Every finding on record at Pruitthealth - Santa Rosa

Based on observation, interviews, and record and policy reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment for 12 of 25 people reviewed. (Residents #66, #52, #33, #105, #102, #60, #93, #100, #128, #15, #21, and #101)The findings include:Resident #66 A review of medical recordS for Resident #66 revealed the resident was admitted on [DATE]. Resident #66's quarterly Minimum Data Set (MDS) (a standardized, mandatory assessment tool in long-term care (LTC) nursing homes, used to evaluate resident functional capabilities, health status, and care needs) dated 2/6/26 reveals resident's Brief Interview for Mental Status (BIMS) of 01, (a cognitive assessment tool) indicating severe cognitive impairment. Further review of the MDS indicated Resident #66 is frequently incontinent of urine and bowel and requires substantial/maximal assistance for toileting, showering and personal hygiene. Resident #66 had a urinary tract infection as per the laboratory results reported on 3/22/2026. The culture reported the organism was Extended-Spectrum Beta-Lactase (ESBL), a Multidrug-Resistant Organism (MDROs), necessitating the use of contact precautions. Further review of the orders reveals an order for contact isolation, dated 3/23/26. The following observations were made: On 3/24/2026 at approximately 2:30 PM, Resident #66 was observed sitting in the common area at a table with other residents watching TV. On 03/24/25 at approximately 3:40 PM, it was noted that Resident #66's roommate was moved to a different room. A Contact Isolation sign was observed on right upper corner of the door of the resident's room . Resident # 66 was not in her room, or in the common area. Staff E, a Licensed Practical Nurse (LPN) located resident in another resident's room, and stated, She was helping a resident back to her room, by pushing her wheelchair. On 03/25/2026 at 9:20 AM, Resident #66 was observed walking around and eventually sitting in a chair at table with other residents. The Contact Isolation sign was still present on her room door. On 03/25/2026 at approximately 1:20 PM, Resident #66 was observed sitting at a table in the common area with other residents who were putting together a puzzle. The Contact Isolation sign was still present. On 3/24/26 at approximately 2:20 PM, an interview was conducted with Staff I, a Certified Nursing Assistant (CNA). Staff I stated the resident can come out of her room because the contact isolation is for her urine. She stated she was not sure what the contact isolation sign directed her to do. 03/24/2026 at approximately 2:45 PM, an interview was conducted with Staff F, a CNA. Staff F confirmed Resident #66 is incontinent and stated the resident changes herself. She stated she is unsure if Resident #66 performs hand hygiene. Staff F stated roommates do not use the same bathroom, however she confirmed she shares the same shower with others, and stated they do not clean the shower between residents.On 3/24/26 at approximately 3:10 PM, an interview was conducted with Staff Z, Unit Manager (UM), a Registered Nurse (RN). She explained when a patient is on contact with ESBL, and the resident has a roommate, they move them, but because Resident # 66's roommate does not use the bathroom for toileting or showering, they don't need to put Resident #66 in a separate room. Staff Z, UM was informed both residents are using the same shower based on interviews with staff. On 03/25/2026 at approximately 9:40 AM, an interview was conducted with Staff Z, the UM. Staff Z was informed based on interviews and review of CNA documentation, Resident # 66 is incontinent of urine and bowel. Staff Z stated, there is no way she can keep resident# 66 confined to her room without restraining her. Resident #52 On 3/25/2026 at approximately 8:20 AM, Resident # 52 was observed receiving oxygen therapy via nasal cannula O2 lines. The humidifiers were not dated A review of Resident #52's medical record revealed that the resident was admitted on [DATE] with diagnoses including end stage chronic pulmonary disease. Further review reveals a physician's order dated 04/12/23 for continuous oxygen therapy at 4 liters per minute (LPM). Additionally, there was a physician's order for oxygen equipment to be changed weekly. On 3/25/26 at approximately 3:40 PM an interview was conducted with Staff E, a Licensed Practical Nurse (LPN). She confirmed the oxygen tubing and humidifier should have the date they were changed. Resident #33 On 3/25/2026 at approximately 8:10 AM, an observation of resident #33's room revealed an O2 concentrator with Oxygen tubing contained in the bag. The humidifier was dated 3/25/26, however the bag containing the oxygen lines, and lines did not have a date. A review of resident #33's medical records revealed the resident was admitted on [DATE] with diagnoses including COPD, emphysema and congestive heart failure. Further review reveals a physician's order dated 10/15/25 for Oxygen at 2 LPM via nasal cannula continuous as tolerated. Additionally, there was physician's order to change respiratory circuit/supplies weekly.On 3/25/26 at approximately 1:00 PM, an interview and oobservation was conducted with Staff D, LPN. Staff D inspected the O2 lines and humidifier in resident #33's room. The humidifier had a date, but the O2 line was not dated. Staff D stated, the O2 lines should also be dated they day they are changed. WOUND CARE Resident #105 On 03/24/2026 at approximately 6:26 AM, Staff A, Registered Nurse (RN) Wound Care Nurse and Staff W, Licensed Practical Nurse (LPN), Skin Integrity and Treatment coordinator, and the Advanced Registered Nurse Practitioner (ARNP) were observed performing wound care on Resident #105. All staff were observed to apply appropriate personal protective equipment (PPE), perform hand hygiene, and don gloves prior to initiating care. Staff A, RN was then observed cleaning Resident #105's personal items on his bedside table to create space for wound care supplies. During this process, Staff A, RN handled the resident's cellular phone, a cup and other personal items. Without removing her gloves or performing hand hygiene, she established a clean field using paper towels, and a basket containing wound care supplies was placed on the surface. Staff A, RN proceeded to remove the resident's abdominal dressing while wearing the same gloves used to handle the personal items. She was observed touching the resident's lower abdomen while removing tape and packing foam with contaminated gloves. She then removed her gloves, performed hand hygiene with soap and water, and donned a new pair of gloves. After complication of the dressing change, Staff A, RN discarded all supplies into the garbage, emptied and tied the garbage, removed her gloves and performed hand hygiene. Staff W, LPN was then observed taking the tied garbage bag with her bare hands and carried it out to the soiled utility room. Resident #102 On 03/24/2026 at approximately 7:00 AM, Staff A, Staff W, and the wound care provider Advanced Registered Nurse Practitioner (ARNP) were observed performing a wound care dressing change to Resident #102's heel. Staff A, RN gathered supplies and retrieved an already opened package of calcium alginate (highly absorbent, biodegradable dressings made from seaweed, designed for moderate to heavily exudating wounds) that was not labeled with a resident name or the date opened. Further observation of the treatment cart revealed four opened packages of calcium alginate stored in the cart. All staff were observed to apply appropriate PPE, perform hand hygiene, and don gloves prior to initiating care. After removing and cutting open the old dressing, the soiled dressing was left underneath Resident #102 heel. Without removing gloves or performing hand hygiene, Staff A, RN proceeded to cleanse the wound. Staff A, RN then removed her gloves, performed hand hygiene, and donned new gloves. She removed the calcium alginate from the already opened package, cut it to the appropriate size, and applied it to the heel wound. A dry dressing was then applied. Following completion of the new dressing application, Staff A proceeded to remove the old, contaminated dressing from underneath the resident's heel. On 03/24/2026 at approximately 7:25 AM, an interview was conducted with Staff A, RN. She stated that Resident #105's personal items should be considered contaminated and recognized that hand hygiene should have been performed prior to initiating the dressing change. She further acknowledged that the calcium alginate used during the treatment for Resident #102, was obtained from an opened package stored on her treatment cart, was not labeled with an opened date or resident name and was not designated for single-resident use. She recognized that maintaining an open, unlabeled dressing in the treatment cart posed a risk for infection control breaches and cross-contamination. On 03/24/2026 at approximately 8:20 AM, an interview was conducted with Staff W, LPN. She acknowledged that she transported garbage containing a soiled dressing for Resident #105 with her bare hands and stated that she was aware that gloves should have been worn. She further acknowledged observing the open calcium alginate dressing package intended for Resident #102 and verbalized awareness of the risk for cross-contamination, indicating that all dressing packages should remain sealed until the time of use. Multi Drug Resistant Organisms (MDRO) Resident #60 On 03/23/2026 at approximately 12:02 PM, during the initial pool interview, Resident #60 stated that he has a wound to his left ankle that is positive for Methicillin-Resistant Staphylococcus Aureus (MRSA). He further stated that when staff enter his room, they do not wear a gown and only wear gloves. Observation revealed that the transmission-based precaution sign was posted outside the residence door, and a PPE cart was in mid hallway; it was observed that no alcohol-based hand rub was present in the cart or in the hallway. During the survey from 03/25/2026 to 03/27/2026, observations of the resident room revealed there were no dedicated patient care items present. Specifically, no stethoscope and no biohazard bag for the disposal of contaminated items were available in the room. On 03/25/2026 at approximately 10:30 AM, Resident #60 indicated that, on the morning of the observation, staff entered the room and obtained vital signs using a shared/common machine. On 03/24/2026 at approximately 9:15 AM an interview was conducted with the Infection Preventionist. She explained that it is her responsibility to track infections and culture results for residents. Regarding Resident #60, who was receiving IV antibiotics, Daptomycin (bactericidal intravenous antibiotic used to treat, but not limited to, complex skin infections like MRSA), she stated that the culture was obtained during the hospital stay; however, she was unaware of the type of infection the resident had. Upon independent review, she indicated that the culture remained pending from the hospital as of 02/06/2026. She further stated that when the resident returned to the facility on [DATE], she did not follow up on the culture results. She acknowledged that this is an oversight and stated that she should have inquired about the culture upon readmission to ensure appropriate precautions were implemented to prevent cross contamination. She further acknowledged the importance of protecting other residents and staff. On 03/24/2026 at approximately 2:20 PM, a combined interview was conducted with the Infection Preventionist, RN, Staff T, RN and the Director of Nursing (DON). They were unaware, as of today, of the culture result from 02/09/2026, which was identified as MRSA. They explained that the patient had been placed on enhanced barrier precautions (EBT) for having a wound, which they described as essentially the same as transmission-based precaution, and that staff already have been appropriately using gowns and personal protective equipment. However, they acknowledged that the cultural result should have been properly tracked by the facility. On 03/24/2026 at approximately 2:35 PM, an interview was conducted with Staff L, RN. She reported that she has been carrying for the residents since his admission on [DATE]. When asked the reason for the resident being placed on EBP, she stated she was unsure but believed it may be related to a hardware infection in the resident leg. She described differences between EBP and TBP, indicating that isolation would require dedicated trash and linen containers in the residence room. She acknowledged that no disposable or dedicated equipment was maintained in the residence room and that linen was handled according to routine facility laundry protocol. She stated she was unaware of the residence culture results and indicated that, to her knowledge, the resident did not have MRSA. She further confirmed that a shared vital sign machine is used on the resident. On 03/24/2026 at approximately 2:40 PM, an interview was conducted with Staff C, Certified Nursing Assistant (CNA). She explained that she was not aware of the reason Resident #60 was on EBP, indicating she believed it may be related to a wound. She explained that the vital sign machine is taken from room to room during morning rounds and is cleaned at the completion of the rounds. Additionally, she stated that she has been emptying the residence garbage and transporting it to the soiled utility and removing the residence linen to the laundry room without the use of any special or designated bagging. On 03/24/2026 at approximately 2:45 PM, an interview was conducted with Staff P, CNA. She explained that she has been caring for Resident #60 since admission. She stated that she was unaware of the type of infection the resident had and believed the resident was on precaution due to the presence of an intravenous (IV). She further indicated that she considers EBP and TBP to be essentially the same. On 03/24/2026 at approximately 2:50 PM, an interview was conducted with Staff N, Physical Therapy Assistant (PTA) stated that for residents on isolation, therapy will be performed in the resident's room, not in the gym. On 03/24/2026 at approximately 3:20 PM, an interview was conducted with Staff A, RN, wound care nurse. She explained that Resident #60 previously had daily dressing changes; however, the treatment orders were changed to a wound vacuum device as of the prior week. She stated that she has been providing wound care to the residents since admission and was not aware that the resident had a MRSA infection. She acknowledged that she discarded the soil dressing in a regular clear garbage bag and transported it to the main trash in the soiled utility. On 03/24/2026 at approximately 3:40 PM, an interview was conducted with Staff Q, housekeeping supervisor. She explained that she was just notified that Resident #60 was in isolation. She explained that she added dissolvable bags and yellow bags to the isolation card located in the hallway. She stated that all soiled linens are to be placed in a dissolvable (melt) bag to ensure the laundry is processed separately. She further explained that the yellow bag serves as the secondary barrier during transport to the laundry room and to alert staff to the presence of contaminated linens and ensures that staff handle, store, process and transport laundry to prevent the spread of infection. On 03/24/2026 at approximately 4:00 PM, an interview was conducted with the Medical Director. He explained that the facility follows the CDC standards regarding infection prevention; however, precautions are evaluated case by case. He explained that it is his expectation for the facility to be aware of cultural results to implement appropriate precautions to prevent cross contamination and ensure the safety of residents and staff. He acknowledged that the MRSA infection should have been identified by the facility. A review of Resident #60's medical record revealed the resident was initially admitted to the facility on [DATE] for acute infection after a left ankle fracture and readmitted with a revision on 03/11/2026 with IV Daptomycin therapy. EBT precautions were initiated on 02/24/2026 for wound. A revise order for TBP dated 03/24/2026, documented EBP Related to MRSA to wound-contained with wound vac. A review of the Infectious Disease provider dated 03/17/2026 documented Resident #60 with a MRSA infection. A review of the Infectious Disease provider dated 03/14/2026 documented Resident #60 with a MRSA infection that discharged from the hospital on Daptomycin IV. Provider noted that Staph transmission and prevention measures were discussed with the patient and nursing staff; they were instructed to practice good personal hygiene, avoid sharing personal items, and implement appropriate precautions when using shared equipment and common surfaces. The staff were further directed to focus cleaning efforts on high touch surfaces that come into frequent contact with bare skin including doorknobs and toilet seats. Further review revealed that Resident #60 was sharing his room with Resident #27, who was admitted on [DATE] and had no documented infections. A review of the facility signage for EBT revealed that everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use of central line, urinary catheter, feeding tube, tracheostomy, wound care with any skin opening requiring a dressing. A review of the facility signage for TBP revealed that everyone must clean their hands, including before entering and when leaving the room. All healthcare personnel must wear gloves and a gown when entering room and remove before leaving the room, use patient dedicated or single use disposable equipment. If shared equipment is used, clean and disinfect between patients. A review of the CDC website reveals that MRSA is a type of staph that can be resistant to several antibiotics. MRSA spreads in the community through contact with infected people, wounds, or things that have touched infected skin and are carrying the bacteria. (https://www.cdc.gov/mrsa/about/index.html) A facility policy titled: Transmission-Based Precautions, dated 03/01/2029 and last reviewed 11/04/2025 stated that the facility Implement and adhere to transmission-based precautions to prevent and protect from exposure and transmission of suspected or confirmed infectious agents within the healthcare setting. Subsection B3 States to promptly initiate isolation precautions for resident who is infectious disease is detected by laboratory results (i.e. Positive culture for MRSA, positive Acid-Fast Bacillus (AFB), positive Clostridium defficile (C-Diff) or other MDROS). B8 to display appropriate signage on the resident's doorframe. B11 all residents on isolation are assessed during each shift to determine the need for continued precautions. C3 documentation of the indicated precaution should be reflected in the resident's medical record. This documentation ensures that all health care professionals and departments providing care or services with the patient are aware of those precautions. A2 place residents in the same room (cohort) who are infected or colonized with the same infectious agent. OXYGEN/NEBULIZER/CPAP Resident #93 On 03/23/2026 at approximately 11:38 AM, observation revealed that a nebulizer treatment tubing/mask was present on Resident #93's bedside table with visible secretion residual noted on the mask. Further observation revealed that the storage bag and respiratory tubing were not labeled with the date. (Photographic evidence obtained) On 03/23/2026 at approximately 11:38 AM, an interview was conducted with Resident #93. She stated that she is unaware of how often the facility changes the nebulizer tubing and mask. She reported that, to her knowledge, the tubing has not been changed since her admission approximately 3 weeks ago. A review of Resident #93's medical record revealed that the resident was admitted on [DATE] with a physician order dated 03/05/2026 for albuterol sulfate solution via nebulizer every 8 hours for Chronic Obstructive Pulmonary Disease (COPD). There is no order to change the respiratory items. Resident #100 On 03/25/2026 at approximately 8:20 AM, observation revealed a nebulizer treatment tubing/mask was present on Resident #100 room. Further observation revealed that the storage bag and respiratory tubing were not labeled with the date (Photographic evidence obtained). A review of Resident #100's record revealed a resident on continuous oxygen therapy that the was admitted on [DATE] with a physician order date 03/06/2026 for albuterol sulfate solution via nebulizer every 12 hours for pneumonia. Additionally, there was a physician's order directing that respiratory equipment be changed weekly on Thursdays. Resident #128 On 03/25/2026 at approximately 9:00 AM, observation revealed CPAP tubing on the floor and an oxygen concentrator was present. Further observation revealed that the storage bag and respiratory tubing were not labeled with the date. (Photographic evidence obtained). A review of Resident #128 revealed a resident on dialysis with central venous access (CVC) with wounds and on enhanced barrier precautions. The medical record revealed that the resident was admitted on [DATE] with a physician order dated 03/22/2026 for oxygen therapy at night via Astral NIV (Provides Bi-level Positive Airway Pressure (BPAP) to ease breathing). Additionally, there was a physician's order directing that respiratory equipment be changed weekly on Mondays. Resident #15 On 03/25/2026 at approximately 9:10 AM, observation revealed that a nebulizer and oxygen treatment tubing/mask was present in Resident #15's room. Further observation revealed that the storage bag and respiratory tubing were not labeled with the date. (Photographic evidence obtained) A review of Resident #15's medical record revealed that the resident was admitted on [DATE] with a physician's order dated 03/20/2026 for continuous oxygen therapy at 3 liters and albuterol sulfate solution via nebulizer every 6 hours for COPD. Additionally, there was a physician's order directing that respiratory equipment be changed weekly on Mondays. Resident #21 On 03/23/2026-03/25/2026, observation revealed that oxygen treatment was present in Resident #21's room, including a humidifier. Further observation revealed that the storage bag and respiratory tubing were not labeled with the date (Photographic evidence obtained). On 03/23/2026 at approximately 11:33 AM, an interview was conducted with Resident #21. She stated that she is unaware of how often the facility changes the oxygen tubing. She explained that the oxygen tubing is changed approximately once a month and typically only upon her request, when the nasal prongs become hard. A review of Resident #21, medical record revealed that the resident was admitted on [DATE] with a physician's order dated 02/09/2026 for continuous oxygen therapy for COPD. Additionally, there was a physician's order directing that respiratory equipment be changed weekly on Mondays. Resident #101 On 03/23/2026 at approximately 11:45 AM, observation revealed that nebulizer tubing was present in Resident #101's room. Further observation revealed that the storage bag and respiratory tubing/mask were not labeled with the date (Photographic evidence obtained). On 03/24/2026 at approximately 4:15 PM, an interview was conducted with Staff L, RN. She explained that both shifts are responsible for changing respiratory items on a weekly basis and indicated that all residents have physician orders for these changes. She further stated that the facility does not require respiratory equipment to be dated to reflect when items are changed. Additionally, she reported that the storage bag used for respiratory items, such as tubing/masks is not routinely replaced. On 03/25/2026 at approximately 8:35 AM, a follow up interview was conducted with Staff L, RN. Upon entering Resident #15's room to assess the oxygen tubing, she was unable to determine the last respiratory equipment change by visually inspecting the tubing and was unable to state when it had been changed, as the tubing was not dated. On 03/25/2026 at approximately 8:40 AM, an interview was conducted with Staff O, RN. Upon entering Resident #100's room to assess the oxygen tubing and nebulizer tubing/mask, she was unable to determine the last respiratory equipment change by visually inspecting the tubing and was unable to state when it had been changed, as the tubing was not dated. A facility policy titled Oxygen administration, dated 12/01/2008 and last reviewed 11/17/2025, stated that oxygen humidifier bottles are disposable bottles and are for single resident use only and changed weekly. All oxygen tubing should be changed when there is visible soiling with the respiratory secretions/mucus and weekly.

Based on interviews and record review, the facility failed to ensure the resident's right to be fully informed and to participate in care decisions, including the provision of a properly executed consent for psychotropic medication for 3 out 3 consents reviewed. (Resident #13, # 60 and #128)The findings include:A review of Resident #13's medical record revealed a psychotropic medication consent form without a date of completion. The consent form contained only the resident's representative typed name in the designated signature line, with no handwritten or authenticated signature present. Additionally, the consent form lacked a witness signature to the facility representative. Furthermore, the consent form did not include documentation of the date and time the consent was obtained, or the relationship to the resident. (Photographic evidence obtained)A review of Resident #60's medical record revealed a psychotropic medication consent form without a date of completion. The consent form contained only the resident's typed name in the designated signature line, with no handwritten or authenticated signature present. (Photographic evidence obtained)A review of Resident #128's medical record revealed a psychotropic medication consent form without a date of completion. The consent form contained only the resident's typed name in the designated signature line, with no handwritten or authenticated signature present. (Photographic evidence obtained).On 03/25/2026 at approximately 12:30 PM, an interview was conducted with the Director of Nursing. She explained that the psychotropic consents are not printed and are directly completed on the computer. She added that the name of the resident/responsible party is typed in the designated signature line. She acknowledged that there are no signatures for authentication.On 03/25/2026 at approximately 12:35 PM, an interview was conducted with Staff R, Social Worker. She acknowledged that psychotropic medication consents were not validated with a handwritten signature. She explained that she called Resident #13's representative, listed as the primary contact, over the phone to obtain the consent. She explained that the consents are not printed and instead the name of the resident and/or representative is typed in lieu of a signature. She further stated that when consent is obtained via telephone, there is no witness to verify or validate the authorization. She acknowledged that this process lacks accountability and credibility, as there is no evidence to support that the consent was reviewed, that risks and benefits were explained, or that informed consent for the administration of psychotropic medications was obtained.On 03/25/2026 at approximately 12:40 PM, a phone interview was conducted with Resident #13's representative and primary contact. She stated that she is not aware of the type of medications the resident is receiving and is not involved in the resident's medication management. She further stated that she has never been contacted by the facility to provide consent for the administration of medications.On 03/26/2026 at approximately 12:35 PM, an interview was conducted with the Interim Administrator. She explained that, for authentication of the consent, she expects the consent form to be printed and signed. She added that, when consent is obtained over the phone, a witness signature should be present to validate it.The consent form for use of psychotropic was reviewed. Under the section Additional information it describes that the resident/responsible party have been informed of available alternatives, benefits of medication use, potential side effects of medication use, right to refuse treatment, the need for continued use will be reviewed quarterly, consent can be withdrawn at any time, questions about medications can be asked at any time. With the resident/family signature: My signature indicates my informed consent for use of the medications listed above and that I understand the reason for use and potential risks and benefits. Per the Senior Nurse Consultant, the facility does not have a policy for informed consents.

Based on interviews and record reviews, the facility failed to ensure the accuracy and completeness of Preadmission Screening and Resident Review (PASRR) documentation for 3 of 4 residents reviewed for PASRR compliance. (Residents #3, #72 and #95) The findings include:Resident #95 Resident #95 was admitted to the facility on [DATE] with diagnoses which included a primary diagnosis of major depressive disorder, recurrent, severe with psychotic symptoms, and secondary diagnoses of anxiety disorder, bipolar disorder, and other disorders of psychological development. Further review of Resident #95's medical record reveals a Psychiatric Periodic Evaluation dated 1/15/26, which revealed the resident has a past history of involuntary inpatient psychiatric care and outpatient psychiatric care. On 3/25/26, a review of Resident #95's Level I PASRR indicates in Section I that this resident had Mental Illness related to diagnoses of depressive disorder and bipolar disorder. However, under Section IV: PASRR Screen Completion, No diagnosis of suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required is checked.On 3/26/26 at approximately 11:30 AM, an interview was conducted with Staff J, Social Worker (SW). He stated he answered the questions based on the information he had at the time of his screening. When the question If the Level I pre-screening of the resident, either prior to admission or within 30 days, in accordance with the state PASRR process, identified that the resident had or may have had an MD, ID or related condition, did the facility refer the resident to the appropriate state-designated authority for Level II PASARR evaluation and determination? was reviewed, he confirmed Resident #95 meets the criteria of a serious mental illness and should have received a PASRR II. Resident #3 A review of the record for Resident #3 showed the resident was admitted to the facility on [DATE] with a completed Level I Preadmission Screening and Resident Review (PASRR). admission diagnoses included catatonic disorder due to a known physiological condition, schizoaffective disorder, bipolar disorder, altered mental status, major depressive disorder, and post traumatic stress disorder. No Level II PASRR evaluation was completed at or after admission. Resident #74 A review of the record for Resident #74 showed the resident was admitted to the facility on [DATE] with a completed Level I Preadmission Screening and Resident Review (PASRR). admission diagnoses included Major depressive disorder, Bipolar disorder No Level II PASRR evaluation was completed at or after admission. During an interview with the SW on 03/25/2026 at approximately 11:30 AM, the SW stated that screening questions are answered based on information received from admission materials and from the resident. When asked who ensures PASRR accuracy and appropriate follow up services, the LCSW stated that the Social Services Director is responsible. After reviewing Resident #3 and #74's diagnoses during the interview, the LCSW agreed that the residents meets criteria for a Level II PASRR evaluation. A review of Resident #3's and Resident #74's care plan revealed that problems and approaches for bipolar disorder and schizoaffective disorder were not added until 03/25/2026, after staff interviews regarding PASRR screening had occurred.

Based on observation, interviews, and record review, the facility failed to ensure that a resident received necessary equipment and services to maintain mobility and quality of life. This deficient practice affected 1 of 1 residents reviewed. (Resident #7) The findings include:On 03/23/2026 at approximately 11:57 AM, Resident #7 was observed asleep in his room. Record review confirmed the resident is a quadriplegic with two ostomies, a feeding tube, a catheter, and is totally dependent for care.On 03/24/2026 at 9:57 AM, Resident #7 reported ongoing difficulty obtaining assistance to replace the battery for the motorized wheelchair, which has been nonfunctional since 2020. The resident stated there have been multiple emails to the corporate office, and that they informed the resident that it is the resident's responsibility to find help. The wheelchair was observed beside the bed with personal belongings stored on it. The resident stated not having been out of bed since an appointment a month ago and shared that the facility-provided high back manual wheelchair is not comfortable.At approximately 12:45 PM on 03/24/2026, a review of a binder containing the resident's printed emails showed repeated requests for assistance with wheelchair repair, leg pumps, and preferred ostomy supplies. An email dated 12/01/2025 showed the resident requested a reference letter from the corporate office for a foundation that donates wheelchairs or batteries; the corporate representative denied the request, stating they do not assist with donations for residents.At approximately 4:20 PM on 03/24/2026, the Social Services Director (SSD) stated awareness that the resident has been requesting help finding a new motorized wheelchair since before the SSD was hired one year ago. The SSD stated uncertainty about who is responsible for providing the resident with resources.On 03/25/2026 at approximately 3:58 PM, the Administrator stated that the Activities Director would be appointed to assist the resident with finding resources for wheelchair repair or replacement. The Activities Director acknowledged awareness that the resident has been seeking such assistance for years.Observations from 03/23/2026 through 03/25/2026 showed the resident did not leave the bed or his room.Review of Activities of Daily Living (ADL) documentation dated 03/23-03/25/2026 showed Activity did not occur for mobility off the unit on all shifts.A review of Progress notes documented longstanding wheelchair malfunction concerns: 11/10/2020 (Nursing): Motorized wheelchair not charging; administration notified. 03/05/2025 (NP): Resident assessed for power mobility device; current wheelchair nonfunctional. Resident physically and mentally able to use powered mobility and cannot self propel manual chair. 03/25/2025 (NP): Resident continued requesting updates on new powered wheelchair. 04/15/2025 (NP): Assessment reiterated need for powered wheelchair; manual wheelchair not feasible due to contracture and weakness.Review of the Minimum Data Set (MDS) dated [DATE] documented that going outside and having fresh air is very important to the resident.

Based on observation, interview, and record review, the facility failed to ensure 3 of 20 residents reviewed for medication administration received the medications as ordered. (Resident #25, #100, and #128) The findings include: Resident #100 A review of records revealed Resident #100 was receiving respiratory services (e.g., inhaler, nebulizer) as of 03/23/2026. A review of Resident #100's record revealed that the resident received Albuterol Sulfate every 12 hours via inhalation. This was not documented as administered per physician's orders 03/20/2026 at 9:00 PM and no documentation to indicate a reason for omission. Resident #128 The facility matrix revealed Resident #128 receiving anticoagulant and insulin therapy as of 03/23/2026. A review of Resident #128's record revealed that Dextromethorphan-Guaifenesin (an over-the-counter medication used to treat cough) was not documented as administered every 12 hours per physician's orders for cough on 03/20/2026 at 9:00 PM; Eliquis 5 mg (milligram) (an anticoagulant) was not documented as administered every 12 hours per physician's orders on 03/20/2026 at 9:00 PM; insulin Glargine 5 units subcutaneous injection (a long acting insulin to treat diabetes) was not documented per physician's orders on 03/23/2026 at 6:00 AM; insulin Lispro (a rapid acting insulin to treat diabetes) per sliding scale, which required blood glucose monitoring prior to administration, had no documented evidence that the Resident #128's blood glucose was checked. There was no evidence in the Medication Administration Records (MARs) to confirm that the blood glucose was checked and medication was administered as prescribed on 03/20/26 at 11:30 AM and 9:00 PM, and on 03/23/2026 at 6:00 AM, and no documentation to indicate a reason for omission. On 03/27/2026 at approximately 11:20 AM, an interview was conducted with the Director of Nursing. After an independent review of the medical records for Resident #100 and #128, she acknowledged the omission of documentation and the absence of a signature on the MAR. She further indicated that when a medication is not administrated or is refused, documentation is still required, and leaving a blank entry on the MAR is not acceptable, as it leaves open possibility that a medication was not given. Resident #25 During an observation conducted on 03/23/2026 at approximately 09:45 AM, medications were found unsecured at Resident #25's bedside. The medications were accessible and not stored in a locked or supervised area as required. Resident #25 reported that she had requested the nurse to leave the medications on the table so she could take them at her own pace. During an interview with Resident #25's nurse, Employee V, on 03/23/2026 at approximately 10:00 AM, she stated that the medications were left at the bedside for the resident to take independently one at a time. Employee V stated this was not standard practice to leave medications at the bedside. A review of Resident #25's medical record on the same date revealed there was no physician order permitting self administration of medications, nor documentation showing the resident had been assessed and deemed safe and competent to self administer medications. In an interview with Employee Y, Registered Nurse (RN), on 03/24/2026 at approximately 2:59 PM, she confirmed that medications may only be left at a resident's bedside if there is a physician's order and the resident has been evaluated and approved to take medications independently. On 03/25/2026, a review of the facility's policy, Self Administration, last reviewed on 12/11/2025, stated that a resident may self administer medication only if the licensed nurse and physician determine the practice is safe for the resident and others in the facility. The policy also applies to family members who wish to administer medications. Bedside storage of medications is allowed only when it does not pose a risk to residents who may wander into rooms. Locked drawers or cabinets are required if unlocked storage is not effective. The attending physician must enter an order for bedside medication storage and self administration.

Based on record reviews, policy review and interview, the facility failed to ensure the reporting of an injury of unknown source for 1 of 3 residents reviewed. (Resident #1) The findings include: On 11/13/24, a record review was conducted for Resident #1. The resident was admitted for respite under hospice services on 10/10/24. The resident had reported pain to the right leg and an X-ray was ordered, which revealed a fracture of the right hip. The resident was transported to the emergency room as ordered. The resident had a diagnosis of dementia and could not say how they were injured. The resident did not have any documented falls. On 11/13/24 at approximately 11:46 AM, an interview was conducted with the Director of Nursing (DON). The DON stated she did not file a federal report for suspected abuse based upon an injury of unknown origin. She stated she was instructed by the Administrator not to do so. On 11/13/24 a review of the facility policy Reporting Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property, 12/1/21, revised 7/29/23, states injuries of unknown origin to be reported . within 2 hours after the allegation is made .

Based on observation, staff interview and record review, the facility failed to ensure 2 of 2 vulnerable residents at risk for elopement (Resident #40 and #48) were not able to exit the building unsupervised. Resident #40 was found unattended in the facility parking lot by a staff member on 3/7/21 and Resident #48 was able to exit the building unsupervised through a fire door on 3/9/21. The facility's failure to prevent an elopement and eliminate potential hazards placed 2 residents at a likelihood of serious injury and death. Residents are at risk for being injured or killed by passing cars on the highly traveled [NAME] Road approximately 0.4 miles south of the facility, falling and injuring themselves, or drowning in holding ponds located south of the facility. The situation resulted in a finding of Immediate Jeopardy at a scope and severity of isolated (J). The facility Administrator and Director of Nursing were notified of the Immediate Jeopardy finding on 4/23/2021 at 3:27 PM. The Immediate Jeopardy was determined to have begun on 3/7/2021, the day Resident #40 was able to exit the building unsupervised. The Immediate Jeopardy was ongoing at the time of exit. Cross reference F867. The findings include: Resident #48 On 4/22/21, a review of the Safety Events - Wandering event report dated 3/9/21 was conducted. Under the section titled Event Information was documented, Resident was found to be outside of facility, sitting on a bag of sand under a tree. Review of the section titled Notifications revealed Attending Faxed: No, Physician Notified: No, Resident Representative Notified: No, Care Plan Reviewed: No. The form further indicated the facility had evaluated the resident and was seeking placement at a secured unit. Also noted on the form was that the resident picture had been posted at the nursing units and other appropriate places, the Immediate Plan of Care for Elopement had been initiated, however No was documented next to Resident monitoring device in place. All other sections on the form we found to be blank, to include Physical Observation (including when and where the resident was found, if the resident sustained any injury during the elopement period and if the resident exhibited any behaviors prior to the elopement), Mental Status, Possible Contributing Factors, Interventions - Immediate measures taken, Notification Guidelines and Orders. A review of the Social Services note dated 3/9/2021 at 2:45 PM, revealed, Note-(Resident #48) continues wandering-ambulating independently throughout the facility and seems to be more restless and easily agitated over the past 2 days. She has always enjoyed being outside and with the weather being sunny and warm for the past 2 days and having exercise class being held in the courtyard, she has been looking to go outside. She did go outside to the dining room patio area-observed by staff and escorted to her hallway area. Place on direct behavior monitoring and LCSW (Licensed Clinical Social Worker) is continuing to seek out a secure facility/unit. Her LTC (long-term care) Rep is also aware of pt's (patient's) needs. A review of a Social Services note dated 3/9/2021 at 3:01 PM, revealed Note-LCSW called and left message for (Resident # 48's daughter) regarding resident's status and seeking secure unit/facility is ongoing. A review of a Nurse progress note dated 3/9/2021 at 7:21 PM, revealed Resident is Alert with confusion. The following behaviors are noted to be baseline: yelling, cussing at staff and herself, talking to herself, wandering in hallways, trying to go home, and exhibiting exit seeking behavior. Redirected by staff, encouraged to participate in activities, and reading to prevent these behaviors. Resident continues with close monitoring due to exit seeking behaviors at this time. A record review was conducted for Resident #48 which revealed the resident had an annual comprehensive Minimum Data Set (MDS) assessment on 2/13/21 which stated under section C- Cognitive Patterns that the resident was rarely or never understood. The Staff Assessment for Mental Status portion of the assessment stated that the resident was severely impaired and never or rarely made decisions. Further review revealed the resident displayed inattention and disorganized thinking. Under section E - Behaviors, indicated that, wandering occurred daily, wandering places the resident at significant risk of getting to a potentially dangerous place. Under section G - Functional Status, it indicated Balance during transition and walking: Not steady, but able to stabilize without human assistance for all. A review of the Elopement Risk Observation Form, the facility's internal elopement risk assessment tool, for Resident #48. The tool was dated 2/24/2021 and revealed a score of 17. The scoring scale at the bottom revealed the following: 0-4 Low Risk, 5-10 Moderate Risk, 11 or Greater - High Risk. A score of 17 indicated the resident was a high risk for elopement. The elopement risk assessment tool interventions included, but not limited to 3-day monitoring, Weekly Behavioral Management, and Wanderguad Program. A review of the nurse progress notes revealed the resident had a history of exit seeking behaviors as evidenced by a note written on 2/14/21 at 7:37 PM, Resident wandered around facility all day, trying to exit via locked doors. Was re-directed by staff, given snacks, and encouraged to drink fluids. Given PRN (as needed) anxiety medication, with no effectiveness noted. Resident continued to wander, cuss at herself and staff, and exhibit anxious behavior. The resident's exit seeking behavior continued after the elopement event on 3/9/21 as a nursing note dated 3/26/2021 at 3:50 PM, revealed Resident continues to exit seek and become very anxious and agitated with confusion. (Resident #48's daughter) states that she has sent 4 placement options to SW (Social Worker) at PH (the facility) today for a locked unit for resident but states it is difficult to find one that will take her insurance and that is secure. A review of the Nurse Practitioner progress notes also revealed documentation of exit seeking behaviors prior to the elopement as evidenced by a progress note dated 2/18/2021 at 1:43 PM, revealed, 87 yo (year old) female in no acute distress seen today per staff's request for increased behaviors, exit seeking, and agitation. The nurse practitioner documented on 3/26/2021 at 11:29 AM, 87 yo (year old) female in no acute distress seen today per staff request to assess ongoing behaviors, exit seeking, and agitation. A review of the Social Services notes revealed documentation of attempts to locate a facility with a secure unit prior to the resident's elopement, as evidenced by a Social Services note dated 2/23/2021 at 8:53 PM, which revealed, Note-LCSW (Licensed Clinical Social Worker) has sent referrals packets to several facilities that have a secure area/unit due to (Resident #48) continuing to seek to exits. Since the resident's elopement on 3/9/21 the LCSW documented ongoing attempts to find placement at a secured unit on 3/22/21, 3/23/21, and 3/26/21. A review of the resident Plan of Care dated 3/09/21 revealed the resident had a problem category listed as Behavioral Symptoms for being socially inappropriate/disruptive behavioral symptoms as evidenced by: yelling, cursing, combativeness with staff The start date is noted to be 4/28/20. Discharge planning was initiated on 2/10/20 however the need for a secured or locked unit was not identified. Wandering or exit seeking behaviors were not initiated until 3/9/21, after the resident eloped. The category was identified as Behavioral symptoms and at risk for elopement related to wandering behaviors. The plan identifies that resident #48 will not have any severe injuries related to elopement and stated, Ensure resident needs are met during wandering episodes such as dry, hunger, and thirst. The care plan failed to contain interventions that would prevent the resident from eloping from the facility. A review was conducted of Resident #48's Medication Administration Record (MAR). On the behavioral monitoring entries, it was noted that the code 8 meant that wandering was displayed during the shift. For the month of March 2021, on day shift, the resident was documented as wandering on 22 of 31 days (the 4th, 5th, 6th, 7th, 8th, 9th, 11th, 13th, 14th, 15th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 24th, 25th, 26th, 27th and the 31st). On night shift for March 2021, she was documented as wandering on 15 of 31days (the 2nd, 3rd, 4th, 7th, 11th, 15th, 18th, 19th, 21st, 22nd, 25th, 27th, 28th, 30th and the 31st). A review of April 2021's MAR for day shift revealed documentation of wandering on 16 of 22 days (the 1st, 2nd, 3rd, 5th, 6th, 9th, 10th, 11th, 12th, 13th, 15th, 17th, 18th, 19th, 20th and the 22nd. For nights in April 2021, Resident #48 was documented as wandering on the evening shift on 7 of 22 days (the 1st, 2nd, 5th, 12th, 14th, 19th and the 22nd). On 4/21/2021 at approximately 8:04 AM, an interview was conducted with Licensed Practical Nurse (LPN) L. She reported that Resident #48 liked to wander around the facility, both inside and outside as well as in the courtyard. She stated that the resident thought she could go home so she would try to go outside. She further reported that the resident had wandered outside, behind the building, was brought back in however she was unsure how long the resident was out of the building. She further reported that all the doors have alarms and will alarm throughout the building when they are opened. At the time of the elopement, the door alarm was functioning. She reported that she notified all the required staff to include Administrator, the Nurse Practitioner, the family and social services. She did verify that the resident has not eloped since the incident on 3/9/21. On 4/21/21 at approximately 10: 37 AM, an interview was conducted with the Risk Manager who stated that she remembered resident #48's elopement, that they had made the announcement and all staff went room to room checking for the resident. She further reported that she, the Clinical Care Coordinator and the Director of Therapy had checked the outside grounds and found the resident sitting on a bag of sand leaning up against a fence. She stated that she felt the resident had gone through the dining room door and that the facility had fire safety doors which will open if you keep pushing on them. When asked how the facility was made aware that the resident was out of the building the Risk Manager stated, We received a call from a neighbor that was behind our fence-line and they wanted to make sure she was okay and should be out there. There was an alarm on the door. The alarm sounds on the door itself, but it is hooked to the whole system so you can hear it throughout the building. The Risk Manager also said the alarm, had been silenced because when the staff member checked to see why the door was going off, (Resident #48) was not in sight. She got away from the door quicker than someone could get to the area to see her. So, they were under the understanding that everything was clear. The person from the neighborhood let us know that she was out there. At this time, the Risk Manager was asked for the incident investigation with the root cause analysis. She stated, The investigation should be in the computer in progress notes. She stated that she would check in her filing system. Documentation of the investigation was not provided by the conclusion of the survey on 4/23/21. On 4/21/2021 at approximately 11:18 AM, an interview was conducted with the Licensed Clinical Social Worker (LCSW) who reported that the resident had a pattern of wandering the facility and that on the day the resident eloped, the alarm sounded and the resident walked out the door. She further stated, She did get out of the door in the back patio area. Dietary and two gentlemen were working back there on the generator. They told us that the resident was sitting on pallets, so we went around there and got her. When she got back in, she was put on direct supervision with one of the CNAs. She also reported that she had spoken with the resident's daughter and We are desperately looking for a secure facility. On 4/21/2021 at approximately 2:00 PM, the Administrator entered the conference room and stated that there was video footage of the elopement incident. She was then asked to produce the video recording for the surveyor to review. She returned a few moments later and stated that she did not have video of the resident exiting the facility, she only had video of the dietary staff going to the door and turning off the alarm. She stated that it is a new system and that one can only pull so much from the past. She was asked how she had video of the staff member checking the door but was unable to get video of the resident leaving. She stated that it is maintained by corporate and that she did not have access to it. She stated that Corporate Maintenance Director P was the one that was able to send it to her. On 4/21/2021 at approximately 2:35 PM, the Administrator returned with a printed email from Corporate Maintenance Director stating that the video camer recordings can only go back 7 days. On 4/21/2021 at approximately 2:43 PM, an interview was conducted with the Corporate Maintenance Director during which he stated, I do not have anything. I did not save anything. It is a brand-new system. It automatically deletes after 7 days. Whatever (the Administrator) has is what we have. I think I texted the video to her. It was my personal phone and it has a limited amount of data and I don't keep it on my phone. On 4/21/21 at approximately 2:49 PM, the video recording was reviewed in the presence of the Administrator and the Business Office Manager (BOM). In the video there is what appears to be a male employee walking from the kitchen area across the dining room and to the door that exits to the area outside the dining room, where resident #48 exited the building on 3/9/21. You can see that he does something near the door for a few moments, ducks and looks for a moment and then walks away from the door and out of the frame. The video does not show the resident exiting the dining room or if the staff member had seen the resident from the doorway. On 4/22/2021 at 1:32 PM, an observation of the area that Resident #48 eloped to revealed that the door which led out to the open area by the gazebo had a pin number lock. However, this area was not secured with gates or locks and led directly into an open area parking lot. On 4/22/2021 at approximately 1:33 PM, an interview was conducted with the Director of Nursing (DON), the Administrator, and the LCSW. The Administrator stated that on the day of the event they called a code Pink (an emergency announcement that uses a color system to identify facility emergencies. Pink is used to identify a missing resident). She stated, I pulled my keys out of my purse and drove around the building and when I got around to the side there were already a bunch of people outside. So, it was like a few seconds. There were generator people working out back. It was the boys on the generator that saw her and called out to us. They came and told the Business Office Manager. During the interview they were asked how staff know which residents are elopement risks, the LCSW stated, We have elopement books at the receptionist's desk and the north and south nurses' stations. She stated that the books contain pictures, face sheets (this has demographic information like name, address, etc.), care plans, and the assessment itself. When they were asked what constituted a reportable elopement, the DON stated, When someone that is not themselves gets out of the facility unannounced and their Brief Interview for Mental Status (BIMS) supports that they are not aware enough. When asked about hazards in the area, the Director of Nursing stated that there was a retention pond south of the facility and that there is a black chain link fence running along the entire property. She also mentioned [NAME] Road was not far from the facility and was a high traffic area. They were asked about standard reporting requirement for elopements. The LCSW stated that she would let the Administrator and Risk Manager know. When asked what the appropriate response would be to a door alarm sounding, the DON stated, When an alarm goes off, they (Nursing staff) are to respond immediately. When they go to the door, they should go through it and investigate the grounds. They should make sure no one went out. They should search. They should call me if there were an elopement. They should be calling if there is any behavior out of the norm. Clear documentation would have made this a lot easier. They were asked about standard reporting requirement for elopements. The LCSW stated that she would let the Administrator and Risk Manager know. She said, It would be immediate like everything else. The Administrator added that the Risk Manager, failed to document appropriately on the in-service form what it is that she was educating staff on. We need to talk to her about root cause analysis and the why, why, why. That is something that we can improve on. The Administrator was then asked who was responsible for oversight of the Risk Manager and who would review her work to determine if it was completed correctly and would have been responsible for following up on her performance and to make a plan of correction. The Administrator then stated, That would be me. She then stated, (The Risk Manager) documented that it was an effective drill. That staff responded appropriately, and the patient had no ill effects. The search went well when I looked at it in my perception, knowing Resident #48 was out for her evening stroll. She likes to talk to people. I think in all reality that for her first drill she did a good job on the paper compliance and assessing the compliance. When I said that this is an opportunity to do it as a drill. We all took our action steps, we all checked for safety and security. But, are we going to use it as a drill, absolutely! I would use it as a drill. She then agreed that the situation was not a preplanned drill and agreed that nothing presented to the surveyors at that time demonstrated a root cause analysis of how the resident was able to elope from the building. On 4/23/2021 at approximately 10:10 AM, an interview was conducted with staff member F, a Registered Nurse/Unit Manager (RN/UM). She said, We do elopement assessments on admission, quarterly and annually, completed by the UM. The admitting nurse does admission elopement assessments. We have a widget (pop up alert) that comes up in our electronic documentation system that reminds you the elopement assessment is due, for example April and May's assessments are in there now. I will analyze the first assessment, or the previous one, and then see what changes occur with the new assessment. If the resident has gone from a moderate to a high risk for elopement, we update the care plan and notify the Risk Manager (RM) who adds them to the book. I notify the MDS nurse to update care plan, or I do it, but normally MDS does it. I have been here a year. The front entrance door has always had a code on it. I believe it has been the same code since I have been here but there was one day I could not get in, as they had changed the code, so at least once. If a door alarm is activated, it is very loud and is easily heard at the opposite side of the building. When the wall alarm monitor goes off it lights up and tells us what part of the facility the alarm is located. The plaque above the monitor has a location list with numbers and location details. There was some discussion about Resident #48, who had exited the facility last month. She had exit seeking behaviors. The DON discussed with me monitoring residents and keeping an eye on those with exit seeking behaviors. On 4/23/2021 at approximately 11:58 AM, an interview was conducted with Certified Nursing Assistant (CNA) K. CNA K was asked if it would be safe if Resident #48 was out in the community without supervision. CNA K stated that it would not be safe for the resident to be out in the community unattended. CNA K stated, I know that Resident #48 wanders and would worry that she would find herself in an unsafe situation. She is steady on her feet and she can walk and get around, but her decision making is not great. Her cognitive (mental) function is very low. I would really be worried if she was out on her own. When asked about elopement training CNA K stated that she was not aware of an elopement book. CNA K stated that she finds out about elopement risks through shift reports. When asked how elopement education is provided, CNA K stated that there was education provided on elopement but did not recall how often and could not remember last time it was done. On 4/23/2021 at approximately 11:03 AM, an interview was conducted with Dietary Aide S. Dietary Aide S confirmed that he was the staff member in the video shown to the surveyor. He stated that he was coming back from break when he heard the alarm to the door going off. He stated that when he walked over, he saw several staff members outside with Resident #48. He stated that he then turned off the alarm and returned to his work area. On 4/23/2021 at approximately 11:07 AM, an interview was conducted with Nurse Practitioner (NP). She said, I just found out yesterday that the resident made her way outside the facility last month, not sure of the exact date. The DON made the comment to me yesterday that the resident had made her way out of the building, so I have not done any research. She has exit seeking behaviors and she would start going towards the door but it was news to me that she actually got out the door. I have no other details about that. There are comments by staff in progress notes that the resident wanders through the halls, is pleasantly confused, and was not identified as exit seeking in December. On 2/18/2021 staff documented the resident had agitation and exit seeking behaviors. I ordered laboratory tests and a urine analysis (UA). She refused the UA, but tests were normal. I saw her again 3/26/2021 for ongoing behaviors, agitation and exit seeking, and she again refused a UA, but tests were normal. I changed some of her medications and I have not seen her since then. I was never notified of the fact that she got out. I was aware that staff were redirecting her, trying to give her chores, activities and busy work. There's no 1 on 1 (direct staff supervision), they try as best as they can as I don't think they are able to staff 1 on 1 for her. I know that the Social Worker has been working on her placement before she started exit seeking behaviors. On 3/9/2021 the SW reached out to her family emergency contact to notify them of the need for a secure facility and again on 3/26/2021 the SW reached out to find her somewhere more secure. I am not aware of any other interventions that are in place for her behaviors and safety. On 4/23/2021 at 11:07 AM, a telephone interview was conducted with the Electrical Contractor. He stated that he was at the facility on 3/9/2021 doing work on the facility's generator. When asked if he recalled the situation, he stated that it may have been the day that one of the sweet little ladies tried to get away. He stated he was out back with the generator when he noticed Resident #48 walking around with a piece of carrot cake. He stated that he asked her if she knew where she was going, to which she replied, Don't worry about it. He said that she moved passed him looking left and right. He decided to walk around the building to let staff know her whereabouts. He said immediately after, about 12 people showed up to bring Resident #48 back into the building. He estimated that the entire incident lasted about 5 minutes. On 4/23/2021 at 1:03 PM, an interview was conducted with the Maintenance Director. He was asked how the alarms work on the magnetically locked doors, like the one in the dining room. He stated that those doors only alarm from the door itself. There are no other alarms in the building that go off to let staff know and there is no indication on a control panel anywhere. On 04/23/2021 at approximately 02:18 PM, an interview was conducted with the Rehabilitation Director during which she stated that a Code Pink means a missing patient or resident. She stated, If a Code Pink alarm goes off, I go outside alert any of my staff nearby, look in hallway and check/ask any staff what is going on and also check outside through our Fire Door, and I observe outside and check for any resident or someone for imminent danger. She stated that she had assisted resident #48 back into the building about 6 to 8 months ago. She further stated, I was sitting here in my office, I heard the Fire door alarm going off, in my gym, I got up and looked out the Main Therapy Gym window. She offered that she saw resident #48 outside in the Gazebo area which has uneven ground and that scared me the most, no staff in sight, around late morning before lunch. I accessed the code for our Fire door and escorted her back into the facility. I asked her how she got out, she told me she read the instructions on the door I called her nurse, can't remember her name and she escorted her back, no sign of injury. She went on to say that Resident's #48's exit was discussed in the morning meeting the next day. Administrator leads those meetings and she talked about it that morning, I can't remember all that she said, but the occurrence was discussed by the Administrator. This most recent elopement was in early March. I just happened to be coming out of my office and looked out through our big window to the Gazebo and saw a nurse running quickly. I observed (resident #48) over towards the far left corner of the area, resident was sitting down near the fence, and I believe she got out through the dining room. When asked if resident #48 wound be safe out in the community, she stated, Absolutely not. Resident #40 A record review of progress notes for Resident #40 found a progress note dated 3/7/21 at 7:16 AM, by Staff J, Resident was found wandering in parking lot outside by staff member. Resident was brought safely back inside, another staff member assisted resident to his room and informed nurse of resident wandering. This nurse assessed resident, no injuries noted, alert and oriented to baseline. This nurse educated resident on safety. Resident apologized and stated understanding. When asked resident stated that he wanted to go outside. When asked what door resident used resident at first stated he went out One of the back doors, when asked which back door resident then stated that there are too many doors to remember, I don't know which one. Noted that this nurse and other staff members did not hear a door alarm when resident was found and brought back inside. Placed note in APRN communication book for wandering. Informed oncoming shift nurse of wandering incident. Instructed resident aid to check on resident more frequently. Attempted x3 to contact Director of Nursing. A review of the resident's annual Minimum Data Set (MDS) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 - moderate impairment. The BIMS score is used to assess the cognitive status of a resident. The resident was noted to require supervision with activities of daily living and ambulation and was not steady in balance but could stabilize without assistance. A review of the adverse event log could not locate a reported event for the Elopement of Resident #40. A review of the medical record for resident #40 showed an Elopement Risk Observation assessment performed on 3/3/2021 identified resident #40 at moderate risk for elopement with a score of 9. Per the Elopement Risk Observation, interventions include, but were not limited to, 3 day monitoring and 4 weeks behavior management program to determine appropriate interventions after 3 day evaluations and quarterly assessments. If significant change occurs or wandering persists, follow recommendations for high risk. A review of the care plan dated 2/15/2021 and last reviewed 4/29/2021 noted Resident #40 Has the potential for elopement relating to wandering behaviors. GOAL. Resident #40 will not sustain any injuries related to wandering through next review date. Intervention: Ensure that basic needs are met when exhibiting behaviors such as eat, drink, and incontinent care. The additional interventions outlined on the Elopement Risk Observation were not implemented on the Care Plan. In an interview on 04/21/21 at approximately 5:02 PM, the Risk Manager was asked at what point the resident is placed in the elopement book at the front desk. She stated they are not placed in the elopement book until they are deemed high risk. The resident was given a moderate risk on the last MDS assessment. She stated that they would perform the Elopement Risk Observation. A copy of the Elopement Risk Observation was provided to this surveyor for review. The Risk Manager stated that Resident #40 was allowed to go outside and would go outside frequently, especially into the courtyard (an open area at the backside of the facility with a gazebo and chairs). She went on to state that the wandering of Resident #40 has increased lately while he has been ill. On 04/21/21 at approximately 10:59 AM, an interview was conducted with the Administrator. She reported that her understanding of an elopement is, exiting the building and off of the compound and stated, it would be if they are not able to find the resident. The Administrator was asked if she had any concerns if the resident makes it out of the building unwitnessed and ends up in the parking lot without escort. She stated if they are observed and returned into the building, she does not consider it an elopement. An interview with the Director of Social Work on 4/22/2021 at approximately 3:48 PM, validated that Resident #40 had not been placed on the 4-week Behavior Management program as a result of the Elopement Risk performed on 3/3/2021. Per the Director of Social Work, the resident was placed on the program following the notification of his wandering into other resident rooms she reported that this was on or about 3/19/2021. On /22/2021 at 1:15 PM an interview with Staff E, an RN and Staff F, an RN Unit Manager. They were asked how they know an exit door has been accessed. They pointed to a panel on the nurse alarm system and stated that it goes off and tells them the part of the building. Staff F stated they are all to head in the direction of the alarm. They were asked what they would do if they found a resident outside? Staff F stated they would redirect them inside the facility, ensure they are safe with no injuries and notify the Risk Manager and Director of Nursing. They were asked how the staff know a resident is an elopement risk. Staff F stated they have a book with high-risk elopement residents. She stated all staff are aware who is high risk and who needs watching. She also stated that Activities works to engage them, so they don't wander. On 4/23/2021 at approximately 11:07 AM, an interview was conducted with Nurse Practitioner (NP). She said, Resident #40, is one of my patients. I was aware that he had started exit seeking behaviors over the last couple of weeks. I documented on 3/9/2021 that the resident exited the facility and made it to the parking lot. At that point he hadn't had any falls. I ordered some laboratory tests to rule out urinary tract infection (UTI) for this new behavior. I did see him that day on 3/9/2021. He told me 'I am trying to get to the store' he didn't remember getting out of the facility when I asked him. Staff said he was trying to get to the hardware store, said this multiple times, and he is still saying it since that date. His tests were all within normal limits (WNL). I also saw him on 3/22/2021 for altered mental status and increased anxiety. Staff reported he wasn [TRUNCATED]

Based on observation, staff interview and record review, the facility Quality Assurance and Performance Improvement (QAPI) process failed to develop appropriate plans of action to correct quality deficiencies related to resident elopement that occurred on 3/7/21 (Resident #40) and 3/9/21 (Resident #48). The facility's failure to follow the QAPI process may prevent the facility from correcting and improving their systems to ensure resident safety and prevent serious harm for residents at risk for elopement (Resident #40 and #48). Resident #40 was found unattended in the facility parking lot by a staff member on 3/7/21 and Resident #48 was able to exit the building unsupervised through a fire door on 3/9/21. This failure has the potential to affect 28 residents at risk for elopement. The facility's failure to prevent an elopement and eliminate potential hazards placed 2 residents at a likelihood of serious injury and death. Residents are at risk for being injured or killed by passing cars on the highly traveled [NAME] Road approximately 0.4 miles south of the facility, falling and injuring themselves, or drowning in holding ponds located south of the facility. The situation resulted in a finding of Immediate Jeopardy at a scope and severity of isolated (J). The facility Administrator and Director of Nursing were notified of the Immediate Jeopardy finding on 4/23/2021 at 3:27 PM. The Immediate Jeopardy was determined to have begun on 3/7/2021, the day Resident #40 was able to exit the building unsupervised. The Immediate Jeopardy was ongoing at the time of exit. Cross reference F689. The findings include: A review of the medical record for resident #48 revealed that on 3/9/21 the resident was found unattended outside the facility sitting on a bag of sand, per the Event Report dated 3/9/21. A review of the Elopement Risk Observation Form, the facility's internal elopement risk assessment tool, dated 2/24/2021 for Resident #48 revealed a score of 17. A score of 17 indicated the resident was at high risk for elopement. On 4/21/21 at approximately 10:37 AM, during an interview the Risk Manager stated that she remembered resident #48's elopement, and that they had made the announcement and all staff went room to room checking for the resident. She further reported that she, the Clinical Care Coordinator and the Director of Therapy had checked the outside grounds and found the resident sitting on a bag of sand leaning up against a fence. She stated that she felt the resident had gone through the dining room door and that the facility had fire safety doors which will open if you keep pushing on them. When asked how the facility was made aware that the resident was out of the building the Risk Manager stated, We received a call from a neighbor that was behind our fence-line and they wanted to make sure she was okay and should be out there. There was an alarm on the door. The alarm sounds on the door itself, but it is hooked to the whole system so you can hear it throughout the building. The Risk Manager also said the alarm, had been silenced because when the staff member checked to see why the door was going off, (Resident #48) was not in sight. She got away from the door quicker than someone could get to the area to see her. So, they were under the understanding that everything was clear. The person from the neighborhood let us know that she was out there. At this time, the Risk Manager was asked for the incident investigation with the root cause analysis. She stated, The investigation should be in the computer in progress notes. She stated that she would check in her filing system. She further stated, I wrote it out in the Elopement Drill form because it is what I am most familiar with. There was also an in-service titled, Disaster Preparedness Drill, with 9 signatures on it. The Risk Manager was asked for a copy of the incident report and a copy of the investigation with root cause analysis, however neither were provided by the conclusion of the survey on 4/23/21. On 4/22/21 a review of the medical record for resident #40 revealed that on 3/7/21 at 7:16 AM, staff nurse J, Registered Nurse (RN) documented in a progress note that the resident was found wandering in the parking lot by another facility staff member. The note goes on to state that the nurse attempted to contact the Director of Nursing three times. A review of the adverse event log could not locate a reported event for the Elopement of Resident #40. A review of the Elopement Risk Observation Form performed on 3/3/2021 identified resident #40 at moderate risk for elopement with a score of 9. Upon review of the elopement book it was discovered that Resident #40 was not identified in the book as an elopement risk. In an interview with the Risk Manager on 04/21/21 at approximately 5:02 PM, the Risk Manager was asked if she recalled an event when Resident #40 was found outside of the facility on 3/7/2021. The Risk Manager did not recall an elopement. The surveyor reviewed the medical record with the Risk Manager and pointed out the documentation on 3/7/2021 regarding Resident #40 being brought in from the parking lot. The Risk Manager stated this event was not brought to her attention. She had not performed an investigation. On 4/22/21 at 1:11 PM, an interview was conducted with Staff W, a Licensed Practical Nurse (LPN) and Staff X, a Certified Nursing Assistant (CNA). They were asked if they have had in-services for elopement. They stated they have had on-line training. When asked if they have been a part of an elopement drill, they responded they had not been a part of a drill and could not describe a drill. On 4/23/21 at approximately 11:58 AM, staff member F, a CNA, stated that she was not aware of an elopement book and that they find out about elopement risks through shift reports. When asked how elopement education is provided, CNA F stated that there was education provided on elopement but did not recall how often and could not remember last time it was done. On 04/23/2021 at approximately 9:44 AM, staff member C, a CNA, stated, I have been here 5 years and have not had an Elopement drill, I've had education on elopement but never been in a drill. On 04/23/2021 at approximately 10:00 AM, Registered Nurse E stated, I have been here less than 3 months. During orientation they gave me the front door code, and it is still the same door code, it has not been changed. I have not had any drills since I was hired. I did get some education and a handout for elopement. On 04/23/2021 at approximately 2:18 PM, the Rehabilitation Director stated, I have not participated in any type of a physical drill for 2 1/2 yrs. On 4/22/2021 at approximately 1:33 PM, an interview was conducted with two members of the QAPI committee, the Administrator and the Risk Manager regarding staff training on elopement. The Administrator stated that the Risk Manager was performing the in-services on Code Pink (an emergency announcement that uses a color system to identify facility emergencies. Pink is used to identify a missing resident) at the direction of the administrator. The Administrator stated the form they use has a space for a topic/subject, date, and signatures. In this case, the Risk Manager pulled the wrong form. She then stated, (The Risk Manager) documented that the elopement of resident #48 as an effective elopement drill. She went on to state that staff had responded appropriately, and the resident had no ill effects. I think in all reality that for her first drill she did a good job on the paper and assessing the compliance. We all took our action steps, we all checked for safety and security. I would use it as a drill. She then agreed that the situation was not a preplanned drill and agreed that nothing presented to the surveyors at that time demonstrated a root cause analysis of how the resident was able to elope from the building. The Administrator verified that she was the person who is responsible for the oversight of the Risk Manager and was responsible for reviewing her work to determine if it was completed correctly. She also stated that she was responsible for following up on her performance and to make a plan of correction for the elopements. On 04/23/21 at approximately 3:42 PM, a follow-up interview on the QAPI program was conducted with the Administrator and the Risk Manager. The surveyor asked about performance improvement projects. The Administrator stated they look at the normal things such as antibiotic usage and falls. The Administrator went on to state they have quite a few systems that track data that they utilize. She stated some of it is reports they receive from corporate, and some is data that they track. The Administrator stated adverse events are tracked for trends. When asked if there was anything the facility had in way of performance improvement plans or investigations related to elopements the Administrator stated the only incident was the Code Pink they had for Resident #48 in March of 2021. A review of the QAPI plan identified various data sources that are utilized for QAPI meetings. The Feedback, Data Systems & Monitoring of the QAPI plan states they will maintain a method for tracking and monitoring adverse events that will be investigated every time they occur, in order to implement interventions to prevent recurrence. A review was conducted of the policy titled, Missing Resident, effective 9/1/2012 and last reviewed/revised 6/1/2017. Under the section titled, When the resident is located and/or on the return of the resident to the center, item number 7 stated, Within 24 hours of the incident, an Incident Report Form shall be completed indicating the results of the center's investigation of the incident and any corrective measures implemented. Item number 9 stated, The resident's care plan shall be reviewed and revised as needed. Item number 12 stated, All Missing Resident incidents shall be reviewed as part of the center's Performance Improvement Program. A review of facility policy Occurrences effective 07/01/2012, revised 5/4/2016 and reviewed 09/09/2019, elopement is listed as an occurrence hazard. The procedure outlines that the licensed nurse will be responsible for completing the following occurrence documentation requirements prior to the end of the shift when the occurrence took place. Under Investigation and Follow-up it states: The Administrator or designee will complete the supervisor investigation on all occurrences, and report to the appropriate state agency and/or other external agencies according to law The policy goes on to say the log is to be reviewed at QA/PI Committee and documented in minutes.

Based on record review and interview, the facility failed to accurately complete a Minimum Data Set (MDS) for 1 of 5 residents (Resident #45) sampled for Unnecessary Medications. The findings include: On 4/21/2021 a record review was conducted for Resident #45. The resident's Quarterly MDS dated [DATE] included use of an anticoagulant. A review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The ordered medication is not classified as an anticoagulant, it is classified as an antiplatelet. An antiplatelet is a drug prevents blood clots by preventing platelets from sticking together while an anticoagulant suppresses the function of clotting factors found in the blood. On 4/21/2021 at approximately 1:31 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated she had conducted this portion of the assessment and it was an error on her behalf and was a misunderstanding of [MEDICATION(S)] not being an anticoagulant.

Based on record reviews and interviews, the facility failed to provide bathing for 1 of 1 resident (Resident #45) sampled for Activities of Daily Living (ADLs). The findings include: On 4/19/2021 at approximately 11:55 AM, an interview was conducted with Resident #45 who stated she has not had a shower or bath in over a week. The resident stated she was supposed to get a bath 3 times a week, but at best she only gets one a week, or none at all. On 4/21/2021 a review of the facility's documentation for ADL care for Resident 45 revealed no bathing services had been provided between 4/11/2021 and 4/19/2021. On 4/21/2021 at approximately 11:48 AM, an interview was conducted with the Unit Manager who stated Residents are scheduled for showers 3 days a week but can bathed 5 days a week if requested. The Certified Nursing Assistants (CNAs) document in the computer and on the vital sign sheets when a bath is given and should notify the nurse if the resident refuses or is unavailable for a shower/bath. Even if the resident refuses, there should be some documentation of the refusal. My expectation as the Unit Manager is that residents are assisted with their ADLs and given their showers when scheduled and or requested. A policy addressing ADL care was requested but not provided by the facility by the time this survey concluded on 4/23/21.

Based on observations, record reviews and interviews, the facility failed to provide appropriate respiratory care services for 2 of 2 residents (#347 and #7) sampled for respiratory care. The findings include: Resident #347 On 04/20/21 at approximately 9:05 AM, an observation was made of Resident #347, the nasal cannula oxygen (O2) tubing was found lying in bed next to the resident. The portion of the nasal canula O2 tubing that is placed in nares (nostrils) was noted to be discolored a reddish tan. (photographic evidence obtained) On 04/21/21 at approximately 9:07 AM, the nasal cannula O2 tubing was located in the plastic bag attached to the O2 concentrator. The portion of the nasal cannula tubing that is placed in the nares was noted to be discolored a reddish tan. On 04/22/21 at approximately 8:19 AM, the nasal cannula O2 tubing was located in the plastic bag attached to O2 concentrator. The portion of the nasal cannula tubing that is placed in the nares is stained a light reddish tan color starting at the tips and up to and including the cannula port. (photographic evidence obtained) On 04/22/21 at approximately 9:37 AM, an interview was conducted with Staff A, Licensed Practical Nurse (LPN) who was assigned to care for resident #347. Staff A was asked, How often is the tubing changed for O2? Staff A stated, I would have to look on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor asked Staff A if O2 tubing can be changed as needed. Staff A replied, Absolutely. The surveyor asked Staff A what reasons would trigger staff to change the O2 tubing. Staff A stated, Well if it was soiled or dropped on the floor. On 04/22/21 at approximately 11:30 AM, Staff A accompanied the surveyor to Resident #347's room. Staff A was asked to examine the O2 nasal cannula in the bag on the residents O2 concentrator. Staff A stated, Oh yes, I see some discolorations. Staff A was asked if the tubing was acceptable to put on the resident. Staff A stated, Oh no, I will be changing that. Resident #7 On 04/19/21 at 10:43 AM, Resident 7 was observed receiving oxygen (O2) at 3 liters (L) per minute by nasal cannula. The tubing was observed, and it was not dated. A gallon sized plastic bag was taped on the O2 concentrator and marked in red with the date of 4/4/2021. (photographic evidence obtained) On 04/20/21 at 9:17 AM, Resident #7 was observed receiving O2 at 3 L per minute by nasal cannula which was attached to the O2 concentrator. A gallon plastic bag was attached to the O2 concentrator and was marked in black with a date of 4/19/21. On 04/20/21 at 2:13 PM, Resident #7 was observed receiving O2 at 3 L per minute by nasal cannula. The O2 tubing was attached to the O2 concentrator. On 04/20/21 at 4:23 PM, Resident #7 was observed receiving O2 at 3 L per minute by nasal cannula. The O2 cannula was observed to be in both nares (nostrils) and attached to the O2 concentrator. On 04/22/21 at approximately 9:18 AM, an interview was conducted with Staff A. Staff A was asked what the purpose was of the plastic bag taped to the O2 concentrator. Staff A stated, It's for storing the O2 tubing when not in use. Staff member A was shown a picture of the oxygen concentrator with a plastic bag taped to it with the resident's name, the date of 4/4/2021 and the O2 flow meter at 3 L per minute. The Surveyor asked Staff A, What is the significance of the date on plastic bag? Staff A stated, It should have been when the tubing was actually changed. Staff A was asked if the O2 in the picture was at the ordered dose. Staff A stated, The order is for 2 liters continuous and in the picture the oxygen appears to be at 3 liters per minute. A review of Resident #7's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #7's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review was conducted of the, Oxygen Administration Policy, effective 12/1/2008, last reviewed 12/7/2020, and last revised 11/01/2019. On Page 2, under, Infection Control Policy of O2 Humidifier Bottles, item number 4 read, Change all oxygen tubing when there is visible soiling.

Based on record review and interviews, the facility failed to immediately notify a patient representative of a change in condition for 1 of 1 resident sampled (#352). The findings include: A record review of resident #352 was conducted and revealed the resident was documented as having a change in condition [DATE] at 7:32PM, when staff member H, an LPN documented that the resident was lethargic, had a low blood pressure and was having difficulty breathing. The Nurse Practitioner (NP) was notified and ordered 2 liters of normal saline solution to be administered via intravenous infusion (IV) at 75 milliliters and hour. The nurses were unsuccessful in starting and maintaining IV access. The NP was again notified and gave an order to send the resident to the emergency room for IV access and return to the facility. The hospital stated they did not provide IV assistance after hours. The NP was notified and the IV order was discontinued and staff were instructed by the NP to keep the resident comfortable. On [DATE] at 6:54AM, the resident was found to have shallow breaths, was pale in color but appeared to be resting comfortably and free of distress. The resident expired on [DATE] at 7:15 AM. The nursing notes contained no documentation of the family being notified of the decline and change of condition of the resident between the onset of the symptoms on [DATE] at 7:32 PM, until after the resident expired on [DATE] at 7:15 AM. On [DATE] a review of the document Record of Partner Corrective Action Form (RPCA) for staff member H for the events of [DATE] and signed by the staff member on [DATE] documented Failure to complete SBAR (Situation, Background, Assessment, Recommendation form) or document a critical change of condition. Failure to notify family of this change. Resident expired next morning family was not aware of decline and was denied chance to visit and spend time with loved one. On [DATE] at approximately 12:27 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the expectation is any time there is a change of condition the family needs to be notified immediately. In regard to resident #352, I disciplined and educated the staff about not notifying the family of the change of conduction. It is not acceptable they did not notify the family. I spoke with the daughter, the primary party. I apologized in person for what happened. When I spoke with the nurses, they didn't have an excuse and said they just didn't call the family.

Based on staff interview the facility failed to complete the required Minimum Data Set (MDS) in a timely manner for 1 of 1 (#2) system selected MDS record over 120 days old. The findings include: Resident #2 was chosen by the system to determine why the MDS was over by 120 days old. An interview was conducted with Employee A, the RN (registered nurse) MDS Case Mix Director, on 9/10/19 at 2:52 PM. She was asked why the MDS had not been completed. She said there should be a discharge return anticipated MDS. She was asked how she knows when MDS's are due. She said they have system in place for census activity. She was asked if it worked in this instance and she said, No.

Based on staff interview and record review the facility failed to properly code hospice services on the Minimum Data Set (MDS) for 1 of 23 residents sampled (Resident #17). The findings include: A review the resident electronic record indicates resident is under the care of hospice. A review of the MDS 6/6/19 quarterly assessment does not indicate the resident is under the care of hospice. An interview was conducted with Employee A, a RN (registered nurse) MDS Case Mix Director, she was asked if Resident #17 was on hospice and she said, yes she has been on hospice since her admission. The resident's admitted is 11/23/18. She was then asked if she coded the resident for hospice on the quarterly assessment for 6/6/19. She looked at the MDS and said no it is not there.

Based on staff interview and electronic record review the facility failed to develop a baseline care plan that included care and instructions for a Foley catheter for 1 of 2 residents sampled for catheters (Resident #353). The findings include: Closed record review revealed resident #353 was admitted to the facility on [DATE]. The admitting nurses note on 8/21/19 at 8 PM, indicated the resident had a Foley catheter draining clear yellow urine. A review of the Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form indicated the resident had a Foley catheter for [MEDICAL CONDITION]. A review of the baseline care plan initiated on 8/21/19 failed to have documentation concerning the Foley catheter or it's care. A review of the physician's orders did not indicate care instructions for the Foley catheter. An interview was conducted with the Director of Nursing (DON) Employee F on 9/12/19 at 10:22 AM. She said that the admitting nurse on the floor is responsible for completing the baseline care plan. She was asked if that would include care instructions for the Foley catheter. She said at a minimum the baseline care plan should have documentation about the Foley catheter.

Based on record reviews and staff interviews the facility failed to implement the care plans for 2 of 23 sampled residents (#46 and 34) by failing to implement the [MEDICAL CONDITION] medications interventions. The findings include: Resident #46 Record review of the physician orders [REDACTED].#46 for 08/1/2019 thru 09/11/2019 revealed physician's orders [REDACTED]. Review of the 8/12/2019 thru 09/11/2019 Medication Administration Record [REDACTED]. Review of the 08/08/2019 pharmacy review revealed the recommendation for a gradual dose reduction for the [MEDICATION NAME]. The pharmacist revealed there were no reported behaviors from Social Services in the last 30 days. The pharmacist recommended a reduction of the [MEDICATION NAME] to 10mg twice a day. Record review revealed the physician agreed with the pharmacist recommendation on 8/12/19. Record review failed to reveal documentation that this recommended dose reduction was implemented. Interview and record review with the facility Director of Nursing (DON), sampled staff F on 09/12/19 07:53 AM, confirmed the pharmacy review on 8/8/2019 with the recommendation to decrease to [MEDICATION NAME] 10mg twice a day. The DON also reviewed the physician orders [REDACTED]. Record review of the care plans for sampled resident #46 revealed a care plan for the use of [MEDICAL CONDITION] drug use. The care plan was implemented on 04/01/2019 and includes the intervention to attempt a gradual dose reduction as ordered/appropriate. Interview and record review with the DON on 09/12/19 at 08:00 AM, revealed they failed to implement the care plan for the [MEDICAL CONDITION] medication reduction for the antianxiety medications. Resident #34 Record review for sampled resident #34 revealed the physician orders [REDACTED]. This order included a start date of 6/20/19 with open End date. Review of the 08/11/2019-08/31/2019 Medication Administration Record [REDACTED]. Record review of 09/01/19 through 09/11/2019 MAR indicated [REDACTED]. Record review and interview with the DON, sampled staff F, on 09/12/19 08:08 AM, revealed there was no end date for the [MEDICATION NAME] and stated the physician should have a stop date and should re-evaluate the resident's medication for continued use. During a follow-up interview with the DON on 09/12/19 08:11 AM, the pharmacy recommendations were reviewed and revealed no pharmacy recommendation to obtain a stop date or re-order the medication or to consider routine if needed. Interview and record review with the facility's consultant pharmacist on 09/12/2019 at approximately 9:45AM, revealed that he had not made a recommendation concerning the continued prn (as needed) use of the [MEDICATION NAME] due to the fact the resident was on hospice; but usually addresses it after a few months. Record review of the care plans for sampled resident #34 revealed a care plan for [MEDICAL CONDITION] drug use which included pharmacist to review medications implemented on 1/18/2019. Interview and record review with the DON, sampled staff F, on 09/12/19 08:13 AM, revealed the staff did not follow the care plan for [MEDICAL CONDITION] medications by not performing appropriate pharmacy reviews.

Based on staff and physician interview, and electronic record review the facility failed to have care instructions for 1 of 2 (#353) residents reviewed for Foley catheters. The findings include: Closed record review revealed resident #353 was admitted to the facility on [DATE]. The admitting nurses note on 8/21/19 at 8 PM indicated the resident had a Foley catheter draining clear yellow urine. A review of the Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form indicated the resident had a Foley catheter for [MEDICAL CONDITION]. A review of the baseline care plan initiated on 8/21/19 failed to have documentation concerning the Foley catheter or it's care. A review of the physician's orders did not indicate care instructions for the Foley catheter. A review of the nursing progress note from admission indicated a Foley catheter, further review of the nursing notes revealed on 8/23/19 3:20 PM - Foley catheter in place and flowing yellow, cloudy urine to gravity; 8/24/19 2:26 AM Foley catheter care provided per order, draining yellow cloudy urine; 8/25/19 4:10 PM Foley in place draining yellow cloudy urine; and on 8/26/19 8:30 AM Foley catheter care in place draining cloudy pale yellow urine. An interview was conducted with the Director of Nursing (DON) Employee F on 9/12/19 at 10:22 AM. She stated that the admitting nurse on the floor is responsible for completing the baseline care plan. She was asked if that would include care instructions for the Foley catheter. She said at a minimum the baseline care plan should have documentation about the Foley catheter. The medical doctor Identifier (N) was interviewed on 9/12/19 at 9:02 AM, regarding the care for resident #373. She was asked to review the orders in the electronic system for Foley catheter care. She reviewed the orders and said she did not see orders for Foley catheter care. She then said if a person is admitted with a Foley catheter then care instructions should automatically be ordered. .

Based on record reviews and staff interviews the facility pharmacist failed to report the need for a stop date or the need for further review of continued use of an antianxiety medication for 1 of 5 sampled residents (#34) reviewed for unnecessary medication review. The findings include: Record review for sampled resident #34 revealed physician orders [REDACTED]. This order had a start date of 6/20/19 with open End date. Review of the 08/11/2019-08/31/2019 Medication Administration Record [REDACTED]. Review of MAR for 09/01/2019 through 09/11/2019 revealed the resident had received the medication one time on 09/02/2019 at 10:13AM. Record review and interview with the DON, sampled staff F, on 09/12/2019 08:08 AM, revealed there was no end date for the [MEDICATION NAME]. At this time the DON stated the physician should have a stop date and should re-evaluate the resident's medication for continued use. A follow-up interview with the DON was conducted on 09/12/2019 08:11 AM, during which the pharmacy recommendations were reviewed and failed to reveal a pharmacy recommendation to obtain a stop date or re-order the medication or to consider routine if needed. Interview and record review with the facility's consultant pharmacist on 09/12/2019 at approximately 9:45AM, revealed that he has not made a recommendation concerning the continued prn (as needed) use of the [MEDICATION NAME] due to the fact the resident was on hospice; but usually addresses it after a few months.

Based on record reviews and staff interviews the facility failed to ensure 2 of 5 sampled residents reviewed for unnecessary medication were free from unnecessary antianxiety medication (#46 and #34). The findings include: Resident #46 Record review for sampled resident #46 revealed the physician orders [REDACTED]. Review of the 8/12/2019 thru 09/11/2019 Medication Administration Record [REDACTED]. Review of the 08/08/2019 pharmacy review revealed the recommendation for a gradual dose reduction for the [MEDICATION NAME]. The pharmacist revealed there were no reported behaviors from Social Services in the last 30 days. The pharmacist recommended a reduction of the [MEDICATION NAME] to 10mg twice a day. Record review revealed the physician agreed with the pharmacist recommendation on 8/12/19. Record review failed to reveal documentation that this recommended dose reduction was implemented. Interview and record review with the facility Director of Nursing (DON), sampled staff F on 09/12/19 07:53 AM, confirmed the pharmacy review on 8/8/2019 with the recommendation to decrease to [MEDICATION NAME] 10mg twice a day. The DON also reviewed the physician orders [REDACTED]. Resident #34 Record review for sampled resident #34 revealed the physician orders [REDACTED]. This order included a start date of 6/20/19 with open End date. Review of the 08/11/2019-08/31/2019 Medication Administration Record [REDACTED]. Record review of 09/01/2019 thru 09/11/2019 MAR indicated [REDACTED]. Record review and interview with the DON, sampled staff F, on 09/12/19 08:08 AM, revealed there was no end date for the [MEDICATION NAME] and stated the physician should have a stop date and should re-evaluate the resident's medication for continued use. During a follow-up interview with the DON on 09/12/19 08:11 AM, the pharmacy recommendations were reviewed and revealed no pharmacy recommendation to obtain a stop date or re-order the medication or to consider routine if needed. Interview and record review with the facility's consultant pharmacist on 09/12/2019 at approximately 9:45AM, revealed that he had not made a recommendation concerning the continued prn (as needed) use of the [MEDICATION NAME] due to the fact the resident was on hospice; but usually addresses it after a few months.

Based on observations, and staff interview the facility failed to ensure opened insulin pens stored in medication carts were appropriately labeled in 2 of 4 medication carts observed and failed to ensure expired medications were discarded for 1 of 4 medication carts observed. The findings include: An inspection of the medication cart on the 200B hall was conducted on 09/10/2019 beginning at approximately 4:53PM, with the medication nurse, sampled staff B. The inspection revealed one [MEDICATION NAME] prefilled syringe (an insulin delivery device perscribed for individual use for residents with diabetes) which was stored in the bottom drawer of the cart along with the other medications for sampled resident #44. Inspection of the insulin [MEDICATION NAME] revealed the resident's medication label, which contained the resident's name was missing. It appeared to have been partially peeled off to allow access to the unit meter on the insulin [MEDICATION NAME]. There was no other labeling present to identify to whom the insulin pen belonged. Further inspection of the cart revealed a [MEDICATION NAME] Flextouch insulin determir injection pen labeled with an open date of 09/01/2019, however no resident name was noted on the insulin pen. There was a partial label which appeared to have been peeled off to allow access to the unit meter on the pen. The nurse was unable to identify to whom the insulin pen belonged. The nurse removed both insulin pens from the cart. Continued inspection on 09/10/2019 at approximately 05:04 PM, an inspection of the medication cart for the 200B hall was conducted with sampled staff A, a Registered Nurse (RN). The inspection revealed on opened, partially used bottle of [MEDICATION NAME] 80mg (used to treat excess gas) with the expiration date of 08/2019. The medication nurse confirmed the medication was expired and removed it from the medication cart. An inspection of medication cart for the 100B hall residents was conducted with the medication nurse, sampled staff D on 09/10/2019 beginning at approximately 05:51 PM. The inspection revealed one [MEDICATION NAME] prefilled insulin syringe with the resident's name label partially removed, the nurse stated she was not sure to whom the insulin pen belonged to. She stated it probably belonged to sampled resident #73, it was in her bin with the rest of her medications, but the nurse stated because she was unsure she removed it from the cart, the insulin pen was marked opened on 8/15/2019.

Based on observation, staff interview, family interview, record review and policy review, the facility failed to honor resident rights by issuing a discharge notice for a first time offense of breaking the facility no smoking policy for 2 of 3 sampled residents #1 and #2. Resident #1 and #2 were observed smoking in the courtyard by facility staff. The discharge notices were issued the same day and documented the reason for discharge as endangerment of resident health and safety. The facility failed to ensure a physician documented discharge necessity in the resident medical records. Resident #1 was discharged to family the following day and Resident #2 remains in the facility. The findings include: On 3/27/19 a record review was conducted for resident #1 in which it was discovered that the resident had been discharged from the facility on 2/27/19. Review of the Nursing Home Transfer and discharge Notice dated 2/26/19 found the reason for the discharge or transfer was The Health of other individuals in this facility is endangered and The safety of other individuals in the facility is endangered. The hand written explanation provided on the document stated Resident was smoking illegal drugs on premises police were notified. Having illegal drugs on campus is a danger to other residents. There was no effective date for discharge listed on the form. A review of the medical record on 03/27/2019 failed to find physician documentation regarding the reasons listed in the discharge notice. Review of the nursing documentation for 2/26/19 at 9:25 PM Behavior: Resident was reportedly smoking Marijuana on the premises. Social Services Director (SSD) called and spoke with resident's sister to notify them of the discharge notice. SSD will call tomorrow morning to set up discharge plans. Progress note dated 2/27/19 at 12:55 AM Resident was seen smoking in resident courtyard with another resident by CNA (certified nursing assistant). CNA smelled marijuana. Family member called by nurse and social worker to inform them of residents discharge due to smoking at this non-smoking facility. Review of the DC (discharge) summary dated 2/27/19 She (resident #1) has worked toward meeting goals in therapy, but was caught smoking marijuana on facility property and sharing with another resident. She agreed to discharge home early with HHC (Home Health Care). The facility completed a HHC referral including ordering a bedside commode and wheelchair. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] indicated resident #1 expected to be discharged as noted in section Q300 for Overall Expectation. Resident #1 had been admitted for rehabilitation. Review of the Notice of Medicare Non-Coverage dated 2/27/19 was not noted to be signed by the resident and had the following notation on the bottom of the form requested discharge today 2/27/19. A review of the Milton Police Department Call History Record revealed that Law Enforcement was notified on 2/26/19 at 20:41 (9:41pm) of a Narcotics Violation. The Officer noted his arrival on scene at 20:45 (9:45pm) and documented that both individuals stated they were smoking cigarettes and that no one was able to confirm if it was actually narcotics. Review of the PruittHealth Santa Rosa Smoking Policy signed by resident #1 on admitted d 1/16/19 revealed under item #4. Procedure Residents who are non-compliant with our smoking policy will be issued a verbal warning followed by a written warning, and ultimately presented a 30-day discharge notice. Smoking cessation resources and supplies will be provide for residents upon request. Review of the resident's record found no evidence that a verbal or written notice had been issued or documented. On 3/27/19 at approximately 1:01 PM an interview was conducted with the Director of Nursing (DON), Executive Director (ED) and the Social Services Director (SSD) in which they stated resident #1 was discharged because she was smoking marijuana in the courtyard and this was against the smoking policy. They stated this was at the direction of their corporate office to immediately discharge the resident. They called the sister who stated that since the police were involved they would take her sister home. On 3/27/19 at approximately 1:47 PM an interview was conducted with the sister and emergency contact of resident #1 during which she stated the facility kicked her (resident #1) out because they caught resident #1 smoking. She stated they did not request to leave but were told they needed to go. A Fair Hearing Request For Transfer or Discharge from a Nursing Home was submitted by resident #1 on 3/1/19 stating, Facility gave her one day to leave the premises because she was caught smoking in the courtyard. Resident #2: A record review was conducted of the 'Nursing Home Transfer and Discharge Notice' issued on 02/23/2019 to Resident #2. The effective date of discharge was left blank. The reasons for discharge were listed as, The health of other individuals in this facility is endangered and The safety of other individuals in this facility is endangered. Under the section for 'Brief explanation to support this action', the facility documented, Resident was smoking illegal drugs on campus serving as a danger to other residents. The discharge notice was signed on 2/26/2019 by the Social Services Director (SSD). Neither Resident #2 nor the physician signed the discharge notice. There was a note which stated that Resident #2 refused to sign. A review of the medical record on 03/27/2019 failed to find physician documentation regarding the reasons listed in the discharge notice. Record review revealed that Resident #2 was discharged to the hospital for planned surgery on 2/27/2019 and readmitted to the facility on [DATE]. On 3/27/19 an observation and interview were conducted with Resident #2 at 11:52am. Resident #2 stated he was not being discharged and was happy with the care he is receiving. Review of Social Services Progress notes found an entry on 3/1/2019 at 1:29pm which stated, On the night of 2/26/2019, resident was caught with illegal drugs and was providing other residents with drugs. Nurse called the police. Staff searched his room for drugs for resident safety and safety of other residents. Social worker explained that he would be provided with a discharge notice due to non-compliance with facility policy and putting other residents at risk. He refused to sign discharge notice. When I was sure that this is how the notice would be handled, social worker faxed the notice to the ombudsman, and mailed a copy to his sister. Today, Social Worker and Admissions visited Resident #2 in the hospital to clarify that the discharge notice was immediate and offered to assist resident with discharge arrangements as needed. On 3/27/2019 at approximately 1:59pm, an interview was conducted with the SSD. The SSD stated Resident #2 was found to be in the courtyard smoking pot with resident #1. He remains in the building and was not discharged . He had surgery the day after the incident but returned to the facility for therapy. He want's to go somewhere he can smoke so they are working on that discharge plan. During this interview the SSD stated that she had completed a discharge notice for this resident however he did not sign it so it was not valid. She stated that he was given a discharge notice but he remains in the building and there is no active plan for discharge.

Based on record review and interview, the facility failed to ensure that residents were given 30 days' notice prior to facility initiated discharge for 2 of 3 residents reviewed (resident #1 and 2). Findings included: On 3/27/19 a record review was conducted for resident #1 in which it was discovered that the resident had been discharged from the facility on 2/27/19. Review of the Nursing Home Transfer and discharge Notice dated 2/26/19 found the reason for the discharge or transfer was The Health of other individuals in this facility is endangered and The safety of other individuals in the facility is endangered. The hand written explanation provided on the document stated Resident was smoking illegal drugs on premises police were notified. Having illegal drugs on campus is a danger to other residents. The discharge notice did not have an effective date for discharge listed on the form. The 'Fair Hearing Request for Transfer or Discharge from a Nursing Home' dated 3/1/2019 was reviewed. Under the section entitled, I disagree with the transfer or discharge for the following reasons was documented, Facility gave her one day to leave the premises because she was caught smoking in the courtyard. On 3/27/19 at approximately 1:47 PM an interview was conducted with the sister and emergency contact of resident #1 during which she stated the facility kicked her (resident #1) out because they caught resident #1 smoking. She stated they did not request to leave but were told they needed to go. Review of the nursing documentation for 2/26/19 at 9:25 PM Behavior: Resident was reportedly smoking Marijuana on the premises. Social Services Director (SSD) called and spoke with resident's sister to notify them of the discharge notice. SSD will call tomorrow morning to set up discharge plans. Progress note dated 2/27/19 at 12:55 AM Resident was seen smoking in resident courtyard with another resident by CNA (certified nursing assistant). CNA smelled marijuana. Family member called by nurse and social worker to inform them of residents discharge due to smoking at this non-smoking facility. Review of the DC (discharge) summary dated 2/27/19 She (resident #1) has worked toward meeting goals in therapy, but was caught smoking marijuana on facility property and sharing with another resident. She agreed to d/c (discharge) home early with HHC (Home Health Care). A review of the Milton Police Department Call History Record revealed that Law Enforcement was notified on 2/26/19 at 20:41 (9:41pm) of a Narcotics Violation. The Officer noted his arrival on scene at 20:45 (9:45pm) and documented that both individuals stated they were smoking cigarettes and that no one was able to confirm if it was actually narcotics. Review of the PruittHealth Santa Rosa Smoking Policy signed by resident #1 on admitted d 1/16/19 revealed under item #4. Procedure Residents who are non-compliant with our smoking policy will be issued a verbal warning followed by a written warning, and ultimately presented a 30-day discharge notice. Smoking cessation resources and supplies will be provide for residents upon request. Review of the resident's record found no evidence that a verbal or written notice had been issued or documented. On 3/27/19 at approximately 1:01 PM an interview was conducted with the Director of Nursing (DON), Executive Director (ED) and the Social Services Director (SSD) in which they stated resident #1 was discharged because she was smoking marijuana in the courtyard and this was against the smoking policy. They stated this was at the direction of their corporate office to immediately discharge the resident. They called the sister who stated that since the police were involved they would take her sister home. Resident #2: A record review was conducted of the 'Nursing Home Transfer and Discharge Notice' issued on 02/23/2019 to Resident #2. The effective date of discharge was left blank. The discharge location was the resident's prior home. The reasons for discharge were listed as, The health of other individuals in this facility is endangered and The safety of other individuals in this facility is endangered. Under the section for 'Brief explanation to support this action', the facility documented, Resident was smoking illegal drugs on campus serving as a danger to other residents. The discharge notice was signed on 2/26/2019 by the Social Services Director (SSD). Neither Resident #2 nor the physician signed the discharge notice. There was a note which stated that Resident #2 refused to sign. Record review revealed that Resident #2 was discharged to the hospital for planned surgery on 2/27/2019 and readmitted to the facility on [DATE]. Review of Social Services Progress notes found an entry on 3/1/2019 at 1:29pm which stated, On the night of 2/26/2019, resident was caught with illegal drugs and was providing other residents with drugs. Nurse called the police. Staff searched his room for drugs for resident safety and safety of other residents. Social worker explained that he would be provided with a discharge notice due to non-compliance with facility policy and putting other residents at risk. He refused to sign discharge notice. When I was sure that this is how the notice would be handled, social worker faxed the notice to the ombudsman, and mailed a copy to his sister. Today, Social Worker and admissions visited resident #2 in the hospital to clarify that the discharge notice was immediate and offered to assist resident with discharge arrangements as needed. On 3/27/2019 at approximately 1:59pm, an interview was conducted with the SSD. The SSD stated Resident #2 was found to be in the courtyard smoking pot with resident #1. He remains in the building and was not discharged . He had surgery the day after the incident but returned to the facility for therapy. He want's to go somewhere he can smoke so they are working on that discharge plan. During this interview the SSD stated that she had completed a discharge notice for this resident however he did not sign it so it was not valid. She stated that he was given a discharge notice but he remains in the building and there is no active plan for discharge. On 3/27/19 an observation and interview were conducted with Resident #2 at 11:52am. Resident #2 stated he was not being discharged and was happy with the care he is receiving.