the facility for 3 years. She revealed she is the only full time CNA on day shift working in the facility. She revealed there is no bath team and added that the residents do not get their baths as they should and that the residents do have body odor. She revealed there is not enough staff to get all the baths done and revealed on Tuesdays, sometimes, the extra part time CNA will do as many baths as she can, but she cannot get to everyone. CNA GG revealed she has spoken to the Director of Nursing (DON) related to the facility being short staffed of CNAs and how this affects resident Quality of Care in a negative way and revealed the DON told her they are working on it. 2. Review of the Master Shower List updated 6/1/22 revealed R#49 is listed on the Saturday/Sunday column only. Review of the shower sheets for R#49 revealed beginning 4/20/22 through 7/22/22 he received a total of seven baths/showers. During an observation on 7/17/22 at 1:15 p.m., 7/18/22 at 11:00 a.m., 7/19/22 at 1:28 p.m., R#49 appeared unkept with greasy hair noted and there was a strong odor of urine. During an interview on 7/20/22 at 9:05 a.m. with WCN EE she revealed she has worked in the facility since March 2022 and since that time there has been a serious staffing issue related specifically to CNAs. She revealed the residents do not receive their baths and are not provided the care they need. During an interview on 7/22/22 at 12:30 p.m. with CNA DD, she revealed R#49 can make his needs known and stated he has not gotten showers as he has asked due to the facility being so short staffed. 3. A review of bathing/shower sheets from 5/1/22 through 7/20/22 revealed R#4 received six baths/showers during this period. During an observation on 7/17/22 at 10:30 a.m. and 2:00 p.m., R#4 was observed lying in bed and was not dressed for the day. During an interview on 7/17/22 at 10:35 with R#4, she revealed being lucky if she gets a bath once in two weeks. She stated the facility has no staff and she lays in her brief for at least an hour waiting for someone to change the soiled brief for bowel movements. During an interview on 7/17/22 at 1:45 p.m. with Licensed Practical Nurse (LPN) AA, she revealed being at the facility is sometimes a challenge with the lack of staffing to take care of the residents every day needs. She stated trying to help the CNA's with changing briefs, turning, and refilling water cups but there are more residents than the CNA staff can handle at one time. 4. A review of bathing/shower sheets from 5/1/22 through 7/20/22 revealed R#48 received five baths/showers during this period. An observation and interview on 7/17/22 at 4:06 p.m., R#48 stated she has not received a bath in several weeks and is placed in her electric wheelchair only once a week. The resident appears with dirty gown, greasy hair and unkept facial hair. The smell of urine is present in the room. An observation on 7/18/22 at 10:00 a.m., R#48 is lying in bed with dirty gown, no bath as of this morning, and continued to appear with greasy hair and unkept facial hair. The smell of urine is present at bedside. During an interview on 7/18/22 at 9:45 a.m. with a Certified Nursing Assistant (CNA) EE, she revealed the facility is short staffed with CNA's and typically the facility does not bring in other CNA's from sister facilities. She stated normally she works on the A hall and these residents need the most care, but it is impossible to get everyone turned every two hours and changed appropriately. The CNA EE further revealed working alone on the A hall multiple days and she does her best to get each residents need met but they do have to wait until she can get to each person. She stated the nurse does help any way she can and tries to give out water during medication pass. The CNA EE stated management continues to say they are bringing over help from sister facilities, but it is very inconsistent with the needs we have here in this facility. 5. During an interview on 7/17/22 at 4:38 p.m. R#276 stated that he did not get a shower last week and none today. He revealed that he asked for a shower 3 times a week but is only getting once a week. Review of the Point of Care History related to bathing for R#276 revealed from 5/1/22 through 7/18/22 the resident received a documented total of six baths/showers, 67 times it is documented that the activity did not occur, and no documented refusal. The last documented shower/bath for R#276 is 7/10/22, eight days ago. During an interview on 7/19/22 at 10:47 a.m., Certified Nursing Assistant (CNA) FF revealed she has worked in the facility for three years and she currently works Monday through Thursday, and on Thursday she revealed she leaves at 3:00 p.m. She revealed there is no bath team and that there is one CNA who has been giving some baths on Tuesday and the weekend staff are doing some as well, but most are not getting done. She revealed she is the only CNA that is fulltime on dayshift and added that sometimes they will send over staff from their sister facility but that does not always happen. She revealed resident care has declined but with the staff they currently have, they are doing the very best they can. During an interview on 7/19/22 at 11:56 a.m., the Staffing Coordinator revealed with the current census, staffing should include 3 Licensed Practical Nurses (LPN)s and 8 to 9 CNAs on day shift, and 5 CNAs on evenings. She revealed the facility currently has only 1, full time, CNA currently employed for day shift, 1 part time CNA for day shift, and no CNA's employed for evening. Staffing Coordinator revealed with the current census on 7:00 p.m. to 7:00 a.m. the facility should have 2 LPNs and 2 CNAs and those are staffed at this time. She revealed it is the responsibility of the Area Vice President of Operations to ensure recruiting of new employees. Staffing Coordinator revealed weekends are fully staffed and there are no issues, and that Monday through Friday is where the facility has a staffing issue. She stated on Mondays she has 2 CNAs staffed for the facility on day shift, one that works 7:00 a.m. to 7:00 p.m., and that there are 2 part time CNAs that work either 2:00 p.m. to 9:00 p.m., or 3:00 p.m. to 7:00 p.m., on Monday through Wednesday evenings, then 2 CNAs and 2 LPNs 7:00 p.m. to 7:00 a.m. Staffing Coordinator revealed on Thursday their 1 full time CNA does not work, nor does either part time CNA, so there is no CNA coverage for 4 hours from 3:00 p.m. to 7:00 p.m. but added nursing management, to include the unit manager, Director of Nursing (DON), and others, will come out to the floor and do the CNA work during that time. She revealed she had a meeting with the facility Administrator 2 weeks ago and he informed her that management should get on the halls to help and in the meantime, he is looking into ways to get staff into the building. During an interview on 7/19/22 at 12:56 p.m. with the Area Vice President of Operations for the facility, she revealed there is a recruiter for the facility, and she has a weekly meeting with the recruiter. She stated they have applied with Nursing Agency Services to be able to utilize their services but because the area the facility is in is small, and there is not a hotel within approximately 30 miles, none of the agencies will take them on which makes it very difficult to staff. She revealed because their sister facility in Rome is staffed the best, she calls on them to send over help from their facility to this facility and offers incentives and bonuses to get those employees to come and help on their off days. During a telephone interview on 7/22/22 at 10:38 a.m. with the Senior Talent Acquisition Recruiter she revealed she has different sources to recruit staff, but the major source is Indeed. She revealed she has left messages for 413 LPNs, 416 for Registered Nurses (RN)'s, and 659 for CNAs. She revealed those people she contacted are active sources that are already on Indeed and she sends a message out to them about positions available. Recruiter revealed she does not handle Agency recruitment for the facility and revealed she believes the facility does this. She stated she reached out to local colleges and was involved in different job fairs and revealed that the DON has spoken to graduating LPN classes as well as CNA classes. Recruiter revealed that she has done hiring events which have not been very successful due to the poor attendance but with information given for return response upon invite to the event she is able to reach back out to them. She stated the facility has offered wage increases to CNAs to be more competitive with salaries in the surrounding area. Recruiter revealed anything farther than a 20 mile range from a potential employee's home is a no for most due to gas prices and distance from home.

Based on observations, record review, and staff interviews the facility failed to develop/implement the care plan for two residents (R) (R#45 and R#62) related to providing baths and/or showers. The sample size was 34. Findings include: 1. R #62 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 7/1/22 Quarterly Minimum Data Set (MDS) for R #62 revealed in section (C) Cognitive Patterns a Brief Interview for Mental Status Score of 7 indicating severe cognitive impairment. Section (G) Functional Status (G0120) Bathing - A. Self Performance - 8. Activity itself did not occur during the entire period. B. Support Provided: One person physical assist. Review of the Care Plan for R#62 revealed a problem start date: 2/17/21. Category: ADL Functional / Rehabilitation Potential: (R#62) requires assistance with ADLs related to Dementia. Interventions include but is not limited to: Approach Start Date: Assist with showers 3x/week and as needed. Review of the Point of Care History, Certified Nursing Assistant (CNA) documentation, related to bathing for R #62 revealed from 5/1/22 through 7/18/22 the resident received a documented total of 10 baths/showers, 67 times it is documented that the activity did not occur, and one documented refusal. The last documented shower/bath for R#62 is 6/22/22, 3 weeks and 5 days ago. During an interview and observation with R#62 on 7/17/22 at 2:17 p.m. revealed a strong smell of urine. The pads were bunched up under him and partially out from under the resident and was observed to have yellow stains. During this time the resident began to cry, and he stated that he had not had a bath in weeks and added that he stunk so bad that it was no wonder no one wanted to be around him. During an interview on 7/19/22 at 10:47 a.m. with CNA GG she revealed she has worked in the facility for 3 years. She revealed she is the only full time CNA on day shift working in the facility. She revealed there is no bath team and added that the residents do not get their baths as they should and that the residents do have body odor. She revealed there is not enough staff to get all the baths done and revealed on Tuesdays, sometimes, the extra part time CNA will do as many baths as she can, but she cannot get to everyone. CNA GG revealed she has spoken to the Director of Nursing (DON) related to the facility being short staffed of CNAs and how this affects resident Quality of Care in a negative way and revealed the DON told her they are working on it. 2. R #49 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 6/17/22 quarterly MDS Assessment for R#49 revealed in Section (C) Cognitive Patterns a BIMS score of 00 indicating severe cognitive impairment. Section (G) Functional Status revealed R #49 is a 2+ person physical, extensive assist, for bed mobility. (G0120 - Bathing) revealed the resident is totally dependent for bathing. Review of the current care plan for R#49 revealed there was no care plan developed related to ADLs. Review of the shower sheets beginning 4/20/22 through 7/22/22 revealed R#49 received a total of seven baths/showers. During an observation on 7/17/22 at 1:15 p.m. of R#49 revealed he was resting in bed with his eyes closed. A strong odor of urine was noted, and the resident appeared unkept.

Based on observation, record review, and staff interview, the facility failed to ensure heals were floated and/or heel boots were used to prevent further decline in one resident's (R#49) wound of four residents reviewed for pressure ulcers. Findings include: R#49 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 6/17/22 Quarterly MDS Assessment for R#49 revealed in Section (C) Cognitive Patterns a BIMS score of 00 indicating severe cognitive impairment. Section (G) Functional Status revealed R#49 is a 2 or more-person physical, extensive assist for bed mobility. Section (M) Skin Conditions revealed R #49 (M0150 - Risk for Pressure Ulcers) is at risk for pressure ulcer and (M0210 - Unhealed Pressure Ulcers) has one or more unhealed pressure ulcers stage 1 or higher. Review of the Care Plan dated 1/15/22 for R#49 revealed he has pressure ulcer on his left lateral ankle with an estimated long term goal target date of 9/12/22 that R#49's ulcer will heal without complications. Interventions included try to keep heels floated/ heel boots on resident due to his confusion and combative behavior. Review of the Wound Management Detail Report dated 6/24/22 for R#49 revealed the left ankle measured 1.5 cm x 1 cm x 0.1 cm has light, serosanguineous exudate that is pale red to pink, thin and watery, is a stage III, has no odors and is stable. The 7/15/22 Wound Management Detail Report revealed the left ankle wound measures 2 cm x 3 cm x 0.1 cm, has light, serosanguineous exudate that is pale red to pink, thin and watery, is a stage III, has no odors and is declining. During observations on 7/17/22 at 1:15 p.m., 7/18/22 at 11:00 a.m., 7/19/22 at 1:28 p.m., R#49 was resting in bed with his eyes closed. He was covered with a thin sheet and his feet were observed resting on the bed and did not appear to have on heel boots. During an interview on 7/20/22 at 9:05 a.m. with Wound Care Nurse (WCN) EE she revealed she has worked in the facility since March 2022 and since that time there has been a serious staffing issue related specifically to CNAs. She revealed the residents are not provided the care they need. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Change two times weekly on Tuesday and Friday and as needed for dislodgement. Treatment Administration Record (TAR) for R#49 was reviewed for the last three months and revealed all treatments were provided to the residents left ankle wound as ordered.

Based on interviews, record reviews, and review of the facility's policies, the facility failed to ensure thirteen residents who tested negative for COVID-19 (R#3, R#6, R#9, R#13, R#14, R#18, R#19, R#21, R#22, R#24, R#27, R#29 and R#30) were housed in rooms separate from the sixteen resident roommates who tested positive for COVID-19. This failure placed those residents at risk for exposure to COVID-19. Findings include: Review of the facility's policy titled, Coronavirus (COVID-19) Infection Prevention and Control Practices Policy, revised [DATE] revealed It is the policy of the PruittHealth organization to initiate the appropriate measures to protect our patients/residents, partners and families from risks associated with the Coronavirus (COVID-19) through mitigation and education tools, utilizing resources as provided by the Department of Public Health and the Centers for Disease Control .I. Communication. 1. All partners, family members, patients, and visitors will receive guidance for infection control practices on prevention and monitoring .V. Coronavirus (COVID-19) has been identified in a HCC (Healthcare Center) or ALF (Assisted Living Facility) location: Once COVID-19 has been identified, outbreak prevention and control measures are to be implemented immediately. The location will also follow the directions from the DPH (Department of Public Health). Implement contact and droplet precautions for all patients/residents with suspected or confirmed flu-like symptoms and for suspected or confirmed COVID-19 .VI. During the care of any HCC or ALF patient/resident with known or suspected COVID-19, healthcare personnel should do the following: If a private room is not available, such as in a pandemic situation, place (cohort) suspected COVID-19 patients/residents with other patients/residents suspected of having COVID-19. Cohort confirmed COVID-19 patients/residents with other patients/residents confirmed to have the same type of COVID-19 virus. In the case of a pandemic, the CDC and/or the DPH will advise whether additional measures are warranted . Review of the facility policy titled, COVID-19 Pandemic New Admission and Readmission process for Healthcare Centers, revised [DATE], revealed .Procedure: Healthcare centers designated to admit COVID-19 positive residents will follow procedures for Level 1. Healthcare centers who are not designated as Level 1 will follow Level II and III procedures. I. Level I Positive COVID-19 Isolation Unit: COVID-19 Positive/Presumptive Positive Resident .1. Healthcare centers approved to admit residents who are presumptive or confirmed COVID-19 positive residents will have a designated unit .5. The Level I Unit will maintain consistent, designated staffing to the extent possible during the COVID-19 pandemic response. Partners will need to self-monitor and report any signs and symptoms of COVID-19 immediately to the supervisor. 6. Designated staff will include: RN (Registered Nurse) and/or LPN (Licensed Practical Nurse), CNA (Certified Nurse Aide), Housekeeper, Therapist .Monitoring .2. Residents will transfer to the Level II Unit when: Asymptomatic Resident: Resident has completed 10 days on the unit. Symptomatic Resident: Resident has completed 10 days on the unit, and Resolution of fever without the use of fever-reducing medications for 24 hours, and Improvement in symptoms .II. Level II Person Under Investigation (PUI) Isolation Unit. Residents in-house with COVID-19 tests pending .2. Residents will remain on Level II unit: Resident has completed at least 10 days on the unit, and if the resident begins to exhibit a fever (99 degrees or above) or shows any signs or symptoms of respiratory illness .3. If the resident does not exhibit symptoms within 10 days of moving to Level II, then the resident will be moved to the Level III: Recover First Unit or Level III: Care First Unit. III. Level III Care Unit: Residents in-house for short-term rehabilitation or long-term care who have tested negative on baseline or meets criteria following their guidelines established in Level II for transfer to Level III .IV. Recovered Resident. The Resident on Level I unit that has been on the unit for 10 days and are asymptomatic will be moved to Level II Unit. If the resident remains asymptomatic for the 10 days on the Level II unit, the resident will be transferred to Level III unit .Residents that have completed time-based or symptom-based strategy will be considered recovered or negative for reporting purposes and to identify those individuals who will not be retested during with COVID-19, they will be re-evaluated for additional testing or isolation/quarantine . 1.Review of R#30's and R#31's undated Census Records, revealed on [DATE] both residents resided on Unit C, in the same room. Continued review of the census records revealed R#31 remained on Unit C, in the same room as R#30 until he expired on [DATE]. Review of the facility document titled, Resident Bed List Report, dated [DATE] revealed the room which R#30 and R#31 resided in on Unit C was a two bed, semi-private room. Review of R#31's undated, Resident Face Sheet, located in the residents electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the undated .Laboratory Correspondence Only document provided by the facility revealed R#31's COVID-19 test result on [DATE] was pos (positive). Review of R#30's undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the undated .Laboratory Correspondence Only document provided by the facility revealed R#30's COVID-19 test result on [DATE] was bad sample (test result could not determine if the resident was positive or negative for COVID) retested [DATE]. Review the undated facility provided .Laboratory Correspondence Only document revealed R#30's COVID-19 test result on [DATE] was neg (negative). Continued review of the laboratory correspondence revealed R#30's COVID-19 test result on [DATE] was positive. Review of R#30's Resident Progress Notes, dated [DATE] revealed Resident passed away . Review of the Death Certificate for R#30, supplied by the facility during Quality Assurance review, revealed the resident expired on [DATE] with a cause of death [MEDICAL CONDITION] and end stage dementia. 2. Review of the facility's unnamed, handwritten document provided by the Administrator on [DATE], revealed after R#12 tested positive for COVID-19, R#13 and R#14 remained in the same room on Unit A with R#12. Both R#13 and R#14 later tested positive for COVID-19. Review of the facility document titled, Resident Bed List Report, dated [DATE] revealed the room which R#12, R#13, and R#14 resided in on Unit A was a three-bed ward. Review of R#12's undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of #12's Resident Progress Notes, dated [DATE] revealed COVID 19 test done [DATE], results received, test results are positive. Review of R#13's undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R#13's Resident Progress Notes, dated [DATE] revealed COVID 19 test done [DATE], results received, test result are negative. Continued review of the resident's progress notes dated [DATE] revealed .COVID rapid test with positive results . Review of R#14's undated, Resident Face Sheet, revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R#14's Resident Progress Notes, dated [DATE] revealed COVID 19 test done ,[DATE], results received, test result are negative. Continued review of the resident's progress notes dated [DATE] revealed COVID-19 test [DATE] with positive results . 3. Review of the facility's unnamed, handwritten document provided by the Administrator on [DATE], revealed after R#15 and R#16 tested positive for COVID-19, R#10 remained in the same room on Unit A with R#15 and R#16. R#10 later tested positive for COVID-19. Review of R#15's undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of #15's Resident Progress Notes, dated [DATE] revealed COVID-19 test done [DATE], results received, test results are positive .Isolation precautions in place r/t (related to) (+) (positive) Covid (sic)-19 results . Review of R#16's undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of #16's Resident Progress Notes, dated [DATE] revealed COVID-19 test done [DATE], results received, test results are positive. Review of R#10's undated, Resident Face Sheet, provided by the facility revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R#10's Resident Progress Notes, dated [DATE] revealed COVID-19 test done [DATE], results received, test result are negative. Continued review of the resident's progress notes dated [DATE] revealed COVID-19 test [DATE] with positive results . 4. Review of the facility's unnamed, handwritten document provided by the Administrator on [DATE], revealed after R#17 tested positive for COVID-19, R#18 and R#19 remained in the same room on Unit A with R#17. R#18 and R#19 later tested positive for COVID-19. Review of the facility document titled, Resident Bed List Report, dated [DATE] revealed the room which R#17, R#18, and R#19 resided in on Unit A was a three-bed ward. Review of R#17's undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of #17's Resident Progress Notes, dated [DATE] revealed Covid (sic) 19 test from [DATE] results positive . Review of R#18's undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R#18's Resident Progress Notes, dated [DATE] revealed COVID-19 test done [DATE], results received, test result are negative. Continued review of the resident's progress notes dated [DATE] revealed COVID-19 test [DATE] with positive results . Review of R#19s undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review the undated facility provided .Laboratory Correspondence Only document revealed R#19's COVID-19 test result on [DATE] was Neg (negative). Continued review of the document revealed R#19's COVID-19 test result on [DATE] was positive. 5. Review of the facility's unnamed, handwritten document provided by the Administrator on [DATE], revealed after R#20 tested positive for COVID-19 on [DATE], R#21 and R#22 remained in the same room on Unit A with the R#20. Both residents R#21 and R#22 later tested positive for COVID-19 on [DATE]. Review of the facility document titled, Resident Bed List Report, dated [DATE] revealed the room which R#20, R#21, and R#22 resided in on Unit A was a three-bed ward. Review of R#20's undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review the undated facility provided .Laboratory Correspondence Only document revealed R#20's COVID-19 test result on [DATE] was pos (positive). Review of R#21's undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review the undated facility provided .Laboratory Correspondence Only document revealed R#21's COVID-19 test result on [DATE] was neg (negative). Continued review of the document revealed R#21's COVID-19 test result on [DATE] was positive. Review of R#22's undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review the undated facility provided .Laboratory Correspondence Only document revealed R#22's COVID-19 test result on [DATE] was neg (negative). Continued review of the document revealed R#22's COVID-19 test result on [DATE] was positive. 6. Review of the facility's unnamed, handwritten document provided by the Administrator on [DATE], revealed after R#23 tested positive for COVID-19 on [DATE], R#3 and R#24 remained in the same room on Unit A with R#23. Both residents R#3 and R#24 later tested positive for COVID-19 on [DATE]. Review of the facility document titled, Resident Bed List Report, dated [DATE] revealed the room which R#23, R#3, and R#24 resided in on Unit A was a three-bed ward. Review of R#23's undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review the undated facility provided .Laboratory Correspondence Only document revealed R#23's COVID-19 test result on [DATE] was pos (positive). Review of R#3's undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review the undated facility provided .Laboratory Correspondence Only document revealed R#3's COVID-19 test result on [DATE] was neg (negative). Continued review of the document revealed R#3's COVID-19 test result on [DATE] was positive. Review of R#24's undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review the undated facility provided .Laboratory Correspondence Only document revealed R#24's COVID-19 test result on [DATE] was neg (negative). Continued review of the document revealed R#24's COVID-19 test result on [DATE] was positive. 7. Review of the facility's unnamed, handwritten document provided by the Administrator on [DATE], revealed after R#25 and R#26 tested positive for COVID-19 on [DATE], R#27 remained in the same room on Unit A with R#25 and R#26. R#27 later tested positive for COVID-19 on [DATE]. Review of the facility document titled, Resident Bed List Report, dated [DATE] revealed the room which R#25, R#26, and R#27 resided in on Unit B was a three-bed ward. Review of R#25's undated, Resident Face Sheet, provided by the facility revealed the resident was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review the undated facility provided .Laboratory Correspondence Only document revealed R#25's COVID-19 test result on [DATE] was positive. Review of R#26's undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review the undated facility provided .Laboratory Correspondence Only document revealed R#26's COVID-19 test result on [DATE] was positive. Review of R#27's undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review the undated .Laboratory Correspondence Only document revealed R#27's COVID-19 test result on [DATE] was neg (negative). Review of the undated document/form titled, COVID-19 POC Testing Log, revealed R#27 tested positive for COVID-19 on [DATE]. 8. Review of the facility's unnamed, handwritten document provided by the Administrator on [DATE], revealed after R#28's COVID positive test results on [DATE] and R#2's COVID positive test results on [DATE], R#29 remained in the same room with R#28 and R#2. R#29 later tested positive for COVID-19 on [DATE]. Review of the facility document titled, Resident Bed List Report, dated [DATE] revealed the room which R#28, R#2, and R#29 resided in on Unit B was a three-bed ward. Review of R#28's undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review the undated .Laboratory Correspondence Only document revealed R#28's COVID-19 test result on [DATE] was positive. Review of R#2's undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review the undated .Laboratory Correspondence Only document revealed R#2's COVID-19 test result on [DATE] was positive. Review of R#29's undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Review the undated .Laboratory Correspondence Only document revealed R#29's COVID-19 test result on [DATE] was neg (negative). Review of the undated document/form titled, COVID-19 POC (Point of Care) Testing Log, revealed R#29 tested positive for COVID-19 on [DATE]. 9. Review of the facility document titled, Resident Bed List Report, dated [DATE] revealed the room which R#4, R#5, and R#6 resided in on Unit B was a three-bed ward. R#6 still resided in the same room with R#4's and R#5's, even though R#6 was still considered a confirmed negative resident. Review of R#4's undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review the undated .Laboratory Correspondence Only document revealed R#4's COVID-19 test result on [DATE] was positive. Review of R#5's undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review the undated .Laboratory Correspondence Only document revealed R#5's COVID-19 test result on [DATE] was positive. Review of R#6's undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review the undated .Laboratory Correspondence Only document revealed R#6's COVID-19 test result on [DATE] was neg (negative). Review of R#6's Resident Progress Notes, dated [DATE] revealed COVID-19 testing [DATE] with negative results .The progress notes indicated the resident had remained in the same room with two residents after both the residents had tested positive for COVID-19. 10. Review of the facility's document titled, Resident Bed List Report, dated [DATE] revealed R#7, R#8, and R#9 all three residents currently resided on Unit A in the same room even though R#7 and R#8 were confirmed positive for COVID-19 and R#9 was still a confirmed negative for COVID-19. Review of R#7's undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review the undated .Laboratory Correspondence Only document revealed R#7's COVID-19 test result on [DATE] was pos (positive). Review of R#8's undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review the undated .Laboratory Correspondence Only document revealed R#8's COVID-19 test result on [DATE] was pos(positive). Review of R#9's undated, Resident Face Sheet, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review the undated .Laboratory Correspondence Only document revealed R#9's COVID-19 test result on [DATE] was neg (negative). Review of R#9's Resident Progress Notes, dated [DATE] revealed COVID-19 testing [DATE] with negative results .The progress notes indicated the resident had remained in the same room after testing negative for COVID-19 with two residents that had tested positive for COVID-19. Interview on [DATE] at 4:20 p.m. with the Administrator revealed many of the residents who had tested negative were in a room with a resident who tested positive, so they (facility) considered them exposed. Continued interview with the Administrator revealed ideally, they would like to cohort the residents as described in the policy, but there were other considerations such as male or female and shared bathrooms. Interview on [DATE] at 11:10 a.m. with an Infection Preventionist with the Georgia Department of Public Health revealed the facility's process was not appropriate, and residents should have been cohorted per the facility's written policy. Continued interview revealed the Georgia Department of Public Health was not aware the facility's current cohorting practices. In an interview on [DATE] at 3:47 p.m. the Administrator stated the week of [DATE], the facility started testing 100% of their residents; however, the test results did not come back until [DATE], with approximately 26 resident positives. The facility continued to test weekly and as positive results came back, they had to shelter in place. When asked what he meant by that, the Administrator stated shelter in place meant if two of three residents who were in the same room results came back positive, the third resident who tested negative would just stay in the room with the positives because they had been exposed. The Administrator stated they did the best they could with the situation. When asked if the facility had reached out to the Department of Public Health or the State Survey Agency, he stated he did not because they thought they were doing the best action plan. Interview on [DATE] at 10:57 a.m. with the Medical Director revealed it was her expectation the facility would have cohorted COVID-19 positive residents together. The Medical Director stated residents who were confirmed negative for COVID-19 had been exposed to positive residents should have been quarantined from the COVID-19 positive residents with other exposed, but negative residents. The Medical Director also stated she was not aware the facility was not cohorting residents appropriately and it would have been her expectation the she and/or the residents' attending Physician would have been notified the facility was not cohorting residents appropriately. The Medical Director further stated leaving the confirmed negative residents in the same room with the confirmed positive residents increased the negative residents' chances of contracting COVID-19. Interview on [DATE] at 1:07 p.m. with the Director of Health Services (DHS) revealed she did not think the facility could have done much different. The DHS stated when a group of approximately 30 residents all tested positive the Administrator and the facility's Corporate Leadership made the decision to shelter in place. She stated that meant if a resident was already rooming with a resident who tested positive for COVID-19 the negative resident would just stay in the room with the positives. The DHS stated the Administrator was the person who was ultimately responsible for deciding what residents were moved or cohorted. The DHS said the way the facility looked at it was, even though some of the residents did test negative, they were already exposed to COVID-19 due to being in the same room with the positive residents for five or six days and the facility presumed the negative residents would test positive the facility's next round of testing because of their exposures.

Based on observation, review of the Cleaning Schedule Form-Weekly and interviews, the facility failed to maintain the kitchen in a clean and sanitary manner. Additionally, the facility failed to discard expired foods stored for disasters and/or emergencies. 81 of 85 residents in the facility received an oral diet. Findings include: Review of the Cleaning Schedule Form-Weekly that the facility uses as the equipment cleaning schedule in the kitchen, with an effective date [DATE] and revised [DATE] documented the following: Floors-Scrub and deck brush all floors areas including under shelves, along baseboard, and in corners. Fans-Clean-remove all dust and debris Large Equipment- Range and drip pans, oven, steamer, fryer, steam kettle, hot box/bread warmer. (**Detail clean and sanitize) Dish Dollies/ Cart/ Rack: Clean and sanitize. Further review of the Cleaning Schedule Forms-Weekly revealed an area for the Date, Assigned to and Initials. The form did not include a cleaning schedule for the ice machine, air vents, reach in cooler, condiment bins or sugar/flour/cornmeal bins. Kitchen observation on [DATE] beginning at 11:20 a.m. and ending at 11:55 a.m. with the Dietary Manager revealed the following observed concerns: * The air vent on the ceiling in the dishwasher area was coated in black moisture marks. There was plates, utensils and plate lids stored on utility carts underneath the air vent. * The drop ceiling tracks in the dishwasher area were coated in rust. * The gray plastic cart holding clean plate lids was dirty with food debris, brownish black substances and dried liquid stains. * The backside of the food prep table next to the steam table had two stacks of small plates on it. There was food debris on the prep table around the plates and dried liquid running down the back of the prep table. The bottom of the food prep table and leg, steam table and steam table pipe were dirty with heavy black substance, food particles and other buildup. The floor in this area was also covered in heavy buildup. * The metal coffee station was dirty with dried liquid substances. There were three gray, plastic bins, with coffee bags and other condiments that were dirty with dried food debris and dried liquids stains all over the bins and in the inside of the bins. * There were two gray plastic bins containing plastic utensils. The bins and lids were dirty with dust, food debris and dried liquid stains. * The Ice Machine next to the coffee station was dirty on the top, front and sides with dust and other build up. The door/lid was dry on the outside and there was brown build up underneath in the corner joints. There was ice to the right front corner of the bin that was brownish in color and had brown unknown particles on it. * There were two reach in coolers that were dirty on the outside with smudges, and dried liquid stains. The lower air vent of one reach in cooler was dirty and dusty. The top air vent on the second reach in cooler was coated heavily with dust. * There were four large return air vents over the two reach in coolers that were covered in dust. Behind the vents there was black substance surrounding the air ducts. * There were large cornmeal, sugar and flour bins that were dirty with smudges and dried liquid substances on the outside of the bins and on the clear lids. * There was one large return air vent over the three compartment sink that was dusty, had black spots and a section that was stained in a dark yellow/orange substance. * The pipes behind the stove and oven were dirty and had spider webs on them. * The air conditioner vent over a food prep table by the stove that was not properly fitted in the ceiling and heavily coated in dust and corrosion. There was a ceiling tile over the food prep table that was not properly fitted around a pipe. The opening had dust hanging from it. * There was a metal cart at the end of the food prep area that contained various spices and cooking materials. There was a large tub of baking powder that was covered in dust, dirt and other build up. There were three large handled, clear containers of Rubbed, Bay Leaves, and Parsley Flakes that were dirty with smudges, dust and sticky substance all over the outside of the containers. * Near the three compartment sink there was a plastic cart low to the floor that had a container of pink liquid soap, a metal container with a plastic clear pitcher with a blue substance in it. The cart was dirty with pink liquid, black spots and other buildup. There was a large opening in the middle of the cart and in which the floor underneath was covered in buildup and debris. * The pipe underneath the three compartment sink had a rag around it that was soaked, had thick yellow substance on it and had a foul odor. The floor underneath the length of the of the three compartment sink and near the PVC pipe was dirty with heavy buildup and debris. * There was a two compartment sink that had a plate lid underneath it and the floor. The floor and sink pipes were dirty with heavy buildup. There was a spider web across the pipes with four spider egg sacs. * There was a speaker on the ceiling that was coated with dust. * The side of the fryer was heavily coated with grease build up streaks all the way down to the bottom. The floor on the side of the fryer had drippings and buildup of grease in puddles. * There was buildup of grease, food debris and dried liquid stains of the front and bottom of the stove. Observation on [DATE] at 12:15 p.m. of the three-day food supply for emergencies revealed the following expired foods: * Two cases of six #10 cans of Beef Stew with a facility received date of [DATE]. * One case of 12, 33.8 Fluid Ounces boxes of Orange Juice with an expiration date of [DATE]. * One case of 12, 33.8 Fluid Ounces of Apple Juice with an expiration date of [DATE]. * Three cases of 12, 3-pound 1-ounce cans of Chicken Noodle Soup with a facility received date of [DATE]. * One case of 12, 15-ounce containers of Pureed Beef with an expiration date of [DATE]. * One case of 12, 15-ounce containers of Pureed Chicken with an expiration date of [DATE]. * One case of 12, 15-ounce containers of Pureed Pork with an expiration date of [DATE]. * Three, five-pound tubs of Peanut Butter with an expiration date of [DATE]. Interview on [DATE] at 11:55 a.m. with the Dietary Manager (DM) confirmed all concerns observed. The DM confirmed that the grease build up running down the side of the fryer had not been cleaned in a while. She stated the Dietary Cook is responsible for cleaning the fryer, stove and oven. The DM stated that the Dietary Aide is responsible for wiping down all the carts, bins and food prep areas. She stated that the air vents are to be cleaned by the Maintenance Supervisor and she had been verbally reporting to him about the heavy dust build up on the air vents and the Reach-in cooler vents. She stated that the Maintenance Director told her that he was going to order new air vents for the ceilings. The DM stated that the ice machine is supposed to wiped down by the dietary staff daily and the Maintenance Director is responsible for deep cleaning every two weeks. The DM stated that the dietary staff mop the floors but the housekeeping department is supposed to scrub the floor every Tuesday and they had not been doing that lately. Interview on [DATE] at 11:40 a.m. with the Dietary Cook FF confirmed that the grease dripping down the side of the fryer had not been cleaned and was unable to state when the last time it was cleaned. Additionally, the Dietary Cook FF was unable to state when the stove was last cleaned. Interview on [DATE] at 11:48 a.m. with the Dietary Aide GG revealed she is supposed to wipe the food prep areas, bins and carts but it had not been done. She stated they just have not had time. During a follow-up interview on [DATE] at 1:20 p.m. with the DM, she stated that they do have a weekly cleaning schedule but they had not been using them for about six weeks. She stated that she does not keep record of the cleaning schedules with the initials indicating the task had been completed. Further the DM confirmed that the three-day emergency food was expired and she stated that it was just an oversight. The food is kept out in the shed and the dates were not checked. She stated the hand-written dates on the cases is the date that the food was received. She stated that the food is good for one year from the received date or manufacturer's expiration date. The DM stated that the dietary staff, Maintenance and Housekeeping is supposed to work as a team with cleaning the kitchen but they have been overwhelmed. She further stated they were extremely busy over the holidays. DM stated she has one cook and two dietary aides from 5:00 a.m. - 1:00 p.m. and one cook and two dietary aides from 1:00 p.m. -7:00 p.m. Interview on [DATE] at 9:38 a.m. with the Housekeeping Supervisor revealed his responsibility in the kitchen is putting food away from deliveries and his department is responsible for deep cleaning and scrubbing the kitchen floors. He stated they used to scrub the floors under and around all the equipment every two weeks but that had not been consistent in the last six months. He stated last Tuesday they only conducted a basic mop. He stated it had been several weeks since the floors had a deep clean and scrub. He further stated it is a team effort between Dietary, Maintenance and Housekeeping. Interview on [DATE] at 9:55 a.m. with the Maintenance Director revealed he is not responsible for cleaning and dusting the air return vents in the kitchen and stated housekeeping is responsible for that. He stated he is only responsible for repairing broken equipment in the kitchen. He stated he deep cleans and descales the ice machine quarterly. The Maintenance Director stated that he has no assistant and is the only person in the Maintenance Department. He stated he ordered new grids for the air flow vents in the kitchen but the cleaning of the existing vents is not his responsibility. Interview on [DATE] at 10:50 a.m. with the Administrator revealed he was not aware of the expired emergency food and stated he figured the Dietary Manager was taking care of that and no one had reported that as an issue. The Administrator reviewed the photos taken in the kitchen and confirmed the concerns. He stated he was not aware that the kitchen was dirty to that degree.

Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in 13 rooms on two of three halls (A2A/C, A6C, A8C, A12C, A16A/C, A18, B1A, B5, B7, B10C, B11, B12A/B/C, B13A/B); warped and broken window blinds in dining room. The facility census was 85. Findings Include: Observation on 1/14/19 at 12:02 p.m., revealed in room A8-C, privacy curtain with two (2) dime sized light brown stains. Observation on 1/14/19 at 12:09 p.m., revealed in room A2-A, privacy curtain with multiple pink colored stains at bottom of curtain. Observation on 1/14/19 at 12:10 p.m., revealed in room A2-C, stained ceiling tile in left upper corner, approximately 12 inches by six inches; chipping paint off bathroom wall; bathroom vent with thick layer of dust buildup on the louvers. Observation on 1/14/19 at 12:29 p.m., revealed in room A6-C, multiple bare patches down to dry wall, around sink in bathroom and left of the sink close to door. Observation on 1/14/19 at 12:40 p.m., revealed in room A12-C, multiple patches of chipped and peeling paint in bathroom; ripped ceiling tile in bathroom; vent in bathroom with heavy layer of dust on louvers and vent loosely hanging from ceiling. Observation on 1/15/19 at 8:32 a.m., revealed in room A16-C, privacy curtain with multiple brown stains in various spots. Observation on 1/15/19 at 9:44 a.m., revealed in room B1-A, two ceiling tiles with light brown stains. Observation on 1/15/19 at 11:19 a.m., revealed in room A16-A, vent in bathroom ceiling dusty and loosely hanging from ceiling; brown dried material on toilet handle; five ceiling tiles ripped and peeling. Observation on 1/15/19 at 11:59 a.m., revealed in room A18-A a cracked ceiling tiles in bathroom around the vent; chipped and peeling paint at the sink and at the toilet paper holder; scuffed wall at entrance, for the length of the wall; missing electrical face plate at socket close to television; broken/missing board at baseboard for head of bed A. Observation on 1/15/19 at 4:48 p.m., revealed in main dining room, blinds on both windows, warped to degree that blinds can't be opened. Broken strings on both sets of blinds. Interview on 1/17/19 at 11:30 a.m. with Housekeeper DD, stated she sweeps and mops each room daily, dusts windows and furniture in room, wipes down bed rails, cleans mattresses, cleans bathroom, toilet, sink and walls. She dusts the light fixtures and vents in bathrooms. She further stated that she inspects the privacy curtains and if needed laundry, will ask maintenance to take down and replace. Interview on 1/17/19 at 2:07 p.m. with Maintenance Supervisor, verified the concerns identified during the survey this week. He stated that staff submit work orders in the maintenance work book that is kept at nurses station. He further stated he has been working on repairs in the facility for awhile, and stated its easier to do when the rooms are empty. He stated he is the only person and he tries to prioritize based on severity. Interview on 1/17/19 at 2:30 p.m. with Housekeeping Supervisor, verified the concerns identified during the survey. stated that he has three housekeeping staff and one floor tech on day shift. He further stated that they are to look at the privacy curtain daily and also supposed to dust the vents in the bathrooms daily. He stated that he does spot checks on the housekeeping staff daily. He also checks behind them on the deep clean days. Observation on 1/15/19 at 8:39 a.m. of room B13 revealed holes and damaged dry wall and peeling paint behind the head of the beds for both A&B. The wall across the length of the room opposite of the beds was heavily scuffed with black marks and damaged dry wall. There were four ceiling tiles that were chipped and one ceiling tile that was heavily stained. Observation on 1/15/19 at 9:00 a.m. of room B12 behind Bed A, the lower wall drywall was damaged and the rubber baseboard is falling away from the wall. Behind Bed B and C, the wall plaster and paint was cracked, peeling and had spackling on it that has not been [MEDICATION NAME] out or painted. The wall near the bathroom was heavily scuffed with black marks, cracked dry wall and spackling that had not been [MEDICATION NAME] out or painted. The rubber baseboard near the air conditioner is coming off the wall and hanging on the floor. The bathroom walls were chipped and damaged down to the dry wall. Observation on 1/15/19 at 9:10 a.m. of room B11 revealed the wall near the bathroom is heavily scuffed and the drywall is damaged and pushed inward. Observation on 1/15/19 at 9:22 a.m. of room B10 revealed the ceiling tile above Bed C was water stained. The wall near the bathroom was heavily scuffed and dirty. The drywall near the entrance door was heavily damaged and chipped.

Based on observation, record review, policy review and staff interviews, the facility failed to implement the care plan related to nail care for one resident R#44; and failed to develop a care plan for smoking for one resident R#27. The sample size was 42. Findings include: Review of the policy titled Care Plans with a review date of 10/25/2018, revealed the comprehensive person-centered care plan is developed to include measurable goals and timeframe's to meet a patient/resident's medical, nursing and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment. 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. Care plans will be updated by nurses, Case Mix Directors (CMD), or any other interdisciplinary team member so that the care plan will reflect the patient/resident's needs at any given moment. 1. Review of the clinical record for R #44 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 12, which indicated mild cognitive impairment. Section G revealed resident requires extensive assistance with dressing, toileting and personal hygiene. Review of the care plan initiated on 11/21/18 revealed R#44 has plan to be long-term resident. Approaches to care include encourage/invite resident to participate in activities of her choice, observe for changes in physical status, encourage socialization with residents/staff, assist with activities of daily living (ADL)'s routinely and as needed (PRN), restorative program as needed, notify Physician/family as needed. Observation on 1/14/19 at 12:37 p.m., 1/16/19 at 8:15 a.m. and 1/17/19 at 8:05 a.m. revealed resident with brown material underneath fingernails on both hands. Interview on 1/16/19 at 2:53 p.m., with Certified Nursing Assistant (CNA) BB stated that activities of daily living (ADL) care consists of getting residents out of bed, dressed, brush teeth, brush hair, shave, feeding, setting up meal trays, transferring and ambulating. She stated that she checks residents nails daily, but shower team and activities usually do the nails most of the time. She further stated that she will cut and clean them if she notices that they need it. She stated she did not notice that R#44 nails were dirty this week. Interview on 1/17/19 at 10:45 a.m. with Director of Nursing (DON) stated that his expectation is that CNA's look at resident's nails daily and clean and cut them when needed. Cross refer to F677 Review of the policy titled Smoke free policy with a review date of 11/5/2018, revealed each patient/resident will be assessed, utilizing the Smoking Observation Form, or electronically, by a licensed nurse upon admission, re-admission, and/or with a significant change. An admission Smoking Care Plan shall be developed by the Licensed Nurse on the Admission Interim Care Plan Form, or electronically. An assessment, utilizing the Smoking Observation Form, or electronic documentation, is completed at least quarterly thereafter only if the answer to either of the first two questions indicated the resident either smokes or has a history of smoking. After completion of the assessment, the care planning team shall review and utilize the assessment when developing the resident's care plan. 2. Review of the clinical record for R #27 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., [MEDICAL CONDITION] reflux disease (GERD), [MEDICAL CONDITION], depression, heart failure and history of [MEDICAL CONDITION]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 7, which indicated moderate cognitive impairment. Section J revealed resident was not a smoker. Review of facilities Smoker Worksheet, revealed R#27 name was not on the list of identified smokers in the facility. Based on review of R#27's baseline care plan and current comprehensive care plan provided, no documentation was found for smoking; subsequently no care interventions or goals were found. Interview on 1/15/19 at 10:06 a.m., with Certified Nursing Assistant (CNA) CC, stated smoking materials are kept at nurses station. Smoking list is provided by administrative team. She stated smoke breaks are every two hours, for 15 minutes and limit is two cigarettes per smoking break. She further stated resident #27 transferred from another facility and did not smoke for first week of being here. She then asked for permission to go out to smoke, second week of being here. Interview on 1/15/19 at 10:31 a.m. with Licensed Practical Nurse (LPN) Unit Manager JJ stated that smoking assessments are done on admission and with each quarterly assessment. Unit manager was able to locate admission smoking assessment in residents file, dated 10/24/18, which indicated that resident is not a smoker. Interview on 1/15/19 at 10:38 a.m., with Minimum Data Set (MDS) Registered Nurse (RN) II, stated the care plans are generated from the MDS assessments. She stated that sometimes their computer system freezes up and will not allow login. She further stated when that happens, they use pre-printed paper care plans. She further stated she cannot remember whether she did a paper care plan for resident #27 and was unable to locate care plan in medical record. Interview on 1/16/19 at 2:47 p.m. with Administrator, stated that if residents are admitted and have a desire to smoke, he puts them on the smoking list and the nursing staff alert the smoking supervisors of who has been added to the list, after a smoking evaluation is completed by the nursing staff. He stated that his expectation is that if the smoking supervisors recognize a resident out in the smoking area, smoking, and they are not on the smoking list, they are to inform the Nursing staff. He further stated that he was not Cross Refer F689

Based on observation, record review and staff interviews, the facility failed to ensure that activities of daily living (ADL) was provided for one dependent resident (R) R#44 related to nail care. The sample size was 42. Findings include: Review of the clinical record for R #44 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 12, which indicated mild cognitive impairment. Section G revealed resident requires extensive assistance with dressing, toileting and personal hygiene. Observation on 1/14/19 at 12:37 p.m., 1/16/19 at 8:15 a.m. and 1/17/19 at 8:05 a.m. revealed resident with brown material underneath fingernails on both hands. Interview on 1/16/19 at 2:53 p.m., with Certified Nursing Assistant (CNA) BB stated that she finds out what her assignment is from the Nursing Supervisor. She stated the Kiosk on the wall lists what care each resident is to receive. She stated that activities of daily living (ADL) care consists of getting residents out of bed, dressed, brush teeth, brush hair, shave, feeding, setting up meal trays, transferring and ambulating. She stated that she checks residents nails daily, but shower team and activities usually do the nails most of the time. She further stated that she will cut and clean them if she notices that they need it. She stated she did not notice that R#44 nails were dirty this week. Interview on 1/17/19 at 10:45 a.m. with Director of Nursing (DON) stated that his expectation is that CNA's look at resident's nails daily and clean and cut them when needed. He stated that the floor CNA's as well as the bath team can clean and cut nails. He further stated that the CNA's are not allowed to cut fingernails for residents that are diabetic, but they can clean them at any time. If the nails need to be trimmed, the CNA's are to inform any licensed nurse to cut/trim them. He verified that resident #44 nails were dirty with thick brown substance underneath them. He stated the facility does not have a policy on providing nail care.

Based on observation, record review and staff interview, the facility failed to ensure that the code status was correctly reflected for one resident (R) #44: specifically documentation in Advanced Directive/Physician order [REDACTED].#44 code status as Allow Natural Death AND Do Not Resuscitate (DNR). The sample size was 42. Findings include: Review of the clinical record for R #44 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 12, which indicated mild cognitive impairment. Section G revealed resident requires extensive assistance with dressing, toileting and personal hygiene. Review of R#44 Physician order [REDACTED]. Review of the medical record for R#44 revealed that there was a red heart sticker on the spine of the medical record, which reflected the resident to be a Do Not Resuscitate (DNR) status, according to Licensed Practical Nurse (LPN) AA. Further review of the medical record for R#44 revealed the (MONTH) Physician order [REDACTED]. The Medication Administration Record [REDACTED]. Review of the care plan initiated on [DATE] revealed R#44 has an advanced Directive: Do Not Resuscitate. Approaches to care include No CPR in the event of a [MEDICAL CONDITION] or respiratory arrest, review directives with patient/family quarterly, Notify Physician and significant others of any changes. Interview on [DATE] at 1:42 p.m. with Licensed Practical Nurse (LPN) AA, stated that she would look at the physician orders, the chart for a red heart (which means DNR) or the advance directive to see what the residents code status is. She further stated that she has been here so long that she knows what the code status is for each of her residents. Interview on [DATE] at 2:47 p.m. with Licensed Practical Nurse (LPN) EE, stated that finds out residents code status based on whether or not there is a red heart on the chart or she will look at the advance directive tab in the chart. She stated that R#44 is a Full Code, according to physician orders. Interview on [DATE] at 3:59 p.m., with Director of Nursing, stated that the leadership team checks the physician orders [REDACTED]. He further stated that two nurses must check before placing on the charts. Interview on [DATE] at 4:12 p.m. with the DON, stated he corrected the Medication Administration Record [REDACTED]. He further stated that he wrote a physician order [REDACTED].>

Based on observation, record review, policy review and interviews, the facility failed to ensure safe smoking was for one resident (R#27) of 13 residents reviewed for smoking. The sample size was 42. Findings include: Review of the facility policy titled Smoke Free Policy with a revised date of 11/5/18, revealed the policy statement to be as of (MONTH) 1, (YEAR), smoking is not allowed on the Healthcare center premises by visitors, partners or patients/residents. Smoking will only be allowed in outdoor designated areas for those residents grandfathered in prior to (MONTH) 1, (YEAR). Assessment and Care Planning section, bullet 2. Each patient/resident will be assessed, utilizing the Smoking Observation Form, by a licensed nurse upon admission, re-admission, and/or with a Significant Change. An Admission Smoking Care Plan shall be developed by the Licensed Nurse on the Admission Interim Care Plan Form. Bullet 3. An assessment is completed at least quarterly thereafter only if the answer to either of the first two (2) questions indicate the resident either smokes or has a history of smoking. After completion of the assessment, the care planning team shall review and utilized the assessment when developing the resident's care plan. Bullet 8. Patients/residents will be assessed for risk/hazards prior to smoking in designated area and shall be supervised as necessary based on the Smoking Observation Form. Bullet 9. When the patient/resident is identified as an unsupervised smoker, the Administrator must be notified immediately. Review of the clinical record for R #27 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., [MEDICAL CONDITION] reflux disease (GERD), [MEDICAL CONDITION], depression, heart failure and history of [MEDICAL CONDITION]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 7, which indicated moderate cognitive impairment. Section J revealed resident was not a smoker. Review of Safe Smoking Form documented that residents were to be assessed for safe smoking on admission, quarterly, annually or with a significant change. Review of Smoking Observation Form for R#27, dated 10/24/18, revealed question one: Does the resident smoke? No column is checked. Question two: Does the resident have a past history of smoking? Yes column is checked. Review of facilities Smoker Worksheet, revealed R#27 name was not on the list of identified smokers in the facility. Based on review of R#27's baseline care plan and current comprehensive care plan provided, no documentation was found for smoking; subsequently no care interventions or goals were found. Observation on 1/14/19 at 12:00 p.m., resident was observed smoking in the designated smoking area, along with twelve other residents. She was wearing a smoking apron and appeared to be smoking safely. There were two staff members present during the smoking period. Further review of medical record revealed that R#27 was not assessed for safe smoking until 1/15/19, after surveyor initiated investigation. Interview on 1/15/19 at 10:06 a.m., with Certified Nursing Assistant (CNA) CC, stated the smoking materials are kept at nurses station. A list is provided by administration team, of which residents are allowed to smoke. She stated smoke breaks are every every (2) hours, for 15 minutes and the limit is two (2) cigarettes per smoking break. She further stated R#27 transferred from another facility and did not smoke for the first week of being here. She then asked for permission to go out to smoke, second week of being here. Interview on 1/15/19 at 10:31 am with Unit Manager JJ, stated that smoking assessments are done on admission and with each quarterly assessment. Unit manager was able to locate smoking assessment in residents file, dated 10/24/18, which indicated that resident is not a smoker. Interview on 1/15/19 at 10:38 a.m., with Minimum Data Set (MDS) RN II, stated they keep a paper record of when assessments are due. She stated the care plans are generated from the MDS assessments. She stated that sometimes their computer system freezes up and will not allow login. She further stated when that happens, they use pre-printed paper care plans. She further stated she cannot remember whether she did a paper care plan for resident #27 and was unable to locate care plan in medical record. Interview on 1/15/19 at 10:54 a.m., with Senior Nurse Consultant HH, stated that resident started smoking 1 month ago. They would do an assessment and create care plan for smoking. Interview on 1/16/19 at 1/16/19 with Administrator, stated that if residents are admitted and have a desire to smoke, he puts them on the smoking list and the nursing staff alert the smoking supervisors of who has been added to the list, after a smoking evaluation is completed by the nursing staff. He stated that his expectation is that if the smoking supervisors recognize a resident out in the smoking area, smoking, and they are not on the smoking list, they are to inform the Nursing staff. He further stated that he was not aware that R#27 had been smoking.

Based on observation, staff interview, and record review, the facility failed to ensure adequate resident supervision to prevent exit from the building for five (5) residents (#1, #2, #3, #4, and #5) from a sample of eight (8) residents who have exited the building unsupervised in the last six (6) months. Resident #1 exited the building three (3) times in six months, twice seated in another residents wheelchair by staff, with no departure alert device attached and on 10/17/2015 fell unsupervised in the facility parking lot, sustaining injuries and requiring transfer to an emergency department, resulting in a [DIAGNOSES REDACTED]. The resident recieved anticoagulants and was at high risk for excessive bleeding. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the liklihood to cause, serious harm, injury, impairment or death. The facility's Administrator and Director of Nursing were informed of immediate jeopardy on December 8, 2015 at 1:35 p.m The non-compliance involving facility staff's failure to provide adequate supervision of Resident #1, who was at risk of elopement, which caused the immediate jeopardy, was identified to have existed on August 6, 2015 (the first day Resident #1 eloped from the facility in another residents wheel chair without a Wander Guard attached to his person or wheelchair), and was removed on December 10, 2015. Record review of Nurses Notes for Resident #2 revealed two attempts to exit the facility on the same day ( 7/9/2015 at 3:00 p.m. and 7:15 p.m.). The resident had a Wander Guard ordered at the time of the second elopement at 7:15 p.m. but it had been attached to her walker and she ambulated out the door after leaving her walker behind. The Wander Guard remained on her walker until 12/8/2015. Three additional residents ( #3, #4, and #5) were able to exit the building in the last six months from doors not equipped with a Departure Alert Alarm, left open or unlocked by employees. An Allegation of Compliance (AoC) was recieved from the facility on 12/8/15 at 4:30 p.m. The interventions included the assessment of placing Departure Alert Devices on the wrists or ankles of 5 residents who had been identified to be at risk for wandering and had the devices on thier wheel chairs or walkers. Other Immediate interventions included monititoring of these 5 residents hourly for twenty-four hours for Wander Guard to person compliance and torlerance by the residents and continuation of daily Wanderguard monitoring for the nineteen residents assessed as elopement risks with Wander Guards and updating the wandering book with location of Wander Guard device. Additional action taken to assure no other residents would be affected in the future included staff education on elopement precautions and change of Departure Alert Devices from wheel chairs and walkers to the person. Education was completed to forty (40) percent (%) of the staff by midnight of 12/8/15 and all staff prior to working thier shift by 12/10/15. All newly admitted residents, once assessed and if needing a Wander Guard, will have the device placed on thier person unless medically contraindicated. Findings Include: 1. Review of the clinical record for Resident #1 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicating an admission date of [DATE], and re-entry from an acute care hospital on [DATE], which documented moderate difficulty hearing, was unable to complete Brief Interview for Mental Status (BIMS) scoring, demonstarted the behaviors of inattention and disorganized thinking constantly, and wandering occurred daily. Resident #1 required extensive assistance in all areas of ADL except eating and used a wheelchair for mobility. A prior MDS quarterly assessment dated [DATE] indicated Resident #1 was delusional at that time and wandered daily. An Annual MDS assessment dated [DATE] revealed he wandered daily and was not assessed to be at risk of getting to a potentially dangerous place Further record review for Resident #1 revealed a Nurses note entry dated 6/16/2015 at 6:30 p.m. indicating Resident #1 exited the front lobby door after a visitor by going out the door before it had time to reclose and lock. He was returned to the facility without incident. A Nurses Note dated 8/16/2015 described Resident #1 propelling himself in the parking lot and was redirected back inside the facility with no injuries. A Nurses note dated 10/17/2015 revealed at 6:15 p.m. the resident was noted to be outside in the parking lot lying on his left side on the pavement, alert and shouting, with a laceration over the left eye and a skin tear on his left elbow. He was transferred by ambulance to a trauma center for treatment and evaluation.He returned to the facility on [DATE] at 1:30 a.m. with a radiology report indicating a Frontal and Periorbital Hematoma and Laceration to his Left Forehead and Left Elbow and a Skin Tear to the Left Elbow and a Closed Head Injury. Review of Nurses Notes dated 10/18/2015 reveal a Wander Guard was placed on his right ankle. Record review of physician orders [REDACTED].#1. Review of Behavior Management Documentation From revealed Resident #1 has the behaviiors of wandering and cursing and the interventions in place were not considered to be effective. There was no record of meetings after 9/1/2015. Observation 12/7/15 at 12:10 a.m. revealed Resident #1 in his wheel chair equipped with Wander Guards on the chair as well as his left ankle. He was talking and laughing with other residents and propelling himself around the dining room and lobby. Interview 12/7/2015 at 3:00 p.m. with the Administrator revealed the Behavioral Management Committee is supposed to meet every week according to policy, and discuss all residents with behaviors. The administrator acknowledged the committee had not met since 9/1/2015. Her investigation of the elopement of Resident #1 on 8/6/2015 indicated he was placed in another residents wheelchair that day when assisted out of bed by Certified Nursing Assistants (CNA's). He was using a wheel chair with no Wander Guard and he was able to exit the building without the front door alarming or locking. The Administrator acknowledged there was no Wander Guard on the resident, only his wheel chair at the time. He had no injuries or problems resulting from this elopement. The Administrator revealed the facilities approach to prevent further elopements was to educate the staff to be sure to place the residents at risk for elopement in wheelchairs with Wander Guards. Interview 12/7/2015 at 3:10 p.m. with Nurse AA revealed Resident #1 had a Wander Guard on his wheel chair until he fell in the parking lot on 10/17/15. The wheel chair he was in that day was not his and it did not have a Departure Alert Device or anti tippers. He had been placed in the wrong wheelchair the morning of 10/17/2015 for the second time, and the door did not lock or alarm. The facility intervention to prevent further elopement was to add a Wander Guard to the residents ankle and educate the staff to place residents in thier own wheel chairs. 2. Review of the clinical record for Resident #2 revealed a quarterly MDS assessment dated [DATE] indicating admission on 10/7/2014. BIMS score for the assessment was twelve. Resident exhibited no wandering and used no mobility devices according to the assessment. Review of the Elopement Risk Observation Form completed on 6/23/2015 revealed Resident #2 was at high risk for wandering and had a Wander Guard in place. Review of Physician orders [REDACTED]. Review of the Care Plan revealed the entire Care Plan for elopement had been discontinued on 6/11/2015, despite the resident being assessed as a high elopement risk. Another Care plan for elopement was initiated on 7/9/2015. Review of Nurses Notes for Resident #2 revealed an entry of 7/9/15 at 3:00 p.m. indicating resident was noted outside facility with her purse and had stated she was going to the store. The resident was returned to the facility and a Wander Guard was placed on her walker. At 7:05 p.m.she was standing at the front door trying to open it. At 7:15 p.m. she left her walker behind and exited the front door and was found standing on the side walk looking around. Observation of Resident #2 on 12/8/2015 at 1:55 p.m. revealed she was in her room sitting on her bed with a Wander Guard bracelet attached to her walker. Interview 12/9/2015 at 3:05 PM with Nurse BB revealed the order to discontinue the Wander Guard on June 11, 2015 was due to resident cutting it off. BB acknowledged the resident eloped twice on 7/9/15, the second time with her ordered Wander Guard on her walker , by leaving her walker behind. BB' indicated she did not remember if she made a second incident report for the second elopement but knew she should have. Interview with AA on 12/8/15 at 3:15 p.m. revealed she was not sure why the entire care plan for wandering was discontinued on 6/11/2015 because the resident remained a high risk. The Wander Guard approach should have been discontinued while the rest of the care plan remained in effect. AA acknowledged there is no process to re evaluate the placements of the wanderguards on devices instead of limbs but at this time it has been placed on her ankle and she is tolerating it there without problems. She does not recall if she was notified that Resident #2 eloped twice in the sam,e day, once after the Wander Guard was placed , but an incident report should have been completed. Interview with Administrator 12/10/15 at 10:45 a.m. revealed she had not been notified of Resident #2's second elopement on 7/9/2015 and she should have been notified according to policy so she could track the incident,and investigate and analyze the elopement. All elopements are considered a behavior and this resident is reviewed by the Behavioral Management Program which according to policy should meet weekly, but have not had a meeting since September 1, 2015. The administrator confirmed there is no increased thirty (30) minute monitoring program as described in the elopemnt precaution policy, when a resident elopes. There is no re evaluation of placement of the Wander Guard devices when they are not placed on the person , but placed on a device for medical or psychological reasons. 3. Closed record review for Resident #3 revealed he was assessed and care planned for wandering and had worn a Wander Guard since 5/19/2015. Nurses notes revealed on 8/4/15 at 9:30 p.m. he was able to exit the facility thorugh the Dining Room door in his wheel chair, in his night clothes, and knocked on the door at the end of the B Hall, after a staff member used the door and did not close it properly. There were no injuries but Resident #3 stated he was glad that was over with. Review of the incident Follow up for this elopement revealed the Wander Guard was checked and functioning properly and staff were encouraged to properly close the doors. Interview 12/9/15 at 5:20 p.m. with the Administrator revealed the floor technician had used the door that day and did not completely close it. There was no actual record of staff education but the assistant house keeping supervisor had discussed the elopement with the floor technician. The Wander Guard did not alarm because the only door in the facility equipped to alarm and lock when a resident wearing a Wander Guard approaches is the front door. No other doors will alarm. Interview 12/10/15 at 9:15 a.m. with Employee CC revealed he had used the Dining Room door on 8/4/15 . He had taken garbage out the front door at 9:00 PM that night and observed a resident in a wheel chair out side the facility gate, trying to get in. He acknowledged he had not closed the Dining Room door thoroughly and the resident was able to exit the door. The lawn maintenance crew had mowed that day and did not padlock the gate in the fenced in yard out side the dining room and the resident in his wheel chair exited through the gate and wheeled himself through the parking lot, up the maintenace drive between the maintenance building and the facility and up to the B hall door. CC confirmed his supervisor had spoken to him about this. 4. Review of the clinical record for Resident #4 revealed an MDS Quarterly assessment dated [DATE] with A BIMS score of eight (8) and requiring extensive assistance with locomotion and transfer, using a walker and wheel chair for mobility. Review of Nurses Notes dated 12/7/2015 for Resident #4 revealed he was observed outside the building - no time is given for the note, and he was inside a fenced in smoking area and said he was looking for his car. He was assisted back inside the facility and did not have injuries. The staff were educated to make sure the door is locked . Observation of Resident #4 12/8/2015 at 1:50 p.m. revealed resident wearing a Wander Guard on his right wrist. Interview 12/10/15 with Nurse DD revealed Resident #4 exited a door that had been left unlocked by staff and it did not alarm because it is not equipped to alarm in response to a resident with a Wander Guard. 5. Record review of Resident #5 revealed a Quarterly MDS assessment indicating a BIMS score of eleven (11) out of fifteen (15) and no wandering behaviors, used a cane or crutch and required limited assistance for locomotion . Review of the care plan revealed he was care planned for wandering and a Wander Guard in place and an update of 8/21/2015 indicating he had exited the facility. He was also care planned for delusions and hallucinations due to a [DIAGNOSES REDACTED]. Review of Behavioral Management Documentation Form revealed residents behavior of wandering was recognized by the committee on 7/28/2015 and no further documentation of committee meeting to address this behavior took place after 9/1/2015. Review of Nurses Notes dated 8/21/2015 revealed resident exited through the B Hall door after a staff member left through this door and did not close it properly. The resident did not sustain injury and was assisted back inside. Staff were educated regarding making sure doors close properly behind them. Interview 12/8/15 at 3:05 p.m. with Nurse AA revealed resident exited through a door not equipped to alarm or lock in response to the approach of a resident with a Wander Guard. Staff education was provided. An AoC entitled Performance Improvement Action Plan for Observation, Documentation, and Management of Risk for Elopement was recieved on 12/9/15 at 2:00 p.m The approaches included: 1. Completion of elopement assessments on admission, readmission, quarterly and as needed for residents change of condition. 2. A three (3) day behavior monitor is to be completed with new admissions. 3. Behavior Management forms are to be completed on new admissions, quarterly and on any residents identified with behaviors. 4. The Behavior Management Committe wiill meet and review weekly and discuss residents with behaviors to include residents with elopement risk and Wander Guards. 5. Residents equipped with Wander Guard devices will be monitored and checked daily for placement and operability. 6. Residents with wander guards will have their care plans in place and to or updated with interventions related to monitoring and assessment. These care plans will be reviewed quarterly and as needed. 7. CNA ADL care plan will be coded and revised when resident has wander guard placement. These will be reviewed monthly and as needed. 8. Resident identified with wandering behavior will have a Wander Guard device placed on their person unless the resident removes the device at will or medically contraindicated (fragile skin, edema, etc.). Alternative measures will be taken up to one to one (1:1) observation until facility can find alternative placement. 9. If the resident removes the device due to behaviors or confusion alternative measures will be to provide safety. The safety measures could include (A) placing the wander guard device on the lower extremity, (B) placing the Wander Guard on the wheelchair that has been marked and designated as the residents wheelchair. If these measures are not appropriate then the resident will receive one on one observation by a staff member until the facility can find alternative placement for the resident. This alternative placement could include giving the family/resident a thirty (30) day notice to be transferred to a facility with a safer environment. 10. The administrator will be notified upon any elopement occurrence. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice at Scope and Severity of K was determined to have been removed on 12/10/15, and the facility remained out of compliance at a lower scope and severity of H while the facility continued the process of ensuring the necessary supervision of residents at risk of elopement with the new action plan and completed a process of staff in-service training related to the new action plan. Observations were made to assess staff performance related to these new procedures. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of residence at risk for elopement and who used Wander Guard alert devices. Additional interviews and observations were conducted to ensure staff compliance with keeping all doors closed and locked and reporting of occurrences in compliance with the occurrence reporting policy. Interview with the Administrator on 12/10/15 at 10:45 a.m. revealed all the doors are being checked today to see if it is possible to add Wander Guard alarm and locking devices to all the exit doors in the facility and to check the front door , the only door equipped with alarms and locking devices and ensure it is functioning properly.

Based on observation, staff interview, clinical record review, and Elopement Risk Observation Forms, the facility failed to develop a comprehensive Care Plan which addressed the wandering behavior/elopement potential of one (1) sampled resident (Resident #2), who had been identified as having wandering behavior and elopement potential, from an abbreviated survey sample of eight (8) residents. The facility failed to ensure that a current care plan addressing the need for staff supervision was developed and implemented, which was necessary to prevent resident elopement and to ensure resident safety. Resident #2, documented to have the ability to ambulate 75 feet unassisted by physical therapy, was discovered to have exited the facility by leaving her walker with the Wander Guard attached, behind and walking through the front door. Resident #2 had been assessed and care planned for a high risk of elopement. Her Wander Guard had been discontinued on 6/11/15 for behvioral problems, and on that date her entire care plan for wandering and elopement had also been discontinued. Resident #2 exited the facility on 7/9/15 at 3:00 p.m. with no care plan for elopement or wandering, and was noted outside the facility on the sidewalk with her purse, stating she was going to the store. The resident was returned to the facility and a Wander Guard was placed on her walker because she had made prior attempts to remove it and experienced increased agitation when a Wander Guard was placed on her body. The resident was noted to be standing at the front door at 7:05 p.m. trying to open the door and at 7:15 p.m. left her walker at the chair where she was sitting and opened the front door. She was discovered standing on the sidewalk looking around and was redirected and reentered the facility. A Care Plan was initiated on 7/9/15 with the problem of attempting to exit facility unattended and the approaches included a Wander Guard bracelet to alert staff of attempts to exit the facility, and to observe resident for unsafe actions. An update to the care plan dated 7/15/15, with approaches to ensure Wander Guard bracelet is in proper working order daily and attempt to redirect when wandering noted. Record review and staff interview revealed no further attempts at assessment or evaluation of the location of the Wander Guard occurred. The Wander Guard remained on the walker of Resident #2, despite the fact that she was able to elope by leaving the walker behind, until 12/8/2015. The facility administrator was informed of the Immediate Jeopardy on 12/8/15 at 1:35 p.m The noncompliance related to the Immediate Jeopardy was identified to have existed as of 6/11/2015, the date when the wandering/elopement care plan of Resident #2 was discontinued. This resulted in a situation in which the facility ' s noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death. An allegation of compliance was received from the facility on 12/8/15 at 4:30 p.m The interventions included the assessment of placing Departure Alert Devices on the wrists or ankles of residents who had been identified to be at risk for wandering and had the Wander Guards on their mobility devices, not their bodies. Other immediate interventions included monitoring of these residents hourly for 24 hours for Wander Guard /person compliance and intolerance by the residents and continuation of daily Wander Guard monitoring for the 19 residents assessed as elopement risks with Wander Guards and updating the wandering book location of Wander Guard device. Additional action taken to assure no other residents would be affected in the future included staff education on elopement precautions and change of Departure Alert Devices from wheelchairs walkers to the person. Education was completed for forty percent (40%) of the staff by midnight of 12/8/15 and all staff prior to working the shift by 12/10/15. All newly admitted residents, once assessed and if needing a Wander Guard, will have the device placed on their person unless medically contraindicated. Findings include: Clinical record review for resident #2 revealed a Minimum Data Set (MDS)quarterly assessment dated [DATE] indicating admission on 10/7/14. The residents Brief Interview for Mental Status summary score for the assessment was twelve (12). The resident did not exhibit wandering and did not use mobility devices according to the assessment Review of Elopement Risk Observation Forms completed on 6/23/15 revealed Resident #2 was at high risk for wandering. Physician orders [REDACTED]. Review of the Care Plan for Resident #2 revealed the entire care plan for elopement had been discontinued on 6/11/15, despite the resident being a assessed as a high elopement risk. A new care plan for elopement was initiated on 7/9/15. Nurses Notes dated 7/9/15, 3:00 p.m. for Resident #2 revealed the resident was outside of the facility stating she was going to the store. The resident was returned to the facility and a Wander Guard was placed on her walker. The next entry in the nurses notes dated 7/9/15 at 7:05 p.m. indicated she was standing at the front door trying to open it. Ten (10) minutes later at 7:15 p.m. she left her walker behind and exited the front door and was found standing on the sidewalk. Resident #2 was observed on 12/8/15 at 1:55 p.m. sitting on her bed in her room with her walker beside her. A Wander Guard bracelet was attached to her walker. Interview 12/9/15 at 3:05 p.m. with Nurse BB indicated the resident had cut off her Wander Guard on 6/11/15 and the physician discontinued it. BB revealed the resident eloped on 7/9/15 with no Wander Guard on her body or mobility device the first time and the second time when a Wander Guard was placed on her walker, by leaving her walker behind. BB indicated she was the Nurse on duty at the time of these events and she knew she should have made a second incident report for the second elopement but was unable to remember if she did. Interview with Nurse AA on 12/8/15 at 3:15 p.m. revealed the resident remained at high risk after the Wander Guard was discontinued on 6/11/15, therefore only the Wander Guard approach should have been discontinued from the elopement Care Plan. The rest of the Care Plan should not have been discontinued. AA acknowledged there is no process to re-evaluate the placement of the Wander Guard on devices instead of limbs but at this time it has been placed on her ankle and she is tolerating it there without problems. AA acknowledged an incident report should have been completed to facilitate investigation and analysis of Resident #2's second elopement. Review of elopement risk observation form dated 6/23/15 revealed Resident #2 remained at high risk and should have had the interventions of weekly behavioral management program to determine appropriate interventions, 3 day monitoring , and wanderguard program. During an interview on 12/10/15 at 10:45 a.m. the Administrator revealed she had not been notified of Resident #2's second elopement on 7/9/15 and she should have been notified according to policy so she could track the incident, investigate and analyze the elopement. No reevaluation of the placement of the Wander Guard for Resident #2 occurred. The Administrator additionally revealed there had been no behavioral management meetings since 9/1/15 due to an oversight. Based on the above example, the facility failed to ensure that a comprehensive Care Plan was developed for Resident #2, who exhibited wandering and elopement behavior, to ensure the adequate staff monitoring and supervision of this resident. The Immediate Jeopardy was determined to be removed on 12/10/15 , after the facility had presented and implemented an Allegation of Compliance entitled Performance Improvement Action Plan for Observation, Documentation, and Management of Risk for Elopement with the following interventions: 1. Completion of elopement assessments on admission, readmission, quarterly and as needed for residents change of condition. 2. A three day behavior monitor is to be completed with new admissions. 3. Behavior management forms are to be completed on new admissions, quarterly, and on any residents identified with behaviors. 4. The behavior management committee will meet and review weekly and discuss residents with behaviors to include residents with the elopement risk and wander guards. 5. Residents equipped with Wander Guard devices will be monitored and checked daily for placement and operability. 6. Residents with Wander Guards will have their Care Plans in place and or updated with interventions related to monitoring and assessment. These Care Plans will be reviewed quarterly and as needed. 7.Certified Nursing Assistant (CNA) Activity of Daily Living (ADL) Care Plans will be coded and revised when resident has Wander Guard placement. These will be reviewed monthly and as needed. 8. Residents identified with wandering behavior will have a Wander Guard device placed on their person unless the resident removes the device at will or medically contraindicated (fragile skin, [MEDICAL CONDITION], etc.). Alternative measures will be taken up to one on one (1:1) observation until facility can find alternative placement. 9. If the resident removes the device due to behaviors or confusion, alternative measures will be to provide safety. The safety measures could include a placing the Wander Guard on the lower extremity, placing the Wander Guard on wheelchair that has been marked and designated as the residents wheelchair. If these measures are not appropriate then the resident will receive 1:1 observation by a staff member until the facility can find alternative placement for the resident. This alternative placement could include giving the family/resident a 30 day notice to be transferred to a facility with a safer environment. 10. The Administrator will be notified upon any elopement occurrence. Based on the corrective action plans which had been developed and implemented by the facility, the immediacy of the deficient practice at scope and severity of J was determined to have been removed on 12/10/15, and the facility remained out of compliance at a lower scope and severity of G while the facility continued the process of ensuring the necessary supervision of residents at risk of elopement with the new action plan and completed a process of staff in-service training related to the new action plan. Observations were made to assess staff performance related to these new procedures. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of residents at risk for elopement and who used Wander Guard alert devices. Additional interviews and observations were conducted to ensure staff compliance with keeping all doors closed and locked and reporting of occurrences in compliance with the occurrence reporting policy. Interview with the Administrator on 12/10/15 at 10:45 a.m. revealed the only door equipped with alarms and locking devices is the front door. All other exit doors are being assessed today regarding the possibility of adding Wander Guard alarm and locking devices. The front door alarms and locking devices will be checked to ensure it is functioning properly. Interview with Case Mix Manager Registered Nurse (RN) conducted on 1/11/16 at 10:03 a.m. revealed the Care Plan for elopement for Resident #2 should not have been discontinued on 6/11/15. It should have been modified to indicate the resident was no longer equipped with a wander guard and other measures should have been implemented.

Based on observation, record review and staff interview, and hospital Emergency Department Discharge Instruction review, the facility failed to ensure that supervision to prevent elopement was provided as specified by a Care Plan Approach, regarding the use of a Wander Guard (Departure Alert Bracelet), for one (1)resident (#1), of a sample of eight (#8) residents who have exited the the building unsupervised in the last six (6) months. Resident #1 exited the building through the front doors three (3) times in 6 months. His departure on 8/16/15 and 10/17/15 were due to being assisted by staff into a wheelchair that was not equipped with a Wander Guard device, as specified by the Care Plan dated 6/30/15. On 10/17/15 Resident #1 was able to approach the front door, open the door, and self-propel to the parking lot unsupervised. The wheelchair he had been placed in by staff did not have a Wander Guard attached and there was no Wander Guard on his person. The wheelchair also did not have an anti-tipping device, another care planned intervention on the fall care plan, to prevent the chair from tipping backwards. Resident #1 was discovered in the parking lot by a visitor, after remaining on the pavement for an unknown length of time, shouting for assistance, bleeding from his forehead and left elbow. He was transported to a Trauma Center and after examination, diagnostic evaluations, and treatment was returned to the facility with a [DIAGNOSES REDACTED]. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment, or death to the resident. The facility's Administrator and Director of Nursing were informed of Immediate Jeopardy on 12/8/15 at 1:35 p.m The noncompliance involving facility staff failure to provide adequate supervision of Resident #1, who was at risk of elopement, which caused the Immediate Jeopardy, was identified to have existed on 8/6/15 (the first day Resident #1 eloped from the facility in another residents wheelchair without a Wander Guard attached to his person or wheelchair), and was removed on 12/10/15. In Allegation of Compliance (AoC) was received from the facility on 12/8/15 at 4:30 p.m. The immediate interventions included were as follows: 1.A meeting conducted by the Administrator and Director of Nurses to determine the appropriate change of Wander Guards from device to person. 2. Nursing to determine appropriate site per resident and change the Wander Guard from device to person. Action taken to assure no other residents will be affected in the future: 1. In-service on elopement precautions and change of Wander Guard from device to the person will be completed with 40% of the staff by midnight tonight and will be completed by all staff prior to working thier shift by 12/10/2015. 2. All newly admitted residents needing a Wander Guard will have the Wander Guard placed on the person unless medically contraindicated. Monitoring: 1: Resident #1 through seven (7) will be monitored every hour for twenty-four (24) hours for Wander Guard to person compliance and tolerance by the resident. 2. Then continue daily Wander Guard monitoring and elopement precautions. 3. Update wandering book with location of Wander Guard device placed on the person. Findings Include: Review of the Minimum Data Set (MDS) for Resident #1 revealed an assessment dated [DATE] indicating an admission date of [DATE], with re-entry from acute-care hospital on [DATE], which documented moderate difficulty hearing, inability to complete brief interview for mental status scoring,constant behaviors of inattention and disorganized thinking, and daily wandering. Resident #1 required supervision for eating and extensive assistance in all other areas of activities of daily living and uses a wheelchair for mobility. A quarterly MDS assessment dated [DATE] indicated Resident #1 was delusional and wandered daily. The MDS annual assessment dated [DATE] revealed he wandered daily and was not assessed to be at risk of getting to a potentially dangerous place. Record review of Nurses Notes dated 6/16/15 at 6:30 p.m.indicated Resident #1 exited the front door by going out the door after a visitor and before it had time to close and lock. No injuries resulted and he was returned to the building without incident. Nurses Notes dated 8/6/15 revealed Resident #1 was discovered self propelling in the parking lot and was redirected back inside the facility with no injury. A Nurses Note dated 10/17/15 revealed at 6:15 p.m.the resident was noted to be outside in the parking lot lying on his left side on the pavement, alert and shouting for help, with a skin tear on his left elbow and a laceration over the left eye. He was transferred by ambulance to a Trauma Center for treatment and evaluation. He was returned to the facility on [DATE] at 1:30 a.m. with a radiology report diagnosing a Frontal and Periorbital Hematoma, and Emergency Department discharge instructions diagnosing a Laceration to Left Forhead and Left elbow Laceration and Skin Tear, and a Closed Head Injury. Further review of Nurses Notes revealed a Wander Guard was placed on the right ankle of Resident #1 on 10/18/15. Observation 12/7/15 at 12:10 p.m. revealed Resident #1 in the Dining Room, in his wheelchair. A Wander Guard was on his left ankle and on his wheelchair. Record review of Door Alarm Device Daily Testing Report Form completed by the Maintenance Supervisor indicated Resident #1 had a Wander Guard attached to his wheelchair for the months of June, July, August, September, October, 2015, and an additional door alarm device was placed on his left ankle on 10/18/15. Review of Care Plan dated 6/30/15 indicated Resident #1 attempted to elope and/or has exited the facility unattended. The initial approach indicated a Wander Guard bracelet would be used to alert staff of attempts to exit facility unattended. A hand written addition to this approach, with no indication of what date it was added, revealed the resident would have a Wander Guard on his wheelchair. Care Plan was updated on 8/6/15 revealing an elopement to the sidewalk from the front door. On 10/17/15 the Elopement Care Plan was updated to include that Resident #1 had exited the facility to the front parking lot. An additional approach indicates the facility would ensure alarms are working properly to prevent elopement. An updated hand written approach, dated 10/17/15 was included to ensure the wheelchair is labeled with resident's name to identify his wheelchair with personal interventions. Record review of physician orders [REDACTED].#1. An interview conducted on 12/7/15 at 3:00 p.m. with the Administrator revealed that on 8/16/15 Resident #1 had been placed in another residents wheelchair when assisted out of bed by Certified Nursing Assistants(CNA's). He was using a wheelchair with no Wander Guard, as included in the care plan, and he was able to exit the building without the front door locking or alarming. Nurse AA was interviewed on 12/7/15 at 3:10 p.m. and confirmed Resident #1 had a Wander Guard only on his wheelchair until he fell in the parking lot on 10/17/15. He had been placed in a wheelchair for the second time that was not his and not equipped with a Departure Alert Device or anti-tippers, requirements that were indicated on his Care Plan. The front door did not lock or alarm in response to his approach, and the wheelchair tipped over in the parking lot due to uneven pavement. The facility intervention was to add a Wander Guard to the residents ankle and educate the staff to place the residents in thier own wheelchairs to prevent further elopement. An Aoc entitled Performance Improvement Action Plan for Observation, Documentation, and Management of Risk for Elopement was recieved on 12/9/15 at 2:00 p.m. The approaches included: Completion of elopement assessments on admission, readmission, quarterly and as needed for residents change of condition.A three (3) day behavior monitor is to be completed with new admissions. Behavior management forms are to be completed on new admissions, quarterly, and on any residents identified with behaviors. The Behavior Management Committee will meet and review weekly and discuss residents with behaviors to include residents with elopement risk and Wander Guards. Residents equipped with Wander Guard devices will be monitored and checked daily for placement and operability. Residents with Wander Guards will have thier Care Plans in place and updated with interventions related to monitoring and assessment. These Care Plans will be reviewed quarterly and as needed. Certified Nursing Assistant (CNA) Activity of Daily Living (ADL) Care Plans will be coded and revised when the resident has Wander Guard placement. These will be reviewed monthly and as needed. Residents identified with wandering behavior will have a Wander Guard device placed on thier person unless the resident removes the device at will or it is medically contraindicated due to fragile skin or [MEDICAL CONDITION], etc. Alternative measures will be taken up to one to one (1:1) observation until facility can find alternative placement. If the resident removes the device due to behaviors or confusion, alternative measures will be to provide safety. The safety measures could include placing the Wander Guard device on the lower extremity, placing the Wander Guard on the wheelchair that has been marked and designated as the residents wheelchair. If these measures are not appropriate then the resident will recieve 1:1 observation by a staff member until the facility can find alternative placement for the resident. This alternative placement could include giving the family/resident a thirty (30) day notice to be transferred to a facility with a safer environment. The Administrator will be notified upon any elopement occurrence. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice at Scope and Severity of J was determined to have been removed on 12/10/15 and the facility remained out of compliance at a lower Scope and Severity of G while the facility continued the process of ensuring the neccessary supervision of residents at risk of elopement with the new action plan and completing the process of staff education related to the new action plan. Observations were made to assess staff performence related to these new procedures. Inservice records and materials were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of the residents at high risk for elopement and who used Wanderguard alert devices. Additional interviews and observations were conducted to ensure staff compliance with keeping all doors closed and locked and reporting occurences in compliance with the occurence reporting policy. Interview on 12/10/15 at 10:45 a.m. with the Administrator acknowledged all the exit doors will be assessed today for the possibility of adding Wander Guard alarm and locking devices. The front door in the main lobby is currently the only door in the facility equipped with Wander Guard alarm and locking devices and it will be checked to ensure it is functioning properly. Interview 1/11/16 at 10:03 a.m. with the Case Mix Manager, Registered Nurse (RN), revealed the Care Planned intervention of a Wander Guard for the prevention of elopement and injury was not in place when Resident #1 was able to exit the facility on 8/6/15 and 10/17/15.