Every finding on record at Ridgeland Nursing Center Inc

Based on facility policy review, record review, and interviews, the facility failed to revise Resident (R)7's care plan from Full Code to Do Not Resuscitate (DNR) after the DNR order was written. This failure had the potential to cause harm if resuscitative measures were taken unnecessarily and against the Resident's and/or Family's wishes in the event of cardiopulmonary arrest. Findings include:Review of the facility policy titled, Advanced Directives with a revision date of [DATE], revealed, 5. Upon notification from resident and/or resident representative of the desire to change or revoke an advance directive, or any issue concerning the capacity, the physician will be notified, and the medical record will be modified accordingly.Review of the facility policy, Care Plans with a revision date of [DATE], revealed, Care plan updates/ reviews will be performed within seven days of each quarterly assessment, each acute episode, and each hospital stay.Review of R7's medical diagnoses list revealed he was admitted to the facility on [DATE]. His diagnoses included, but were not limited to, metabolic encephalopathy (dysfunction of the brain due to chemical imbalances in the body), nontraumatic chronic subdural hematoma (bleeding in the brain not caused by trauma), type 2 diabetes, muscle weakness, dysphagia (trouble swallowing), epilepsy (seizure disorder), dependence on renal dialysis, and altered mental status. Review of R7's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed R7 had a Brief Interview of Mental Status (BIMS) score of 05 out of 15, indicating he had severe cognitive deficits.Review of R7's advanced directive paperwork titled, South Carolina Emergency Medical Services revealed a Do Not Resuscitate Order. The document indicated, This notice is to inform all emergency personnel who may be called to render assistance to (R7) that he/ she has a terminal condition which has been diagnosed by me and is at least eighteen (18) years of age and has specifically requested that no resuscitative efforts including artificial stimulation of the cardiopulmonary system by electrical, mechanical, or manual means be made in the event of cardiopulmonary arrest. The document was signed by R7's surrogate on [DATE]. The document was also signed by R7's medical doctor. Review of R7's order recap report from [DATE] revealed a Full Code/ CPR order from [DATE] - [DATE]. The report revealed a DNR order from [DATE] - [DATE]. Review of R7's care plan revealed a focus of, The resident has an advanced directive of Full Code. This focus was initiated on [DATE]. The goals included, The resident will be informed of the advanced directive choices available through the review period, and The resident will have their advanced directives wishes honored through review period.During an interview on [DATE] at 1:15 PM with the MDS Coordinator, revealed a Resident's advanced directives sheet gets uploaded into the computer system, and a physician's order is entered reflecting the wishes of the Resident. She stated they usually get the signature from the Resident or the family member for the advanced directives right away, and the Provider will sign the advanced directives as soon as possible. She revealed she is unable to put a Resident's status as DNR in the chart unless there is an order. She stated once she sees the order, she will make the changes to the Care Plan. She stated she put what she was told in R7's Care Plan, which was that R7 had a status of Full Code. She stated if the advanced directives were changed to a DNR, she was not aware of it. She revealed she remembered there was confusion about his code status because of the wishes of different family members. She stated in this situation, some family members wanted the Resident to be a DNR, and some did not. She stated she is unable to change advanced directives in the care plan unless she has the directive to do so from someone in Nursing, the Director of Nursing (DON), or the Administrator. She revealed if R7's advanced directives were changed to a DNR, this change would have been discussed in their morning meeting, but she did not remember R7's change being discussed.During an interview on [DATE] at 3:36 PM, the DON revealed whenever a Resident changes his/ her advanced directives from Full Code to DNR, they will get a physician's order for the change. She stated if R7's care plan indicated Full Code, then the care plan was not updated to reflect the R7's new DNR order, and they did not catch the omission.

Based on review of facility policy, record review, interview, and observation, the facility failed to ensure a safe environment and failed to provide adequate supervision to prevent elopement for 1 of 5 residents reviewed for elopement risk (Resident (R)1), a cognitively impaired resident with dementia and an inactive wander guard in place. This failure allowed R1 to exit the facility unsupervised through an unlocked front entrance on 05/22/26. On 06/02/26 at 6:05 PM, the Administrator was provided a copy of the CMS Immediate Jeopardy (IJ) Template and notified that the facility had failed to prevent Resident (R)1's elopement which occurred on 05/22/26, creating a reasonable expectation that serious injury, harm, impairment, or death could have occurred, constituting IJ. The IJ was related to 42 CFR 483.12 - Quality of Care.The facility provided an acceptable plan for removal of the IJ on 06/02/26 at 7:34 PM. The survey team validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance, the SA is considering this IJ at Past Non Compliance as of 05/23/26.An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care.Findings include: Review of the facility's undated policy titled, Exit Seeking/Elopement Policy and Procedure identified, Definition of Elopement: Any resident who has left the building UNWITNESSED and is found to be past the RNC [Ridgeland Nursing Center] parameters. Parameters include: a. past the flower bed of the front door to the oak trees of hospital yard. b. past the fences at each end of the building to property line. c. past the dumpsters at the back of the building to the church yard. Review of R1's admission Records revealed she was admitted on [DATE], with diagnoses including but not limited to, intracerebral hemorrhage, dementia, mild protein calorie malnutrition, adjustment disorder with mixed anxiety and mood disorder. Review of R1's Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 05/12/26, revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating the resident was unable to complete the interview. Review of R1's record revealed a referral dated 05/11/26 from the hospital for long-term care placement due to increased confusion with orientation to self only, noting she was confused and restless at baseline. Review of R1's elopement risk evaluations dated 05/13/26 and 05/22/26 revealed scores of 8 and 14, respectively, indicating high risk for elopement. Review of R1's physician orders revealed an order for Wander Guard placement to the left ankle 05/13/26 with checks to be documented on each shift. Review of the R1's record did not identify routine Wander Guard checks every shift. Review of R1's care plan revealed a focus area, ELOPMENT: The resident is an elopement risk/wanderer r/t Disoriented to place, Impaired safety awareness, Resident wander aimlessly, with an initiation date of 05/12/26. Interventions included assess for fall risk, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, identify pattern of wandering, monitor for fatigue and weight loss, provide structured activities, and Wander Guard to left leg. There was no update to the care plan when 15-minute checks were implemented on 05/21/26 following identification the Wander Guard was not working, as indicated in the progress notes. A review of R1's care plan revealed a focus area, The resident has impaired cognitive function and impaired thought processes r/t Dementia, Impaired decision-making, Short-term memory loss, with an initiation date of 05/12/26. Interventions included medication and monitoring side effects and effectiveness, communication regarding resident capabilities and needs, communication, cues and reorientation, and a consistent routine. The facility complaint survey completed on 05/13/26 identified noncompliance regarding elopement. Review of the facility investigation included a timeline of the elopement, staff statements, and a document outlining R1's 15-minute checks as follows: Review of the facility documented titled, Resident Elopement Timeline - 5/22/2026, revealed, Approximately 5:00 AM. [Certified Nursing Assistant (CNA)EE] checked on resident [R1]. Resident was observed in her room asleep/in bed. [CNAGG] stated the resident was asleep in her room when morning rounds began around 5:50 AM. Approximately 6:00 AM. [Licensed Practical Nurse (LPN)AA] documented that the resident was last observed asleep in her room before beginning wound care on another resident. Approximately 6:15 AM. Staff were informed/called that the resident had been seen across the street near Polaris school. An officer was contacted/responded regarding the resident's location. 6:31 AM. DON [Director of Nursing] notified of resident elopement per nursing note documentation. Between 6:55-7:00 AM. One of the CNAs met with the responding officer to assist in securing the resident. Resident was safely returned to the facility by CNA and responding officer. Upon return to the facility. Nursing assessment completed by nurse. No adverse finding noted.7:00 AM Administrator and physician notified of elopement. Review of the police report from the Ridgeland Police Department dated 05/22/26 05:59:03 revealed, Incident. Incident Nature: Suspicious Person. Occurred From: 05/22/2026 05:58:44. Occurred To: 05/22/2026 05:59:08.Narratives. Supplemental Narrative 06/02/2026 14:41:38. On May 22, 2026, at approximately 0559 hours, [NAME] County Communications received a call from a school cafeteria employee reporting an unknown adult female on school property attempting to gain entry into the building prior to student arrival. The caller advised the female, described as a Black female wearing pink pajama pants and a gray/black tank top, was observed hiding in bushes near the school, pulling on exterior doors, looking through windows, and attempting to enter through the kitchen and main entrance doors. The caller stated the female did not appear to be a student and appeared to be older in age. Throughout the incident, the caller provided real-time updates on the female's movements around the campus. The female was observed entering and exiting through a front door area, walking around the building, checking windows, and repeatedly pulling on locked doors. Officers responded and made contact with the female. Based on the officer's observations, EMS was requested for an altered mental status evaluation at approximately 0616 hours. Further investigation revealed the female was identified as [R1], a resident of a local nursing facility. Contact was made with the nursing home, and staff initially believed Ms. [NAME] was in her room. After being advised she was located at the school, nursing home staff responded to meet with officers. The incident was resolved without reported injuries or criminal activity. EMS evaluated the subject, and appropriate arrangements were made with nursing home staff. Review of the document outlining R1's 15-minute checks revealed that the 15-minute checks began on 05/21/26 at 2:30 PM and continued every 15 minutes throughout the night and the morning of 05/22/26. The document revealed the resident was walking hallways between 2:30 PM 4:30 PM and again from 5:15 PM to 6:00 PM. R1 was noted to be sleeping between 6:15 PM and 9:00 PM with the exception of restroom documented at 7:30 PM. These timeframes did not have staff names or initials to identify who completed the checks. Licensed Practical Nurse (LPN)AA's documentation (identified by her initials) began with her documenting sleeping from 9:15 PM through 5:45 AM on 05/22/26. LPNAA then documented at 6:00 AM, Check (in room) on pt.before starting wound care [LPNAA initials]. Across the lines designated for 6:15 AM and 6:30 AM, were the words *Pt Eloped!!!* The line designated for 6:45 AM was blank. LPNAA documented Vitals check at 7:00 AM. The 15-minute checks continued to be documented through 05/23/26 at 6:15 AM despite the resident having been placed on one-on-one supervision on 05/22/26 between 7:00 AM and 7:59 AM. According to the police report, R1 could not have been at the facility at 6:00 AM as the facility documented on the 15-minute check log. During an observation on 06/02/26 revealed the distance from the facility's front door to the school parking lot was counted at approximately 100-120 steps, depending on the specific place/door of the school building. The distance from the front door to the highway was approximately 115-130 steps where a 55 mile-per-hour sign was observed to be posted. Review of a document titled Ad Hoc Quality Assurance & Performance Improvement Meeting, dated 5/22/2026 revealed, a column titled Opportunity for Improvement, contained, Resident exited the facility without staff knowledge. The second column titled Data., contained, Resident exited the facility without staff knowledge. The resident was able to exit out of the front lobby door without staff knowledge. The resident was returned to the facility 5/22/2026.the third column titled Analysis. contained, Based upon root cause analysis to include staff interviews and observation of the front lobby door, the resident was able to exit out the front lobby door without staff knowledge. r/t (related to) the below: Malfunction of the front lobby door. Resident not placed on 1:1 (one-to-one) supervision when Wander Guard malfunctioned. Q (every) 15 min (minute) checks. Wander guard door not receiving power from fire panel. Review of R1's progress note dated 05/18/26 at 2:44 PM revealed, Residents wandering around the unit all day long was able to re-direct for meals. There was no indication of staff interventions attempted besides mealtimes to address wandering. Review of R1's progress note dated 05/19/26 at 1:35 PM revealed, She continues to wander but can be redirected for meals. There was no indication of staff interventions attempted besides mealtimes to address wandering. Review of R1's progress note dated 05/19/26 at 3:03 PM revealed, Residents wandering around the unit all day long was able to re-direct for meals. There was no indication of staff interventions attempted besides mealtimes to address wandering. Review of R1's progress note titled, Orders - Administration Note, dated 05/21/26 at 2:30 PM revealed, WANDER GUARD to left ankle MONITOR/CHECK PLACEMENT QSHIFT every shift inactive, .15 minute monitoring initiated. Review of R1's progress note titled, Orders - Administration Note, dated 05/22/26 at 1:44 AM revealed, WANDER GUARD to left ankle MONITOR/CHECK PLACEMENT QSHIFT every shift Wander Guard inactive: 15 minute monitoring initiated. [LPNAA typed initials]. Review of a progress note titled, Nurses Note, dated 05/22/26 at 7:00 AM by the Director of Nursing (DON) revealed, Pt has been placed on 1 on 1 for exiting the center without staff knowledge. Review of a progress note titled, eINTERACT SBAR (Situation, Background, Assessment, and Recommendation) Summary for Providers, dated 05/22/26 at 7:21 AM revealed, The Change In Condition/s reported on this CIC (Change of Condition) Evaluation are/were: Other change in condition.Outcomes of Physical Assessment: Positive findings reported on the evaluation for this change in condition were:.Nursing observations, evaluation, and recommendations are: Pt (patient) exited building without staff being made aware through front door, pt (patient) was placed on 1 on 1, no changes noted. Primary Care Provider Feedback:.A. Recommendations: Pt (patient) need 1 on 1 sitter until further notice. Review of a progress note titled Nurses Note and dated 05/22/26 at 7:28 AM by LPNAA revealed, This nurse last observed the patient asleep in her room at around 0600am, before I started wound care on another patient. As I was wrapping up care on my wound patient, the CNA came to inform me that the patient had eloped and was across the street at the Polaris school and an officer had called to inform us of this information. One of the CNAs met with the officer to secure the patient, and they both returned the resident safely to the facility. Upon return to the facility, this nurse assessed the patient - no adverse findings.The DON notified of elopement at 6:55am. The Administrator and MD (medical doctor) notified of elopement at 7:11 am. The RP (responsible party) notified of elopement at 7:42 am. Care ongoing per patient's orders. The timeline documented by LPN AA does not match the elopement timeline documented and provided by the Administrator. Review of a progress note titled Nurse Note by LPNAA, dated 05/22/26 at 7:59 AM revealed, Per Administrator, patient will have 1:1 care. Review of an elopement reported dated 05/22/26 by the DON revealed, Staff was notified by Polaris elementary school's [NAME] [sic] (SRO) School Resource Officer) officer that pt has gotten out of facility without staff knowledge.Pt states she was ready to go.Pt has been placed on 1 on 1 until further notice . No injuries observed at time of incident. The boxes next to Oriented to person and Oriented to Place were checked. The boxes next to Confused and Impaired Memory were also checked. The box next to Sensor Alarm was in Place was checked. The report also included the date and times of notification made to the DON, the physician, the family member, and the administration, and by whom the notifications were made. Review of Certified Nurse Aide (CNA)GG's statement dated 05/22/26 revealed, I witness [sic] [R1] in her room sleep [sic] when I started my rounds at 4am. When I went to change my last resident, [R1] was still in her room at 5:50a. When I walked out the residents [sic] room to continue charting, the town called stating [R1] was across the street at Polaris with an officer (6:15 am). Resident was returned safely to the facility by CNA and officer. Review of CNAEE's statement dated 05/22/26 revealed, I [CNAGG] got check [sic] on [R1] at 5:00am before I started my round, she was in her room safe and sound. I continue [sic] giving patient care to my other residents as I was walking out the room to give care to my next resident my coworker then told me to go and get the nurse because the police was [sic] on the phone because [R1] was across the street at the school. Review of CNAKK's statement dated 05/22/26 revealed, I was in the middle of walking the premises when my coworker informed me of one of the residents escaped. I immediately tried to help any way I could, but my coworkers had it under control at that point in time. I returned to document my patrol. CNAKK said he had been performing fire watch duties. Review of R1's progress note titled, Orders - Administration Note, dated 05/23/26 at 1:44 PM revealed, WANDER GUARD to left ankle MONITOR/CHECK PLACEMENT QSHIFT every shift inactive, 15-minute monitoring in effect. This was following the order for one-on-one supervision. During an observation on 06/02/26 at 9:00 AM, the front door was observed to be unlocked. During an observation on 06/02/26 at 8:00 PM, the front door was observed to be locked, and a code was required to exit the facility. During an interview with the Administrator on 06/02/26 at 9:30 AM, he said, Yes, she got out and went next door to the school resource officer. When inquiring about the facility's investigation and other requested documents, he stated, They were so close together. We have combined all of the information for both elopements into this book, which was a red, three-ringed binder. He said that initially, the front door was on a timer that automatically locked them between the hours 7:00 PM and 7:00 AM. After R1's elopement, they changed the lock schedule from 7:00 PM to 8:00 AM, and he showed this surveyor the device to set the times within a panel near the front door. He stated that this was all related to the fire alarm system that had been dysfunctional since approximately October or November for which the facility had a plan in place and was performing 24-hour fire watch monitoring. He further stated that he had personally checked the door before he left on 05/21/26. Review of the Ridgeland Nursing Center Exit Door Daily Log indicated, If the doors are not locked at anytime (sic) ACTION needs to be taken immediately and report to the Administrator. The log identified eight exit doors throughout the facility to be checked, including the Front Exit Door. There were columns that were to be completed for each door: Date; Time Checked; Locked (to be marked if true); Not Locked (to be marked if true); Name Print; and Signature. On the document dated 05/21/26, there were check marks for all doors except the Front Exit Door at 10:00 AM. The front door was not check-marked. The other doors check-marked by the Administrator failed to identify whether the door was locked or unlocked and did not print or sign their name in the corresponding columns, rather the Administrator and the DON initialed/signed below the check marks. The document dated 06/02/26 at 7:00 AM revealed all doors were check-marked locked and signed by the Maintenance Director with a note, All doors are locked. Front entry door & exit door by laundry Wonder [sic] guard not working on these (2) doors. Several documents dated 05/10/26 through 05/22/26 revealed that the front door was check-marked locked during times it was scheduled to be unlocked (7:00 AM to 7:00 PM) and, on each document, all eight (8) doors were check-marked as being checked at the same time. Several documents dated 05/23/26 through 06/02/26 revealed that the front door was check-marked locked during times it was scheduled to be unlocked (8:00 AM to 7:00 PM) and, on each document, all eight (8) doors were check-marked as being checked at the same time. During an interview with R1's family on 06/02/26 at 2:29 PM revealed, The facility has no safety protocols. She said that they had recently updated and added door locks and . they don't have people at the front (entrance) and are short-staffed. No one is at the main entrance, the front, and said any random person can enter. During an interview with CNAGG on 06/02/26 at 3:37 PM, she said she was on duty the night of 05/21/26 through the morning of 05/22/26, during the 11 PM to 7 AM shift along with CNAEE and LPNAA, stating, [CNAEE] was assigned to [R1]. She said she was not assigned to R1 during the shift, but that she checked on R1 at 5:50 AM on behalf of CNAEE. CNAGG stated that she answered the phone at approximately 6:00 AM and discovered that R1 was with the officer at the school next to the facility. CNAGG informed the nurse immediately who was providing wound care to another resident. CNAGG said R1 had been on 15-minute checks because the Wander Guard was not working. R1 had been asleep the entire night and had not exhibited any signs of wandering or elopement. CNAGG was then sent over to retrieve R1 from the officer which took a little while. When she and R1 returned, R1 was immediately placed on one-to-one supervision. During an interview with CNAEE on 06/02/26 at 4:35 PM, revealed she was on duty and assigned to R1 on the night of 05/21/26 through the morning of 05/22/26, during the 11 PM to 7 AM shift. She said she documented 15-minute checks throughout the night because R1's Wander Guard was not working. She said she had begun her 5 AM rounds, and I documented she was in bed at 5:50 AM. During an interview with the Administrator on 06/02/26 at 6:30 PM, he stated, I was not aware that the fire alarm was causing issues or lack of power to the Wander Guard doors. As we tested them prior to, they were working appropriately as evidenced by me checking personally. These checks were on the logs from 05/10/26 through 5/21/26, prior to [R1's] elopement. If the facility had been aware this was an issue, a guard would have been placed at the door to ensure the safety of the residents as was placed when facility became aware. Referring to both elopement events (05/13/26 and 05/22/26) and asked about other sources of supervision aside from the Wander Guard devices, the Administrator stated, They were two totally separate issues. The initial plan included assessing residents for elopement risk and implementing a plan to prevent elopements based upon their assessment outcomes which were completed. The resident on the second elopement risk had already been identified as an elopement risk. Her elopement occurred as the result of a mechanical failure. She had interventions in place already to include the Wander Guard and q15 checks. In all assessments, the facility for elopement risk goes through the interdisciplinary team which provides interventions that are least-to-most restrictive, if warranted by the resident's medical condition and under the direction of the physician. In her situation, we did that. The team met, determined the least restrictive safety prevention measure for the resident to include being placed on one-to-one as the final measure. During an interview with LPNAA on 06/03/26 at 7:55 AM, revealed CNAEE had been assigned to R1's care throughout the night and that she and CNAGG alternated checking on R1 throughout the night as well. Just before LPNAA completed her check, CNAGG had completed a check of the resident. LPNAA performed a check of the resident just before 6:00 AM on 05/22/26. During both checks, the resident was noted to be in bed and asleep. LPNAA then went to another resident's room to provide wound care. CNAEE then entered the room of the resident for whom LPNAA was providing wound care and notified R1 had been found at the school. LPNAA stated she had no responsibility to complete door alarm checks, but that Wander Guard checks are performed each shift. She had learned from the nurse on the previous shift that R1's Wander Guard was not working, and that was the reason she was on 15-minute checks. She did not know why the Wander Guard was not working, but it was still not working at the beginning of her shift. During an interview with the school resource officer on 06/03/26 at 2:49 PM, he stated he had received a call from his dispatch that a woman was trying to enter the school building. Dispatch had received a call from a worker inside the school building. The officer then contacted R1 and was able to determine she had eloped from the facility next to the school, and he contacted the facility to inform them of her being in his custody until they could retrieve her.On 06/02/26 at 7:34 PM, the facility provided an acceptable plan for removal of the IJ, which included the following:Criteria One:1. The identified resident exited the center 5/22/2026 without staff knowledge through the front door was not locked. Resident returned safely by staff and Law Enforcement and placed on 1:1 supervision 5/22/2026 at 7am.2. Change in Condition completed on 5/22/2026.3. Skin assessment completed on 5/22/2026.4. Pain assessment completed on 5/22/2026.5. Risk Management completed on 5/22/2026.6. Psych Services consulted on 5/22/2026.7. Physician notified on 5/22/2026 8. Responsible party notified on 5/22/2026 .Criteria Two:9. A staff member assigned to sit at front door 24/7 started 5/22/2026. Removed on 05/31/2026.10. Front door assessed by outside vendor on 5/22/2026. The Dietary Door is repaired as of 05/27/2026 .11. Identified resident's elopement risk assessment updated on 5/22/2026.12. The dietary exit door to the outside was not working properly and repaired by . on 05/24/2026. Education to the dietary staff on 05/22/2026 by the Maintenance Director.13. The Front door auto lock was changed . on 05/27/2026 from 7p-7a to 7p to 8am. Administrator and DON checked all wander guard doors, and all are locked down correctly. Checked 06/01/2026 and 06/002/2026 [sic] .14. Identified resident's elopement risk care plan was updated to include 1:1 supervision 5/22/2026 15. 100% of all current residents were reassessed for risk of elopement completed on 5/22/2026 16. CPs and orders reviewed and current for residents at risk for elopement as of 5/22/2026 .17. 100% facility head count of current residents completed immediately . All resident are present.18. A second facility wide head count of current residents completed on 5/22/2026. All residents are present.19. Residents who identified at risk for elopement wander guards were checked for placement and function by Director of Nursing on 5/22/2026 Criteria Three:20. Maintenance to check all doors to ensure proper functioning to be completed by 5/22/2026 .21. A licensed nurse to complete a head count of all residents upon arrival and before leaving five times a week . initiated 5/22/2026.22. Maintenance to check all facility doors to ensure proper functioning twice a day x 3 days initiated 5/22/2026 .23. Maintenance/designee to check all facility doors to ensure proper functioning 7 days per week initiated 5/25/2026 24. VP of Clinical Services completed education with Director of Nursing and Executive Director r/t the Elopement policy .25. Facility education for current staff r/t the Elopement policy . initiated 5/22/2026. Staff reeducation began on elopement on 06/02/2026.26. Ad hoc QAPI meeting with the CNO and IDT team to review Safety Plan to be completed 5/26/2026 .27. Ad hoc QAPI Meeting to include a Root Cause Analyses with IDT team . to be completed 05/22/26 .28. Facility to conduct Code Orange Drills daily x 5 days . initiated 05/22/26 . 87 out of 87 employees. Empeon Blast has been sent for Fire Watch and Elopement 29. Facility to conduct unannounced drills 3 x a week . initiated 05/22/2026 . 30. Residents at risk for elopement have names and photos in a binder at the reception desk and nursing stations are at 100% as of 5/22/2026.31. Staff education on elopement and missing residents to be completed annually and upon hire .32. Resident Council Meeting held to . 05/25/2026.33. Residents to be evaluated for risk of elopement upon admission, re-admission, and/or significant change. 34. Staff completing fire watch re-educated on how to identify a nonfunctioning door and report it to the ED . re-educated 5/22/2026 .35. Immediate Federal Reporting completed 05/23/2026 .36. Timeline of events 05/23/26 . Approximately 6:15AM Staff were informed/called that the resident had been seen across the street .37. Staff interviews initiated 05/23/2026 .Criteria Four:38. The results of the quality checks will be reviewed with the QAPI Committee Monthly for further follow up and recommendations as indicated.39. Date of Correction for the Immediate Plan Correction is May 23, 2026.

Based on review of facility policy, record review and interview, the facility failed to develop and implement approaches to maintain a Quality Assurance and Performance Improvement (QAPI) program to prevent repeat deficiencies. Cross Reference F689Findings include: Review of the Summary Statement of Deficiencies, for a complaint survey on 05/13/26, indicated the facility was cited at Immediate Jeopardy-F689 when a resident eloped from the facility. Review of facility policy dated 08/01/23 and titled, Policies and Procedures. Subject: Quality Assurance Performance Improvement Program (QAPI), revealed, . Leadership: The Center Executive Director is accountable for the overall implementation and functioning of the QAPI program. This includes but is not limited to: a) implementation b) identifying priorities c) Ensure adequate resources d) Ensures performance indicators, resident and staff input and other information is used to prioritize problems and opportunities e) ensure corrective actions are implemented to address identified problem in systems f) evaluates the effectiveness of actions g) Establishes expectations for safety, quality, rights, and choice and respect. 4. The program is a coordinated effort among departments and services within the organization that involves leadership working with input from Center staff, residents, and families.Data Collection Systems and Monitoring: The center will collect and monitor data from different departments reflecting its performance. The center will identify data sources and timeframe for collection.13. The center will review and develop corrective actions on medical Errors and adverse Events.Identifying Quality Deficiencies and Corrective Action: The center will monitor department performance systems to identify issues or adverse events. 15. If a quality deficiency is identified, the committee will oversee the development of corrective action(s). Review of facility policy dated 10/14/25 and titled, Elopement - Wandering Risk, revealed, Policy: To evaluate and identify residents that are at risk for elopement and develop individualized interventions. Procedure: . (10). Review trends of elopement drills by the QAPI team as indicated. Review of the facility policy dated 04/24/25 titled, Incidents and Accidents, revealed, Definitions: Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. An incident is defined as an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization. This can involve a visitor, vendor, or staff member. Policy Explanation: The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented; corrective actions are taken to prevent recurrences and improve the management of resident care. Conducting root cause analysis to ascertain causative/contributing factors as part of the Quality Assurance Performance Improvement (QAPI) to avoid further occurrences. Alert risk management and/or administration of occurrences that could result in claims or further reporting requirements. Meeting regulatory requirements for analysis and reporting of incidents and accidents. Review of a 24-page untitled documented identified by the Administrator as all the QAPI meeting minutes related to the elopements, the header section of the document revealed, Center Stabilization Plan Last Updated: 05/18/2026 Center: Ridgeland Nursing and Rehabilitation Center, LLC. SFF . No. Last Annual Survey: May 2025. The body of the document revealed, Weekly ADHOC Mtg (meeting) on Tuesdays Full QAPI Review 03/31/2026, 04/28/2026, 05/12/2026, with columns labeled, Item/Goal. Action. Person. Target Date. Follow Up. Comment. There are headings for each topic as follows: Operations and Clinical. Administration. Business Office. Admissions. Clinical. Medical Records. MDS. Pharmacy. Therapy. Grievances. HR. Education. Social Services / Activities. Physical Plant - Maintenance. Housekeeping / Laundry. Dining Services. Within the section Operations and Clinical, the Item/Goal: G+ Citations: indicated Action: F696 [sic] Accidents hazards Abated 5/13 (05/13/26) Lowered to a D (scope and severity rating) Contained in the section titled, Physical Plant - Maintenance, the item/goal identified as Elopement Drills identified the action as Elopement Drills have been conducted by the Nursing administration since I have been at RNC (Ridgeland Nursing Center) with the person identified as [DON], and target dates listed as 04/16/2026 and 05/18/2026. In the Follow Up column, there is a statement, Day shift 05/10/2026 Safety Plan Drills. Without additional documentation of any elopement drills completed. The section FRI (Facility Reported Incidents)/Incidents included in the Action column reference to actions taken following the 05/22/26 elopement. There was no action dates related to elopement correction or improvement activities with dates of initiation prior to 05/22/26. The QAPI documentation failed to include any evidence of a comprehensive focus on development, implementation, evaluation of corrective actions or performance improvement activities following the complaint survey on 05/13/26 which identified Immediate Jeopardy cited at F689 related to the elopement of a resident. Review of a document titled Ad Hoc Quality Assurance & Performance Improvement Meeting, dated 5/22/2026 revealed a column titled Opportunity for Improvement, contained, Resident exited the facility without staff knowledge. The second column titled Data., contained, Resident exited the facility without staff knowledge. The resident was able to exit out the front lobby door without staff knowledge. The resident was returned to the facility 5/22/2026. The third column titled Analysis. contained, Based upon root cause analysis to include staff interviews and observation of the front lobby door the resident was able to exit out the front lobby door without staff knowledge. r/t the below: Malfunction of the front lobby door. Resident not placed on 1:1 supervision when wander guard malfunctioned. Q15 min checks. Wander guard door not receiving power from fire panel. The fourth column titled Plan contained, See attached safety plan initiated 5/22/2026. Resident returned without injury and placed on 1:1 supervision. The fifth and final column titled Responsible Team Member(s), contained, ED (Executive Director), DON, MDS (Minimum Data Set Coordinator), Social Services, Maint. (Maintenance) Director, Activities team, Dietary. Review of an undated document titled, Best Practices. Elopement/Wandering Risk, revealed, . Elopement Drills: Schedule monthly (include different shifts, weekends, and holidays) to include all shifts quarterly. Scheduled drills at unannounced times. Activate the door alarm during a drill and observe staff responsiveness. Sign in sheet with date/shift and staff signatures to document who participated in drills. Review results of Drills during monthly QAPI meeting. A request was made to the Administrator on 06/02/26 for copies of the facility's elopement drills. The facility failed to provide documentation or evidence that elopement training or drills were conducted monthly, on varying shifts, following the first elopement on 05/10/26 and prior to the second elopement on 05/22/26. The only drill records provided were completed after the elopement of Resident (R)1 on 05/22/26, with dates of 05/22/26 at 12:00 PM and 05/25/26 at 8:00 AM. Neither of these drills were conducted on varying shifts. Review of a document titled, Urgent Response to Missing Persons Checklist, had handwritten words, Elopement Drill #2 8AM 5/25/26. The checklist included checkmarks on each of the following seven (7) items on the list: Immediately assign staff to search center including the outside. Obtain the patient / resident's Elopement Risk Sheet. Designate one point person (usually Charge Nurse or supervisor in the absence of the ED or DON). Complete a head count of all other patients / residents in the Center. Point Person to contact the ED, DON, Physician, and Responsible Party. ED or DON to notify local law enforcement after discussion with CEO / CNO. ED or DON to notify the CEO / CNO. There were associated documents titled Education In-Service Attendance Record, revealing the same date and time, Conducted by [DON]. Topic: Elopement Drill/inservice [sic]. Mock drill #2 @ 8:00 AM. This was a 2-page document containing the names of the participants. Review of the same checklist dated 05/22/26 at 12:00 PM was also made with marks on each of the seven (7) items on the list. There were associated documents titled Education In-Service Attendance Record, revealing the same date and no time, Conducted by [DON]. Topic: Elopement. This was a 3-page document containing the names of the staff trained. Review of a document titled Education In-Service Attendance Record, dated 5/22/26, conducted by Registered Nurse (RN). Handwritten words, Mock drill 12PM and what appear to be initials, were also written on the document. Topic: Elopement Drill Process / Missing resident process. 1. Code Orange = missing resident. 2. ED and DON are to be contacted immediately upon initiation of a code orange. 3. Code orange and room location are paged 3 times when a resident is identified as missing. 4. Staff should report to the nursing station of the missing resident. 5. The licensed nurse assigned to that resident is the lead during the drill and/or actual missing resident response. 6. The licensed nurse will get the elopement binder, remove the search grid sheet and assign staff areas to begin looking for the missing resident. 7. When the resident is located staff are to return the resident to the assigned nurse for evaluation and further reporting / documentation process per regulation. 8. Code orange all clear is then called 3 times to alert staff the missing resident has been located. During an interview with the Administrator on 06/02/26 at 9:30 AM, referring to the initial request for documents, he stated, They were so close together, we have combined all of the information for both elopements in this book, which was a red, three-ringed binder presented in response to the initial document requests. During an interview and observation with the Administrator on 06/02/26 at 11:00 AM, revealed the facility has been having issues with the fire alarm panel since November 2025, and they have been utilizing fire watch to ensure safety until the entire system can be replaced. He said that fire watch consisted of an assigned staff walking around building and monitoring for signs of fire 24 hours per day and 7 days per week. This is and will be ongoing until the state removes it. He said pull tabs are, hit and miss when they work. When asked if he knew this issue had the potential to impact the Wander Guard system, he said, No. I thought it was a completely separate system. And I know it is now. During an interview with R1's family on 06/02/26 at 2:29 PM revealed she is a nurse, and she stated, The facility has no safety protocols. They recently updated and added locks but the don't have people and the front and are short-staffed. She said no one is at the main entrance, the front, and said any random person can enter. During an interview with the Administrator on 06/02/26 at 6:14 PM revealed that one would know individual Wander Guard devices were not working if a red light was not found to be flashing when checked. He said that the doors are checked with a Wander Guard/AccuTech test device daily, starting on 05/10/26. The failure of the door alarm system as related to the Wander Guard device was discovered when the technician came to inspect the system on 05/22/26 (following R1's elopement). It is not currently in policy but is in the Quality Assurance (QA) tool that was created following the recent previous elopement and has been trained on. He said there are no parameters identified on an elopement risk assessment to indicate which interventions to place according to the score of the assessment, that each intervention is determined by the IDT. When asked about resident supervision and there being two incidents of elopement in a 12-day period, the Administrator said, They were two totally separate issues. The initial plan included assessing residents for elopement risk and then implementing a plan to prevent elopements based upon their assessment outcomes which was completed for both residents. [R1] had already been identified as an elopement risk. Her elopement occurred as a result of a mechanical failure. She had interventions in place already to include the Wander Guard and 15-minute checks. In all assessments, the IDT provides interventions that are least restrictive to the most restrictive. If warranted by the resident medical condition under the direction of the physician, and in this situation, we did that. (However, they admitted the 15-minute checks were not appropriate, and the resident should have been on 1:1 as this contributed to the cause of the elopement, along with an unlocked front door.) The team met, determined the least restrictive safety prevention measure for the resident to include one-to-one as the final measure. I was not aware that the fire alarm was causing issues or lack of power to the Wander Guard system on the doors. If the facility had been aware this was an issue, a guard would have been placed at the door to ensure the safety of the residents as was placed when the facility became aware.

Based on record review and interview, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee included active and meaningful participation by the Medical Director in the facility's Quality Assurance and Performance Improvement (QAPI) program. This had the potential to affect all residents in the facility. Findings include: Review of facility policy dated 08/01/23 and titled, Policies and Procedures. Subject: Quality Assurance Performance Improvement Program (QAPI), revealed, . 6. QAA Committee members include but are not limited to: . b) Medical Director / designee . Review of the facility document titled, Quality Assessment Performance Improvement, dated 05/27/26 at 2:11 PM, identified a pre-populated list of mandatory committee members. Under the column titled Name, next to the pre-populated title Medical Director, the handwritten notation VIA Phone Text was documented. However, on the adjacent column designated for Signature, a handwritten signature was present on the Medical Director's line, creating a conflicting record regarding the Medical Director's actual physical presence and participation in the meeting. The lack of active governance was evidenced by a review of the document titled Ridgeland Safety Plan-Missing Resident. The record indicated the plan was initially implemented on 05/22/26 following a resident elopement; however, a handwritten notation at the top of the page stated, ADHOC QAPI. [Name of Medical Director] Notified of [triangle symbol representing changes] 5/27/26 @ (at) 2:18 PM. This timeline demonstrates that the facility operated a safety plan for five days without the Medical Director's input. The 2:18 PM notification time documented on this document compared with the 2:11 PM QAPI meeting document's start time confirms that the Medical Director was sent an after-the-fact text message summarizing pre-determined revisions, rather than actively participating in the development and approval of the QAPI process. There was no evidence presented to indicate that the Medical Director engaged in meaningful participation in the QAPI/QAA meetings.

Based on review of facility policy, interview, observation, and record review, the facility neglected to provide a safe environment and adequate supervision to protect residents from elopement, when they failed to monitor a known elopement risk for Resident (R)1, failed to update the comprehensive care plan with targeted intervention;, failed to provide adequate supervision when the resident's Wander Guard system was inactive; failed to conduct monthly elopement drills per facility policy; failed to verify door locks per protocols; and failed to develop and implement a performance improvement plan following an actual elopement on 05/13/26. The facility's neglect to provide these services resulted in 1 of 5 sampled residents (R1), who exhibited known wandering behaviors, eloping from the facility unsupervised on 05/22/26. Findings include: Review of the Summary Statement of Deficiencies, for a Complaint Survey on 05/13/26, indicated the facility was cited at Immediate Jeopardy-F689 when a resident eloped from the facility. Review of the facility's undated policy titled, Abuse/Neglect Policy & Procedure revealed, Policy. It is the policy of this facility that Abuse/Neglect . will not be tolerated. This includes residents, employees, . Procedure . c) appropriate and sufficient supervision to ensure that staff are able and are meeting the needs of residents with behavior problems, and those who need special care in areas of assistance in ADL's, etc.; d) ensure that the assessment care planning and monitoring of all resident care, especially those with specific behavior problems, is current and appropriate and is being utilized. Procedures were identified as screening, training, prevention, identification, investigation, protection, and reporting responses, but did not include a definition of neglect. Review of the facility's undated policy titled, Exit Seeking/Elopement Policy and Procedure identified, Definition of Elopement: Any resident who has left the building UNWITNESSED and is found to be past the RNC [Ridgeland Nursing Center] parameters. Parameters include: a. past the flower bed of the front door to the oak trees of hospital yard. b. past the fences at each end of the building to property line. c. past the dumpsters at the back of the building to the church yard. Review of the police report from the Ridgeland Police Department dated 05/22/2026 at 5:59:03 revealed, Incident. Incident Nature: Suspicious Person. Occurred From: 05/22/2026 05:58:44. Occurred To: 05/22/2026 05:59:08 . Contact: . Supplemental Narrative 06/02/2026 14:41:38. On May 22, 2026, at approximately 0559 hours, [NAME] County Communications received a call from a school cafeteria employee reporting an unknown adult female on school property attempting to gain entry into the building prior to student arrival. The caller advised the female, described as a Black female wearing pink pajama pants and a gray/black tank top, was observed hiding in bushes near the school, pulling on exterior doors, looking through windows, and attempting to enter through the kitchen and main entrance doors. The caller stated the female did not appear to be a student and appeared to be older in age. Throughout the incident, the caller provided real-time updates on the female's movements around the campus. The female was observed entering and exiting through a front door area, walking around the building, checking windows, and repeatedly pulling on locked doors. Officers responded and made contact with the female. Based on the officer's observations, EMS was requested for an altered mental status evaluation at approximately 0616 hours. Further investigation revealed the female was identified as [R1], a resident of a local nursing facility. Contact was made with the nursing home, and staff initially believed [R1] was in her room. After being advised she was located at the school, nursing home staff responded to meet with officers. The incident was resolved without reported injuries or criminal activity. EMS evaluated the subject, and appropriate arrangements were made with nursing home staff .Review of a document titled Ad Hoc Quality Assurance & Performance Improvement Meeting, dated 5/22/2026 revealed, . the third column titled Analysis . indicated, Based upon root cause analysis to include staff interviews and observation of the front lobby door, the resident was able to exit out the front lobby door without staff knowledge. r/t (related to) the below: Malfunction of the front lobby door. Resident not placed on 1:1 (one-to-one) supervision when Wander Guard malfunctioned. Q (every) 15 min (minute) checks. Wander guard door not receiving power from fire panel . Review of Certified Nursing Assistant (CNA)GG's statement dated 05/22/26, revealed, I witness [R1] in her room sleep when I started my rounds at 4 am. When I went to change my last resident, [R1] was still in her room at 5:50a. When I walked out the residents [sic] room to continue charting, the town called stating [R1] was across the street at Polaris with an officer (6:15 am). Resident was returned safely to the facility by CNA and officer. Review of CNAEE's statement dated 05/22/26 revealed, I [CNAGG] got check [sic] on [R1] at 5:00am before I started my round, she was in her room safe and sound. [sic] I continue giving patient care to my other residents as I was walking out the room to give care to my next resident my coworker then told me to go and get the nurse because the police was on the phone because [R1] was across the street at the school. [sic] Review of CNAKK's statement dated 05/22/26 revealed, I was in the middle of walking the premises when my coworker informed me of one of the residents escaped. [sic] I immediately tried to help any way I could, but my coworkers had it under control at that point in time. I returned to document my patrol. CNAKK said he had been performing fire watch duties. Review of the untitled document outlining R1's 15-minute checks revealed that the 15-minute checks began on 05/21/26 at 2:30 PM and continued every 15 minutes throughout the night and the morning of 05/22/26. Specifically, Licensed Practical Nurse (LPN)AA documented on 05/22/26 at 5:30 AM, and 5:45 AM, that R1 was sleeping in bed. The document indicated at 0600, Check on pt (patient) .before starting wound care. The document indicated, *Pt (patient) Eloped!!! for the times of 6:15 AM through 6:45 AM. LPNAA documented Vitals check at 7:00 AM. According to the police report, R1 could not have been at the facility at 6:00 AM. Review of R1's admission records revealed she was admitted on [DATE], with diagnoses including but not limited to, intracerebral hemorrhage, dementia, mild protein calorie malnutrition, adjustment disorder with mixed anxiety and mood disorder. Review of R1's Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 05/12/26, revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating the resident was unable to complete the interview. Review of R1's record revealed a referral dated 05/11/26 from the hospital for long-term care placement due to increased confusion with orientation to self only, noting she was confused and restless at baseline. R1's progress notes were reviewed and indicated the following: On 05/18/26 at 2:44 PM, Residents (sic) wandering around all day long was able to re-direct for meals. There was no indication of staff interventions attempted besides mealtimes to address wandering. On 05/19/2026 at 1:35 PM, She continues to wander but can be redirected for meals. There was no indication of staff interventions attempted besides mealtimes to address wandering. On 05/19/26 at 3:03 PM, Residents (sic) wandering around unit all day long was able to re-direct for meals. There was no indication of staff interventions attempted besides mealtimes to address wandering. On 05/21/26 at 2:30 PM, Wander Guard to L (left) ankle monitor/check placement Q shift inactive .15-minute monitoring initiated. On 05/22/26 at 1:44 AM, Wander Guard check, inactive 15-minute monitoring initiated. On 05/22/26 at 7:00 AM, placed on 1:1 for exiting the center without staff knowledge. Review of R1's Care Plan revealed a focus area, ELOPMENT: The resident is an elopement risk/wanderer r/t (related to) Disoriented to place, Impaired safety awareness, Resident wander aimlessly, with an initiation date of 05/12/26. Interventions included assess for fall risk, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, identify pattern of wandering, monitor for fatigue and weight loss, provide structured activities, and Wander Guard to left leg. There was no update to the care plan when 15-minute checks were implemented on 05/21/26 following identification the Wander Guard was not working, as indicated in the progress notes. Review of R1's Elopement Risk Evaluations dated 05/13/26 and 05/22/26, revealed scores of 8 and 14, respectively, indicating high risk for elopement. Review of R1's Physician Orders revealed an order for Wander Guard placement to the left ankle 05/13/26 with checks to be documented on each shift. Review of the R1's record did not identify routine Wander Guard checks every shift. Review of R1's Care Plan revealed a focus area, The resident has impaired cognitive function and impaired thought processes r/t Dementia, Impaired decision-making, Short-term memory loss, with an initiation date of 05/12/26. Interventions included medication and monitoring for side effects and effectiveness, communicate regarding resident capabilities and needs, communication, cues and reorientation, and a consistent routine. During an interview and observation with the Administrator on 06/02/26 at 10:00 AM, he stated, Yes, she got out and went next door to the school resource officer. An observation from the front door to the school parking lot revealed a count of approximately 100-120 steps, depending on the specific place/door of the school building and approximately 115-130 steps to the highway where a 55 mile-per-hour sign was posted. During an interview and observation with the Administrator on 06/02/26 at 11:00 AM, revealed the facility has been having issues with the fire alarm panel since November 2025, and they have been utilizing fire watch to ensure safety until the entire system can be replaced. He said that fire watch consisted of an assigned staff walking around building and monitoring for signs of fire 24 hours per day and 7 days per week. This is and will be ongoing until the state removes it. He said pull tabs are, hit and miss when they work. When asked if he knew this issue had the potential to impact the Wander Guard system, he said, No. I thought it was a completely separate system. And I know it is now. He said the Wander Guard devices are checked for each resident every shift, and the Wander Guard system is checked at the doors daily, every 24 hours. He said the doors had been checked and were all working at 6:00 PM on 05/21/26. He said when the Wander Guard device was checked on 05/21/26 and noted to not be working, the resident was placed on 15-minute checks. When asked if the Wander Guard system should be checked more frequently, he said, No. The daily door checks are placed on a log, and the individual residents' devices are checked each shift. Review of the Ridgeland Nursing Center Exit Door Daily Log indicated, If the doors are not locked at anytime (sic) ACTION needs to be taken immediately and report to the Administrator. The log identified eight exit doors throughout the facility to be checked, including the Front Exit Door. There were columns that were to be completed for each door: Date; Time Checked; Locked (to be marked if true); Not Locked (to be marked if true); Name Print; and Signature. On the document dated 05/21/26, there were check marks for all doors except the Front Exit Door at 10:00 AM. The front door was not check-marked. The other doors check-marked by the Administrator failed to identify whether the door was locked or unlocked and did not print or sign their name in the corresponding columns, rather the Administrator and the DON initialed/signed below the check marks. Review of the facility's Center Stabilization Plan Last updated 05/18/2026, revealed Center: Ridgeland Nursing and Rehabilitation Center, LLC. Last Annual Survey: May 2025. The body of the document revealed, Weekly ADHOC Mtg (meeting) on Tuesdays Full QAPI Review 03/31/2026, 04/28/2026, 05/12/2026, with columns labeled, Item/Goal. Action. Person. Target Date. Follow Up. Comment. There are headings for each topic as follows: Operations and Clinical. Administration. Business Office. Admissions. Clinical. Medical Records. MDS. Pharmacy. Therapy. Grievances. HR. Education. Social Services / Activities. Physical Plant - Maintenance. Housekeeping / Laundry. Dining Services. The facility's QAPI Program was reviewed and identified there was no performance improvement initiative developed and implemented following the complaint survey on 05/13/26 to ensure correction and monitoring to prevent future noncompliance with elopement at the facility. During an interview with R1's family on 06/02/26 at 2:29 PM, revealed she is a nurse, and she stated, The facility has no safety protocols. They recently updated and added locks, but they don't have people at the front (entrance) and are short-staffed. She said, No one is at the main entrance, the front, any random person can enter. She offered that she did not agree with the resident being transferred to a different facility, stating, they don't want the liability, and citing that R1's mother had lived at the facility and had dementia as well. She requested to speak with the DON. During an interview CNAGG on 06/02/26 at 3:37 PM, she said she was on duty the night of 05/21/26 through the morning of 05/22/26, during the 11 PM to 7 AM shift along with CNAEE and LPNAA, stating, [CNAEE] was assigned to [R1]. She said she was not assigned to R1 during the shift, but that she checked on R1 at 5:50 AM on behalf of CNAEE. CNAGG stated that she answered the phone at approximately 6:00 AM discovered that R1 was with the officer at the school next to the facility. CNAGG informed the nurse immediately who was providing wound care to another resident. CNAGG said R1 had been on 15-minute checks because the Wander Guard was not working. R1 had been asleep the entire night and had not exhibited any signs of wandering or elopement. CNAGG was then sent over to retrieve R1 from the officer which took a little while. When she and R1 returned, R1 was immediately placed on one-to-one supervision. During an interview with CNAEE on 06/02/26 at 4:35 PM, revealed she was on duty and assigned to R1 on the night of 05/21/26 through the morning of 05/22/26, during the 11 PM to 7 AM shift. She said she documented 15-minute checks throughout the night because R1's Wander Guard was not working. She said she had begun her 5 AM rounds, and I documented she was in bed at 5:50 AM. During an interview with LPNAA on 06/03/26 at 7:55 AM, revealed CNAEE had been assigned to R1's care throughout the night and that she and CNAGG alternated checking on R1 throughout the night as well. Just before LPNAA completed her check, CNAGG had completed a check of the resident. LPNAA performed a check of the resident just before 6:00 AM on 05/22/26. During both checks, the resident was noted to be in bed and asleep. LPNAA then went to another resident's room to provide wound care. CNAEE then entered the room of the resident for whom LPNAA was providing wound care, and notified R1 had been found at the school. LPNAA stated she had no responsibility to complete door alarm checks but that Wander Guard checks are performed each shift. She had learned from the nurse on the previous shift that R1's Wander Guard was not working, and that was the reason she was on 15-minute checks. She did not know why the Wander Guard was not working, but it was still not working at the beginning of her shift. During an interview with the Administrator on 06/02/26 at 6:14 PM, revealed that one would know individual Wander Guard devices were not working if a red light was not found to be flashing when checked. He said that the doors are checked with a test Wander Guard device daily, starting on 05/10/26. The failure of the door alarm system as related to the Wander Guard device was discovered when the technician came to inspect the system on 05/22/26. It was not currently in a policy, but was in the Quality Assurance (QA) tool put into place recently and had been trained on. He said there were no parameters identified on an elopement risk assessment to indicate which interventions to place according to the score of the assessment, that each intervention was determined by the IDT. When asked about resident supervision and there being two incidents of elopement in a 12-day period, the Administrator said, They were two totally separate issues. The initial plan included assessing residents for elopement risk and then implement a plan to prevent elopements based upon their assessment outcomes which was completed for both residents. [R1] had already been identified as an elopement risk. Her elopement occurred as the result of a mechanical failure. She had interventions in place already to include the Wander Guard and 15-minute checks. In all assessments, the IDT provides interventions that are least restrictive to the most restrictive. If warranted by the resident medical condition under the direction of the physician, and in this situation, we did that. The team met, determined the least restrictive safety prevention measure of the resident to include one-to-one as the final measure. I was not aware that the fire alarm was causing issues or lack of power to the Wander Guard system on the doors. As we tested them prior to [R1's elopement on 05/22/26], they were working appropriately as evidenced by me personally checking them daily, and they are on the logs between 05/10/26 through 05/21/26. If the facility had been aware this was an issue, a guard would have been placed at the door to ensure the safety of the residents as was placed when facility became aware. There was no record or log provided by the facility to indicate specific testing of the Wander Guard system daily. Review of the Ridgeland Nursing Center Exit Door Daily Log identified areas for staff to document whether eight exit doors were locked or unlocked. There was no area on the log directing staff to test and evaluate Wander Guard functionality, nor was there a column for this to be documented. During an interview with the school resource officer on 06/03/26 at 2:49 PM, he stated he had received a call from his dispatch that a woman was trying to enter the building. Dispatch had received the call from a worker inside the school building. The officer then made contact with R1 and was able to determine she had eloped from the facility next to the school, and he contacted the facility to inform them of her being in his custody until they could retrieve her. He added that he did not see R1 leave the facility, no one was following her and that he did not know how long she had been out of the facility.

Based on review of the facility policy, interview, observation, and record review, the facility failed to ensure Resident (R)5 was adequately supervised to prevent him from eloping on 05/10/26 between 8:45 AM- 9:15 AM, for 1 of 3 residents reviewed for elopement. On 05/10/26 between 8:45 AM- 9:15 AM, R5 had a successful, unwitnessed elopement from the facility. R5 was found by staff members on the sidewalk, off the facility's premises, next to an active highway. On 05/13/26, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death.On 05/13/26 at 11:53 AM, the Centers for Medicare and Medicaid Services (CMS) IJ Template was presented to the Administrator for the identified failure at 42 CFR 483.25 Quality of Care related to R5's elopement. On 05/13/26 at 2:04 PM, the facility presented an acceptable IJ removal plan. Verification of the removal plan on 05/13/26 at 4:15 PM, indicated the facility had identified and corrected their own deficiency, indicating Past-noncompliance as of 05/11/26. Findings include:Review of the facility's undated policy titled, Exit Seeking/Elopement Policy and Procedure revealed, Definition of Elopement: Any resident who has left the building UNWITNESSED and is found to be past the RNC parameters. Parameters include: a. past the flower bed of the front door to the oak trees of hospital yard. b. past the fences at each end of the building to property line. c. past the dumpsters at the back of the building to the church yard.Review of R5's Face Sheet revealed R5 was admitted to the facility on [DATE], with diagnoses including but not limited to cerebral infarction, traumatic subdural hemorrhage, and altered mental status.Review of R5's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/30/26, indicated R5 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating he was severely cognitively impaired. Further review of the MDS indicated under Behaviors, cognitive skills for daily decision making, disorganized thinking coded as 1, indicating continuously present, does not fluctuate.Review of R5's electronic medical record (EMR) revealed progress notes that stated, 05/08/26 23:27 [11:27 PM], Note Text: Resident in wheelchair. Alert w/confusion at this time. Resident being combative during the shift. Difficult to redirect and repeatingly [sic] insisting on going home. Verbal. redirection and reassurance attempted with minimal effect. Resident monitored closely for safety at nurse station. No acute distress noted at this time. An additional note indicated, 05/10/26 09:00 Note Text: Supervisor notified of resident walking outside premises. Staff immediately located resident and assisted back to facility. No acute distress noted. Resident placed on 1:1 supervision and Q15 min monitoring; Accutech monitoring system currently unavailable. Elopement Drill Process in-service provided to staff. DON, MD, Facility Administrator and FRP notified.Review of R5's Care Plan revealed a focus area, The resident has impaired cognitive function/dementia or impaired thought processes r/t altered mental status s/p CI, impaired decision making with an initiation date of 04/27/26. Interventions included, Cue, reorient and supervise as needed. The care plan also indicated a focus area, The resident is a high risk for falls r/t confusion deconditioning, gait/balance problems, poor communication/comprehension, unaware of safety needs, vision/hearing problems with an initiation date of 04/27/26. Interventions include to anticipate and meet the resident's needs.During a telephone interview on 05/13/26 at 10:56 AM, Registered Nurse (RN)1 indicated, [R5] was found outside by himself. He was down the road and we were not aware that he was gone. Another patient notified a staff member that the tall, white man with the blue shirt was gone. A staff member came and asked her if she knew who it was. RN1 stated she had last seen R5 previously in the hall with another staff member sitting. She stated, Yes, this was an elopement. We did not know he was gone. Once we got him back inside, I assessed him then followed the elopement protocol and began educating the staff that was in the building, on both units.During a telephone interview with RN2 on 05/13/26 at 11:05 AM, she stated, I saw people running. Some staff members went out and brought him back in. We assessed him and he did not have any injuries. He was put on 1:1 with a sitter and we started documenting rounds every 15 minutes. We were going to put a monitor on him, but it was locked in the office. RN2 stated that RN1 in-serviced all staff in the building on elopements and missing patients.During a telephone interview with R5's Resident Representative (RR) on 05/13/26 at 11:09 AM, she stated, From the minute [R5] got to this facility, he has wanted to get out. Based on his diagnosis, he doesn't always understand what's going on and sometimes tries to leave to think he is going to meet someone. I knew it was a matter of time before he got out the building successfully, because the door is always unlocked and sometimes there is no one at the desk on the weekends.During an interview with the Administrator on 05/13/26 at 11:55 AM, he stated, Yes, it's true. I was made aware of the elopement. I thought it was an assisted exit, but I just found out it was an actual elopement. When asked about the availability of the Accutech monitors, he indicated the staff did not communicate that they could not access them, but this is why [R5] was placed on 1:1 until they could access them on Monday.An attempt was made to interview R5 with no success.During observations of R5 on 05/13/26 at 10:42 AM, 05/13/26 at 12:15 PM and 05/13/26 at 6:22 PM, showed R5 with a sitter. He was up walking the halls with a monitor on his left ankle.The facility presented an acceptable removal plan which indicated:Credible Allegation Compliance Plan of Correction Date 05/11/2026Resident #5 on May 10, 2026 was found outside of the facility at approximately 9:00 am. The nurse was notified and immediately brought the resident back into the facility, provided a head-to-toe assessment without injury and placed the resident on q-15 minute checks. The resident's family friend/RR was notified of the occurrence on 05/10/2026. The MD was notified on 05/10/2026. His elopement assessment was completed and identified him as a wandering resident. His care plan was updated to reflect the use of the wander guard by the MDS nurse on 05/10/26.All other residents that are at risk of elopement had their elopement evaluation updated on 05/13/2026 by the Director of Nursing. Each resident that has been identified as a high elopement risk (score of eleven or higher) has had their picture and identifying information placed in the facility's elopement risk binder which is maintained at the nurses' station and receptionist desk.Each resident identified as a high elopement risk has had a care plan developed and implemented to address the resident's elopement risk including appropriate safety interventions. Each resident identified as an elopement risk with a score of eleven or higher has now had a wander guard bracelet added to their person. The facility began educating the staff on elopement by the RN Supervisor on May 10, 2026 for all staff on the facility's elopement risk policy and procedures to ensure their knowledge level on the policy as well as to ensure the staff members understand their responsibility of ensuring that each resident's safety interventions are in place in accordance with their individualized plan of care. The nursing staff is also responsible for checking the residents wander guard placement q-shift and documenting on the MAR/TAR each shift.Residents upon admission or significant change will have their elopement evaluation completed to ensure the resident is adequately assessed for wandering behavior by the licensed nurse and reviewed by the Director of Nursing.All new hires will be educated on the elopement risk assessment and ensuring resident safety.The DON will review in the daily clinical meeting the elopement risk evaluation and care plan to ensure the proper interventions and care plan has been updated. The DON will review the Elopement binders daily for 4 weeks and weekly thereafter for 6 months to ensure the elopement binders are maintained. The Director of Nursing will review the results of the elopement audits and elopement binders with the Monthly Quality Assurance and Assessment Committee for further follow-up and recommendations as indicated.

Based on review of the facility policy, observation, interview, and record review, the facility failed to ensure Resident (R)7 received appropriate care and services to prevent complications related to enteral feeding, for 1 of 2 residents reviewed.On 05/13/26, R7's Gastrostomy tube (G-Tube) site was observed with a dressing dated 05/03/26 stuck to the skin and a brown, crusted substance noted around the stoma. On 05/13/26, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 05/13/26 at 4:25 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 05/03/26. The IJ was related to 42 CFR 483.25 Quality of Care.On 05/13/26, the facility provided an acceptable IJ Removal Plan. On 05/13/26, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F693 at a lower scope and severity of D.Findings Include:The facility did not have a policy to address these concerns.Review of R7's Face Sheet revealed the facility admitted her on 08/06/25, with diagnoses including but not limited to gastrostomy status, dysphagia and aphasia.Review of R7's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/12/26, revealed R7 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating severe cognitive impairment. Further review of the MDS revealed no indications of R7's G-tube.Review of R7's Physician Orders revealed an active order dated 10/23/25 for weekly skin assessments. However, there were no physician orders addressing the care, cleaning, or management of R7's G tube. Further review revealed R7 had just finished a course of Augmentin for a G-tube infection from 05/02/26 - 05/12/26.Review of R7's Electronic Medical Record (EMR) revealed a skin assessment was completed 01/29/26.Review of R7's Care Plan did not reveal any indications of care for the G-tube.Review of R7's Progress Notes revealed the following:04/12/26 23:10 Health Status Note: Nurse gave resident a shower and notice resident GTube site had drainage and odor coming from it. When dressing was removed Gtube site was red, bleeding and raw. Nurse cleaned site, and applied new dressing. ADON and weekend supervisor notified of change.04/13/26 12:03 Order Note: Bactrim DS Tablet 800-160 [milligram] MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth two times a day for bacterial infection for 10 days.04/14/26 21:32 Acute Care Note: Assessment/Plan: L03.311 - Cellulitis of abdominal wall. The patient developed drainage, erythema, bleeding, and odor at the gastrostomy tube site, consistent with a localized infection, and was started on a 10-day course of Bactrim DS on 04/14/2026. There have been no adverse reactions to antibiotic therapy, and the patient remains afebrile with a temperature of 97.6 F and no systemic symptoms. The gastrostomy tube site is being monitored for signs of infection and response to therapy. Signed by the Medical Director (MD)04/25/26 14:20 Infection Note: Resident continues on antibiotics therapy for gt infection with no adverse reactions noted. Will continue to monitor for signs of infection and response to therapy.During an observation on 05/13/26 at 12:54 PM, R7's G-tube site was observed with a dressing dated 05/03, the dressing was stuck to R7's skin and her stoma had a brown crust surrounding it. R7's tube was cut off and black in color.During an interview on 05/13/26 at 1:05 PM, Licensed Practical Nurse (LPN)1 stated R7 was admitted to the facility with a G tube. LPN1 stated that R7's family wanted the tube removed. LPN1 further stated that she had not observed R7's G tube that day, noting that night shift cleans and changes the dressing.During an interview on 05/13/26 at 1:29 PM, LPN2 stated R7 was not receiving anything through her G tube. LPN2 reported that the tube was cut at the provider's office about two months ago and that the provider did not give the facility specific instructions on what to do. LPN2 was unsure when R7's dressing was supposed to be changed. LPN2 also stated she had not looked at R7's G tube site. She noted that the tube was molded from the inside, so providers were unable to remove it. She reported she was unaware of R7 having an infection. She stated that whatever the Nurse Practitioner (NP) or MD orders is what they follow.During an observation and interview on 05/13/26 at 2:04 PM, the Facility Administrator confirmed the dressing on R7's site was dated 05/03. He stated the nurses should be changing the dressing but he was unsure when or how often it should be changed. He put on gloves and began to lift the dressing to assess the site. As he lifted the dressing, it was stuck to R7's skin, and R7 winced in pain.During an interview on 05/13/26 at 2:23 PM, the Director of Nursing (DON) confirmed that no orders had been entered for R7 and stated she had now placed an order. The DON stated that R7 has weekly skin audits and any concerns should have been reported to providers. She noted that R7's tube was unable to be flushed due to mold. Lastly, she stated R7 was placed on antibiotics after her last appointment.During an interview on 05/13/26 at 2:29 PM, the NP stated that there should have been orders entered to keep R7's G tube site clean and dry daily. She reported that she had not been made aware of any recent concerns. The facility's removal plan included: Resident #7 had a verbal order from the MD for daily dressing change to the G-Tube site entered the orders on 05/13/2026. MD and RR were made aware of the new treatment order by the DON on 05/13/2026.The MD through virtual assessment with the DON observed the G Tube Site with no new orders.The DON will review all residents with G-Tube orders to ensure they have the necessary orders for care and treatment of the G-Tube insertion site and feeding parameters by 05/13/2026.The Licensed nurses will be educated by the Director of Nursing on ensuring the residents that have G-Tubes will ensure the G-Tube Insertion Site Dressing is cleaned and dressed daily.The treatment nurse or DON will review the G-Tube Sites daily to ensure the dressing has been changed daily for 2 weeks weekly for 4 weeks them monthly for 4 months. Any area of concern will require the nurse to be re-educated and disciplined if applicable. The MD and NP will be notified upon any identified sign and symptoms redness, swelling, drainage, odor, or any other abnormality.All new hired nurses will be educated on G-Tube Dressing Changes upon hire.The DON will review the results of the G-Tube audit with the IDT during the weekly Ad-HOC meeting for 4 weeks then monthly and PRN.The Director of Nursing will review the results of the G-Tube Dressing Change audits with the Monthly Quality Assurance and Assessment Committee for further follow-up and recommendations as indicated. Date of Correction: 05/14/2026

Based on review of facility policy, record review, and interviews, the facility and the pharmacy failed to provide pharmaceutical services to meet each resident's needs by not maintaining an effective system for ordering, receiving, and supplying medications, resulting in multiple missed medication doses. This failure had the potential to cause uncontrolled symptoms, worsening medical conditions, avoidable pain, and preventable decline. Findings Include:Review of the facility policy titled Ordering and Receiving Non-Controlled Medications, last revised August 2020, documented, Policy: Medications and related products are received from the pharmacy on a timely basis . Procedures . I. Ordering Medication from the Pharmacy: 1. Medications orders are written on a physician order form, telephone order sheet, or reorder from provided by the pharmacy, written in the chart by the physician, or entered into the facility's EHR systema and transmitted to the pharmacy. 2. Repeat medications (refills) are . requested via the facility's EHR system and ordered as follows: a. Reordering of medications is done in accordance with the order and delivery schedule established by the pharmacy provider . b. The refill order is called in, faxed, sent electronically, or otherwise transmitted to the pharmacy.Review of the facility policy titled Receiving Controlled Substances last revised August 2020, documented, Procedures . Controlled substances are requested when a five-day supply remains, or in accordance to facility policy, to allow for transmission of the required written prescription to the pharmacy. Review of the facility policy titled Non-Controlled Medication Orders, last revised August 2020, documented, Procedures . II. Order Clarification . 3. The prescriber is contacted by nursing for direction when the medication is not or will not be available for administration or on accordance with facility policy. Review of the facility policy titled Controlled Substance Prescriptions, last revised August 2020, documented, Policy . A chart order is not equivalent to a prescription for controlled medications. Therefore, the prescriber issuing the chart order must also provide the pharmacy with a valid prescription to ensure delivery if medication . Procedures . V. Communicating with the Prescriber . 2. The prescriber is contacted by nursing for direction when the medication is not or will not be available for administration or on accordance with facility policy . VII. Refill Requests . if one or more refills or a partial refill quantity remains, the facility must request the medication from the pharmacy. Review of R2's Face Sheet revealed the facility admitted her on 03/18/25, with diagnoses including but not limited to; hereditary and idiopathic neuropathy, chronic kidney disease, essential primary hypertension, atrial flutter, gastro-esophageal reflux disease (GERD) and gout.Review of R2's Medication Administration Record (MAR) for March, April and May 2026, revealed the following missed doses: Lyrica Capsule 75 Milligrams (mg), give 1 capsule by mouth three times a day related to Hereditary and idiopathic neuropathy. May 10.Atorvastatin Calcium Oral Tablet 80 mg, give 1 tablet orally at bedtime related to pure hypercholesterolemia. March 26, 28, 31.Lactobacillus capsule, give 2 capsules by mouth in the morning for digestive health. March 19, 21-24.Mag-Oxide Tablet, give 1 tablet by mouth in the morning related to chronic kidney disease. March 15-16, 19. April 9.Valsartan 40 mg, give 1 tablet by mouth the morning related to essential primary hypertension. March 8, 19.Eliquis 5 mg, give 1 tablet by mouth two times a day related to typical atrial flutter. March 26, 28, 31. April 5, 10, 22.Pantoprazole 40 mg, give 1 tablet by mouth two times a day related to GERD. March 15. April 15.Allopurinol 100 mg, give 1 tablet orally in the morning related to gout. April 13,16,17.Olopatadine, 1 drop in both eyes two times a day related to acute atopic conjunctivitis, left eye. April 13, 16-17. May 5.Pataday 1 drop in both eyes one time a day for dry eyes. May 6.Review of R3's Face Sheet revealed the facility admitted her on 05/10/24, with diagnoses including but not limited to; generalized anxiety disorder, primary insomnia, hyperlipidemia, primary generalized osteoarthritis, pain, major depressive disorder and GERD.Review of R3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/15/26, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R3 was cognitively intact.Review of R3's Medication Administration Record (MAR) for March, April and May 2026 revealed the following missed doses: Ambien 5 mg (Zolpidem), give 1 tablet by mouth at bedtime related to primary insomnia; March 5, May 3-4, 8-9, 12. Ezetimibe 10 mg, give 1 tablet by mouth at bedtime related to hyperlipidemia; March 5 and April 27 Hydroxyzine 25 mg, give 1 tablet by mouth at bedtime related to generalized anxiety disorder. March 1, 3, 5, 21, & 29. April 18, 21-23, 27. May 5-8.Lactobacillus capsule, give 2 capsules by mouth in the morning for abdominal health. March 9.Alprazolam 0.5 mg, give 1 tablet by mouth two times a day related to generalized anxiety disorder. March 1, 5.Diclofenac oral tablet, give 75 mg by mouth two times a day related to primary generalized osteoarthritis. March 1, 5. May 13.Buspirone 5 mg, give 1 tablet by mouth three times a day related to generalized anxiety disorder. March 1, 5, 17.Doxycycline 100 mg, give 1 tablet orally three times a day related to cellulitis. March 1, 5.Tylenol oral tablet, give 500 MG by mouth four times a day for pain. March 1, 17. April 5, 27.Nystatin Powder, apply to groin topically every shift for yeast. March 1, 4, 8-9, 13-15, 19, 21-22, 25. April 3, 6, 8-10, 16, 18-19.Citalopram 10 mg, give 1 tablet by mouth in the morning related to major depressive disorder. April 17.Lamotrigine 25 mg, give 1 tablet by mouth in the morning related to persistent mood disorders. April 17.Loratadine 10 mg, give 1 tablet by mouth in the morning for allergy symptoms. April 4.Potassium Chloride ER 10 MEQ, give 1 by mouth two times a day for taking medications for edema. April 4-8, 10, 27.Review of R6's Face Sheet revealed the facility admitted her on 04/27/26, with diagnoses including but not limited to; pure hypercholesterolemia, benign prostatic hyperplasia with lower urinary tract symptoms, long term use of anticoagulants and muscle spasms. Review of R6's Medication Administration Record (MAR) for 04/27/26 revealed the following missing doses: Atorvastatin Calcium Oral Tablet 80 mg, give 1 tablet orally at bedtime related to pure hypercholesterolemia.Tamsulosin Oral Capsule 0.4 mg, give 1 capsule orally in the afternoon related to benign prostatic hyperplasia.Apixaban Oral Tablet 5 mg, give 1 tablet orally two times a day related to long term (current) use of anticoagulants. Cyclobenzaprine Tablet 10 mg, give 1 tablet by mouth three times a day for muscle spasm relief.During an interview on 05/13/26 at 9:35 AM, Licensed Practical Nurse (LPN)1 stated that medications were sometimes not available. LPN1 reported that they would place medication orders but would not receive them until the following day. LPN1 also stated that some medications were unavailable because they required a new prescription once they reached their one year renewal date.During an interview on 05/13/26 at 11:19 AM, R3 stated that she had been without her prescribed sleep medication, Ambien, for the past five days. She further reported that some staff documented her medications as administered even though she had not received them.During an interview on 05/13/26 at 12:02 PM, the Director of Nursing (DON) stated that most missed medication doses occurred because nursing staff either failed to reorder medications, did not know how to reorder them, or did not obtain the necessary prescriptions. The DON added that the facility keeps non narcotic medications in the stockroom and receives multiple pharmacy deliveries each week. She also stated that the provider should be notified when medications are not available.During an interview on 05/13/26 at 2:29 PM, LPN2 stated that they are responsible for calling the pharmacy to reorder medications when they observe that a resident is running low.During an interview on 05/13/26 at 8:25 PM, the Medical Director stated he was unaware of the extent of the facility's medication issues. He added that he should have been notified of the missed medication doses and that the situation was not acceptable.

Based on observations, interviews and record review, the facility failed to ensure all drugs and biologicals were safely and securely stored. Specifically, the B-wing medication room was observed unlocked, and the treatment carts were unlocked with the key hanging in the lock. Findings Include:Review of the facility policy titled Storage of Medications last revised August 2020, documented, Policy: Medications and biologicals are stored safely, securely, and properly . The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. I. General Guidance . 2. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access.Review of the undated facility policy titled Storage and Expiration of Medications, Biologicals, Syringes and Needles, documented, Medications will be securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. Only authorized, licensed facility staff will have possession of the keys to medication storage areas.During an observation on 05/12/26 at 5:55 PM, both treatment carts on A and B Wing were unlocked with the keys left in the locks and no staff present. During an observation on 05/13/26 at 9:01 AM, the treatment cart on B Wing was unlocked, with the key left hanging in the lock. Additionally, the medication storage room on B Wing was unlocked and no staff were present at the nurses station or in the medication room. During an interview on 05/13/26 at 9:05 AM, LPN1 stated that the medication storage room was supposed to be locked, but another nurse must have forgotten to lock it after leaving. LPN1 then stated, I just locked it now.During an interview on 05/13/26 at 12:02 PM, the Director of Nursing (DON) stated that the medication storage areas are required to remain locked. She reported that the facility has had previous issues with medication storage and that staff have been previously educated and are aware of the expectations.

Based on review of the facility policy, observations, and interviews, the facility failed to ensure expired food items were removed from storage and food items were properly stored and labeled.Findings include:Review of the facility's policy titled, Kitchenette Policy and Procedure, dated 01/29/19 revealed, Policy: Food storage areas will be maintained in a clean, safe and sanitary manner. Food items not stored will be disposed of. Procedure: . 3. All foods requiring refrigeration will be stored in the kitchenette refrigerator behind the nurse station. Items will be marked with resident name, date and time on receipt by staff. Review of the facility's undated policy titled, Food Storage revealed . 4. Food shall be rotated as delivered and used in a first in, first out method. Items will be dated on receipt, opening and/or replaced for storage to facilitate this procedure.Review of the facility's undated policy titled, Date Marking, Potentially Hazardous Food Policy and Procedure, revealed, Procedure: . 2. Foods must be marked at the time of preparation, or in the case of a commercially processed food, at the time the container or packaging is opened in a retail facility.During a tour of the kitchen on 05/13/26 at 8:48 AM, observation of the dry storage area revealed six (6) 46 fluid ounces (oz.) cartons of [NAME] Ready Care Thickened Apple Juice with a use by date of 04/25/26. In the walk-in cooler, there was 1 - 10 count package of [NAME] B's Jumbo XL biscuits, thawed, with a manufactured notice Keep frozen until ready to use. There was also one unlabeled and undated, clear container, which contained an item that appeared to be baked beans. These items were confirmed by the Dietary Manager (DM) to be unlabeled and undated.Observation of the A Wing Nourishment Room on 05/13/26 at 9:01 AM, revealed two (2) unlabeled and undated sandwiches that appeared to be peanut butter and jelly. Observation of the resident refrigerator, located in the Nourishment room contained, two watermelon halves, that appeared to be half eaten, one to-go tray containing what appeared to be rice and grilled chicken legs, unlabeled and undated and multiple open personal cans and bottles of beverages, that were unlabeled and undated.During an interview on 05/13/26 at 9:05 AM, Certified Nursing Assistant (CNA)1 stated, Night shift keeps putting their personal items in this refrigerator. I keep trying to clean it out. Those sandwiches should be labeled and dated, but I am unsure when they were prepared. I know most of the staff here give residents bread and items for sandwiches with money out of our own pockets, to ensure they get what they want to eat.During a follow-up visit to the kitchen on 05/13/26 at 4:50 PM, an unlabeled, undated clear container containing what appeared to be diced pears was observed in the walk-in cooler. This was confirmed by the Dietary Aide.Additionally, review of the steam table on 05/13/26 at 4:55 PM, revealed the unlabeled, undated, baked beans observed earlier that morning, being served. The [NAME] was unable to confirm when the beans had been prepared.

Based on review of the facility policy, observation and interview, the facility failed to ensure a successful elopement was reported timely to the State Agency (SA) within two (2) hours of its occurrence. Findings include:Review of the facility's policy titled, Abuse, Neglect, Exploitation & Misappropriation dated 10/23/2023, indicated, Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Examples include but are not limited to; failure to adequately supervise a resident known to wander from the facility without the staff knowledge . Procedure: . 7. Reporting/Response- Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made .On 05/10/26 between 8:45 AM- 9:15 AM, Resident (R)5 had a successful, unwitnessed elopement from the facility. R5 was found by staff members on the sidewalk, off the facility's premises, next to an active highway. Review of R5's Face Sheet revealed R5 was admitted to the facility on [DATE], with diagnoses including but not limited to cerebral infarction, traumatic subdural hemorrhage, and altered mental status. Review of R5's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/30/26, indicated R5 had a Brief Interview of Mental Status (BIMS) score of 0 out of 15, indicating he is severely cognitively impaired. Further review of the MDS indicated under Behaviors, cognitive skills for daily decision making, disorganized thinking coded as 1, indicating continuously present, does not fluctuate. Review of R5's electronic medical record (EMR) revealed progress notes that stated, 05/08/26 23:27 [11:27 PM], Note Text: Resident in wheelchair. Alert w/confusion at this time. Resident being combative during the shift. Difficult to redirect and repeatingly insisting on going home. Verbal. redirection and reassurance attempted with minimal effect. Resident monitored closely for safety at nurse station. No acute distress noted at this time. An additional note indicated, 05/10/26 09:00 Note Text: Supervisor notified of resident walking outside premises. Staff immediately located resident and assisted back to facility. No acute distress noted. Resident placed on 1:1 supervision and Q15 min monitoring; Accutech monitoring system currently unavailable. Elopement Drill Process in-service provided to staff. DON, MD, Facility Administrator and FRP notified. During a telephone interview on 05/13/26 at 10:56 AM, Registered Nurse (RN)1 indicated, [R5] was found outside by himself. He was down the road and we were not aware that he was gone. Another patient notified a staff member that the tall, white man with the blue shirt was gone. A staff member came and asked her if she knew who it was. RN1 stated she had last seen R5 previously in the hall with another staff member sitting. She stated, Yes, this was an elopement. We did not know he was gone. Once we got him back inside, I assessed him then followed the elopement protocol and began educating the staff that was in the building, on both units. During a telephone interview with R5's Resident Representative (RR) on 05/13/26 at 11:09 AM, she stated, From the minute [R5] got to this facility, he has wanted to get out. Based on his diagnosis, he doesn't always understand what's going on and sometimes tries to leave to think he is going to meet someone. I knew it was a matter of time before he got out the building successfully, because the door is always unlocked and sometimes there is no one at the desk on the weekends. During an interview with the Administrator on 05/13/26 at 11:55 AM, he stated, Yes, it's true. I was made aware of the elopement. I thought it was an assisted exit, but I just found out it was an actual elopement. I am reporting it now and will be educating staff on reporting.

Based on observations and interviews, the facility failed to ensure resident preferences were honored in relation to dietary meals. Specifically, the facility did not provide residents preferences or substitutes. This deficient practice had the potential to effect all residents obtaining food items from the kitchen.Findings include:During a kitchen tour on 05/12/26 at 4:48 PM, observations revealed no posted alternative menu.During an interview conducted with Cook1 on 05/13/26 at 4:55 PM, revealed she was unaware of any alternatives for residents. Cook1 stated she was preparing the supper meal, which consisted of grilled cheese sandwiches and stewed tomatoes. When asked what the alternative was for individuals who did not eat those items, she stated, I am not sure. I do not know anything about alternative choices.During an interview with Resident (R)1 on 05/13/26 at 5:58 PM, he stated, I've been here for a few weeks. No one has asked me what I like to eat. They just serve us small helpings of food. Some of the staff here has gone and brought me Kentucky Fried Chicken (KFC), or my friends will bring me something. When I asked for something different, they told me I could only get what was served. Now, I just make peanut butter and jelly (PB&J) sandwiches in my room. Observation at this time revealed R1 actively making a PB&J sandwich during the interview.During an interview with Certified Nursing Assistant (CNA)1 on 05/13/26 at 9:05 AM, she stated, The food here is limited. We, the staff do sometimes go out and get residents different meals because that is all they have to offer, so we know they are sometimes still hungry.During an interview with R4 on 05/13/26 at 10:15 AM, he stated, See all my snacks here. The food here is horrible. There are no choices or options. The staff will sometimes bring us something they got with their own money. Observation of R4's room showed personal snacks and drinks.During an interview with the Dietary Manager (DM) on 05/13/26 at 12:10 PM, she stated, I just started. I am aware we have some issues and there are some things I want to change. We do not offer an alternate menu, or preferred options. That is something I want to start incorporating once I get things fixed. The DM confirmed there was no policy.

Based on observation and interviews, the facility failed to label and date all food stored in the walk-in cooler and ensure food was cooked at the proper temperature prior to service with the potential to affect 79 of 83 residents who consumed food prepared from the facility's kitchen. This failure had the potential to lead to food borne illnesses. Findings include: During initial observation of the kitchen and interview on 05/21/25 at 9:45 AM with the Dietary Manager (DM), the walk-in refrigerator revealed a container of leftover meat that he could not identify; not labeled or dated. A box of sausage links in the walk-in refrigerator was opened and sausage links wrapped in aluminum foil were not labeled or dated. The walk-in refrigerator also contained a half full pitcher with the appearance of orange juice/pulp that separated from the water content with no label or date. The DM said, oh we don't serve from a pitcher anyway, we use the juice dispenser. The walk-in cooler also contained an opened package of cheese, not labeled, or dated. The prepared cups of tea did not have lids that properly fit the cups, and the DM did not know what happened to the correct lids for the serving cups. During observation and interview on 05/23/25 at 12:10 PM, the Dietary Manager (DM) utilized a digital thermometer to check the food temperature of the meat patties being served. It was found to be at a temperature of 126 degrees Fahrenheit (F). He stated he had checked the temperature before serving the meat and determined it was not at the proper temperature, so he removed a portion of the meat patties and placed them back in the oven to increase the temperature. However, he continued to serve some of the meat patties at an unacceptable safe temperature for meat patties. A re-check of the meat patties temperature at 12:20 PM indicated the temperature was 155 degrees and appeared to be crisp and dry. During an interview on 05/23/25 at 1:00 PM, the DM stated that he was aware that re-heating the meat patties had caused them to be dry and tough and should have been prepared to the proper temperature initially, before serving the residents. The DM stated his expectation was for the temperature to be 165 degrees F with a holding temperature of 135 degrees F.

Based on record review, observation and interviews, the facility failed to ensure residents received alternative measures prior to the installation of side rails and that assessments were completed for the risk of entrapment for one of two residents (Resident (R) 12) reviewed for side rails out of 21 sample residents. The lack of alternate side rail measures and proper assessment could lead to potential restraint or side rail entrapment. Findings include: Review of R12's admission Record located in the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE] with diagnoses including intellectual disabilities. Review of R12's quarterly Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 02/13/25, revealed a Brief Interview for Mental Status (BIMS) assessment could not be completed. Review of R12's Care Plan, located under the Care Plan tab of the EMR and dated 03/31/24, revealed The resident was at risk for ADL [activities of daily living] decline. Interventions in place were bilateral siderail per family request. Review of R12's Physician Orders, located under the Orders tab in the EMR and dated 05/22/25, revealed, no order for siderail use. Review of R12's Siderail Assist Device, located under the Observations tab in the EMR and dated 05/20/25, revealed no evidence of alternates explored or an assessment of the risk for entrapment. During observations on 05/22/25 at 3:15 PM and 05/23/25 at 10:33 AM, the resident was lying in bed with head of bed upright, full side rails up on both sides. During an interview on 05/22/25 2:38 PM, the MDS Coordinator (MDSC) stated she completed R12's side rail assessment. She stated they were not exploring alternates prior to side rail use or assessing for risk of entrapment. She said the facility was unaware of these requirements. During an interview on 05/23/25 at 4:15 PM, the Director of Nursing (DON) said upon siderail use staff completed a side rail assessment and they got signed consent. The DON stated they were not exploring alternatives or assessing for entrapment.

Based on record review, observations and interviews, the facility failed to allow family visitation for one of one resident (Resident (R) 38). This failure violated R38's right as a resident of the facility and had the potential to violate the rights of 83 residents that lived in the facility. Findings include: Review of R38's admission Record located in the electronic medical record (EMR) under the Profile tab revealed R38 was admitted to the facility on [DATE]. Review of R38's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/22/25, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of five out of 15 which indicated the resident was severely cognitively impaired. During observation of the facility entrance on 05/21/25 at 12:40 PM, a sign was posted that read, ATTENTION! ATTENTION! VISITING HOURS: 7 AM - 7 PM, NO RE-ENTRY AFTER 7 PM. CALL [Phone number] FOR AUTHORIZED RE-ENTRY. During an interview on 05/21/25 at 12:33 PM, the Receptionist stated the facility had a visitor's policy of 7:00 AM to 7:00 PM with no re-entry to the facility after 7:00 PM without authorized entry. She stated she usually left the building between 4:30 PM - 5:00 PM. During an interview on 05/21/25 at 12:45 PM, the Administrator stated the facility had a visitor's sign posted at the front door of the facility restricting visitors to 7:00 AM to 7:00 PM unless authorized to re- enter the building. During an observation on 05/21/25 at 3:30 PM, the phone number listed on the posted sign for visiting hours located by the front door entrance was called. The phone number was answered by the facility receptionist. During an interview on 05/21/25 at 11:30 AM, Family (F) 4 stated during a recent visit with R38, she requested some food items from a nearby grocery store. F4 stated he left the facility to go to the grocery store and when he returned at 7:10 PM, he was denied re-entry by a staff member (name unknown). He stated the staff member said she would deliver the food items to R38 but could not allow him to come inside as instructed by the Administrator. F4 also stated he worked during the week and got off work too late to visit R38, because the posting at the front door to the facility stated he must have authorization to enter the facility after 7:00 PM. He stated he called the phone number listed on the posted sign multiple times, but no one answered the phone. He stated he also called to speak to R38 during business hours and was transferred to the charge nurse for R38. He stated most of the time, a nurse would not answer his calls but if a charge nurse answered, he was told the batteries for the portable phones were not charged and they could not take the phone to her room. During an observation on 05/22/25 at 7:10 PM, 7:30 PM, and 7:45 PM, the phone number listed on the posted sign for visiting hours located by the front door entrance was called. The phone number was not answered by a staff member or by an answering service and had no voice mail service. During an interview on 05/23/25 at 4:15 PM, the Director of Nursing (DON) stated visiting hours for the facility were from 7:00 AM to 7:00 PM as posted at the front door entrance. She also stated that visitors could call the listed phone number for authorized re-entry to the facility. She stated the phone number was answered by the nursing staff and that they have portable telephones that could be answered from anywhere in the facility and that were used by residents needing to receive phone calls from family members. She stated she never called the phone number to audit the phone was answered by the nursing staff during business hours or after business hours. During an interview on 05/23/25 at 4:30 PM, the Administrator stated the visiting hours posting located at the front door entrance indicated visiting hours to be 7:00 AM - 7:00 PM but she said family members could call the phone number listed at any time and be allowed entrance to the facility. She stated that she was not sure where the phone number was routed in the facility, but the nursing staff were responsible for answering the phone after business hours. The surveyor informed the administrator that the phone number was answered by the receptionist at 3:30 PM but was not answered on three subsequent calls after 7:00 PM. The Administrator was asked if she ever audited the phone number to verify staff members answering the phone number after 7:00 PM. She replied she had never called the phone number after business hours and was not aware that the phone number was unanswered. She stated her expectation was for the phone to be answered by the nursing staff after hours but that sometimes they were too busy to answer the phone.

Based on review of the facility policy, observations and interviews, the facility failed to ensure residents' equipment was kept clean and blinds were in good working order for two of two residents (Residents (R) 47, and R72) reviewed for the environment of 21 sample residents. Specifically, R47's bedside fall mats were observed with a dry brown substance, and R72's window blinds were in disrepair. This failure had the potential to not support the residents' right to a safe, clean, comfortable, and homelike environment. Findings Include: Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment dated 12/08, revealed Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] recommendations for disinfection and the OSHA [Occupational Safety and Health Administration] Bloodborne Pathogens Standard. 1. During observations conducted on 05/21/25 at 10:29 AM, 05/22/25 at 9:09 AM, and 05/23/25 at 10:00 AM, R47's fall mats, located on the floor next to the resident's bed, had dried brown colored substance splattered on the mats. During an interview on 05/23/25 at 10:02 AM, Housekeeper (Hskp) 1 was asked who was responsible for ensuring the resident's bedside equipment was kept clean from spills. Hskp1 stated that the nurse aides were responsible for keeping the bedside equipment clean. During an interview on 05/23/25 at 10:03 AM, Certified Nursing Assistant (CNA) 1 was asked who was responsible for ensuring the resident's bedside equipment was kept clean from spills. CNA1 responded that they (CNAs) did it, or they could contact housekeeping to assist. During an interview on 05/23/25 at 10:09 AM, the Assistant Director of Nursing (ADON) confirmed R47's fall mats were soiled, and the expectation would be that the staff would clean any spills right away. During an interview on 05/23/25 at 12:19 PM, the Director of Nursing (DON)was questioned what her expectations were related to keeping resident's bedside equipment, such as the floor fall mats. The DON responded that housekeeping was responsible for cleaning the floor fall mats and would have expected that staff would do a check and cleaning throughout their shifts for soiled equipment. 2. During observations conducted on 05/21/25 at 10:46 AM, 05/22/25 at 1:30 PM, and 05/23/25 at 9:50 AM, the window blinds in R72's room appeared to be bent and not in good working order. During an observation and interview on 05/23/25 at 9:50 AM, the window in R72's room had been opened allowing the fully extended window blinds to flap in the wind. R72 was asked if he would like the window blind raised so it would stop flapping in the wind. R72 shook his head to indicate yes. CNA2 was asked to raise the window blinds in R72's room to stop the flapping of the blind. CNA2 tried to raise the window blinds but the bent slats of the blinds would not allow her to raise the blinds, and the center of the blinds appeared to fall from the middle of the blind support. During an interview on 05/23/25 at 4:30 PM, the Administrator stated she was not aware that the window blinds were not in good working order and that the maintenance department staff was responsible for making sure the window blinds in each resident room were in good working order. She stated she had not visually seen the window blinds and did not ensure the maintenance department staff consistently monitored the condition of the window blinds. She stated a staff member (name unknown) had reported the broken window blinds in R72's room and that it had been repaired on 05/23/25.

Based on review of the facility policy, record reviews and interviews, the facility failed to report an allegation of resident-to-resident abuse for two of three residents (Resident (R) 28 and R35) reviewed for abuse out of 21 sampled residents. This had the potential to affect all residents who received care. Findings include: Review of the facility's undated policy titled, Abuse Prevention Policy and Procedure, revealed once a complaint or situation is identified involving alleged mistreatment, neglect, exploitation, or abuse, including injuries of unknown source and misappropriation of resident property the incident will be immediately reported. If the event that caused the allegation involves abuse or results in serious bodily injury, the report must be made within two hours to the Administrator, Director of Nursing, Physician and Medical Director, and SC-DHEC (South Carolina Department of Health and Environmental Control). Review of R28's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was re-admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD). Review of R28's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/01/25 and located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R28 was cognitively intact. Review of R28's Nurse's Note, dated 11/23/24 at 10:54 PM located in the EMR under the ''Notes'' tab, written by Licensed Practical Nurse (LPN) 3 revealed, Resident was throwing punches with another resident. During an interview on 05/22/25 at 3:15 PM, R28 stated R35 accused him of taking his money so he hit him in his d*** face. He said the staff broke it up and separated them. He said when the staff asked him about what happened that he told the staff he hit the other resident. Review of R35's Face Sheet located in the EMR under the Profile tab revealed the resident was re-admitted to the facility on [DATE] with diagnoses which included major depressive disorder. Review of R35's quarterly MDS with an ARD of 03/13/25 and located in the resident's EMR under the MDS tab revealed a BIMS score of 12 out of 15 which indicated R35 was moderately cognitively impaired. During an interview on 05/22/25 at 3:00 PM, R35 stated on 11/23/24, R28 wanted to borrow a dollar from him and then he rolled off. R35 stated then he wheeled forward and they hooked up. He said that meant they started fighting. He stated R28 hit him in the face, and then the staff stepped in and broke it up. He stated he was not afraid, and it hasn't happened again. Review of Facility Reportable Logs, from May 2024 to May 2025, revealed the incident that occurred on 11/23/24 was never reported to the state survey agency. During an interview on 05/23/25 at 2:14 PM, the Director of Nursing (DON) stated they did not suspect abuse and that was why it was not reported within two hours. She said she interviewed the residents the following day and neither told her that R28 hit R35. She confirmed she did not interview the resident within two hours, and did not report it.

Based on review of the facility policy, record reviews and interviews, the facility failed to investigate an allegation of resident-to-resident abuse for two of three residents (Resident (R) 28 and R35) reviewed for abuse out of 21 sampled residents. This had the potential to affect all residents who received care. Findings include: Review of the facility's undated policy titled, Abuse Prevention Policy and Procedure revealed, once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property, the following investigation and reporting procedures will be followed: I. The description of the alleged complaint is written on the investigation form. Any physical evidence and description of emotional state will be documented. 2. Information gathering - The following information will be gathered: Who did it? (who is the suspect); Who did they do it to? (who is the resident); What happened? (be specific about the event that occurred); When did it happen? (be as specific as you can with date and time it occurred); Where it happened? (the residents room, bathroom, dining room, etc.); Why? (or any extenuating circumstances that you might have information about. For example, the resident became very combative and was hitting at the aide and the aide hit back). 3. Interviews will be conducted of all pertinent parties. Written signed statements from any involved parties will be obtained and notarized, if possible. Statements will be gathered from the suspect, person making accusations, resident involved, reliable residents who may have witnessed the incident, and any other persons who may have some information. 4. Past performances and/or previous incidents of involved parties will be evaluated. 5. All investigative information will be kept on file in a secure location. All information gathered is confidential in nature. Review of R28's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was re-admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD). Review of R28's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/01/25 and located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R28 was cognitively intact. Review of R28's Nurse's Note, dated 11/23/24 at 10:54 PM, located in the EMR under the Notes'' tab, written by Licensed Practical Nurse (LPN) 3, revealed Resident was throwing punches with another resident. During an interview on 05/22/25 at 3:15 PM, R28 said R35 accused him of taking his money so he hit him in his d*** face. He said the staff broke it up and separated them. He said when the staff asked him about what happened that he told the staff he hit the other resident. Review of R35's Face Sheet located in the EMR under the Profile tab revealed the resident was re-admitted to the facility on [DATE] with diagnoses which included major depressive disorder. Review of R35's quarterly MDS with an ARD of 03/13/25 and located in the resident's EMR under the MDS tab revealed a BIMS score of 12 out of 15 which indicated R35 was moderately cognitively impaired. During an interview on 05/22/25 at 3:00 PM, R35 said on 11/23/24, R28 wanted to borrow a dollar from him and then he rolled off. R35 stated then he wheeled forward and they hooked up. He said that meant they started fighting. He stated R28 hit him in the face, and then the staff stepped in and broke it up. He stated he was not afraid, and it hasn't happened again. During an interview on 05/23/25 at 2:14 PM, the Director of Nursing (DON) stated they did not suspect abuse and that was why it was not investigated.

Based on record review and interview, the facility failed to ensure a written transfer notice that contained all required information was provided for two of five residents and/or their representatives (Resident (R) 11 and R39) reviewed for hospital transfer out of 21 sample residents. This failure had the potential to affect the residents and their Resident Representative (RP) by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired. Findings include: 1. Review of R11's admission Record located in the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses including intellectual disabilities. Review of R11's quarterly Minimum Data Set (MDS) located under the MDS tab of the EMR and with an Assessment Reference Date (ARD) of 04/24/25, revealed he had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated R11 was cognitively intact. Review of the R11's Evaluations tab, Documents tab, and Progress Notes tab of the EMR did not reveal evidence that a written notice of transfer was provided to R11 or their RP after a facility-initiated transfer to the hospital on [DATE]. 2. Review of R39's admission Record located in the Profile tab of the EMR revealed he was admitted to the facility on [DATE] with diagnoses including major depressive disorder. Review of R39's quarterly MDS located under the MDS tab of the EMR and with an ARD of 02/06/25 revealed he had a BIMS score of 11 out of 15, which indicated R39 was moderately cognitively impaired. Review of the R39's Evaluations tab, Documents tab, and Progress Notes tab of the EMR did not reveal evidence that a written notice of transfer was provided to R39 or their RP after a facility-initiated transfer to the hospital on [DATE] and 07/27/24. During an interview on 05/22/25 at 2:19 PM, the Administrator stated the facility has not been sending out a transfer notice anytime a resident was discharged from the facility. She said she was unaware they were supposed to.

Based on record review, observation and interviews, the facility failed to ensure there was an active physician ' s order for oxygen administration for one of one residents reviewed, (Resident (R) 12) reviewed for oxygen administration of 21 sample residents. This failure had the potential for residents to receive increased oxygen causing hyperoxia (cells, tissues and organs are exposed to an excess supply of oxygen). Findings include: Review of R12's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses including intellectual disabilities. Review of R12's quarterly Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 02/13/25, revealed a Brief Interview for Mental Status (BIMS) assessment could not be completed. Review of R12's Care Plan located under the Care Plan tab of the EMR, dated 03/31/25, revealed the resident was on continuous oxygen therapy. Review of R12's Physician Orders located under the Orders tab in the EMR, dated 07/21/23, revealed no current order for oxygen. During observations on 05/21/25 at 4:35 PM, 05/22/25 at 3:15 PM, and 05/23/25 at 10:33 AM the resident was lying in bed using a nasal cannula and the oxygen cannister was set at two LPM (liters per minute). During an observation and interview on 05/23/25 at 10:33 AM, Licensed Practical Nurse (LPN) 2 observed R12 in bed with nasal cannula on at two LPM. She stated R12's oxygen order was two liters continuously. She said she had not looked at the order in a while, but she was sure she had seen one. She stated staff should be looking at the order every time they were checking the resident's oxygen saturation and flow. During an interview on 05/23/25 at 12:06 PM, the Nurse Practitioner (NP) said R12's order for oxygen was discontinued and he should not be receiving continuous oxygen. She said she was unaware that staff were still administering. She said she would have expected staff to discontinue the order and stop administering it to R12. During an interview on 05/23/25 at 4:15 PM, the Director of Nursing (DON) said nursing staff should be looking at the physician orders each time they assessed the resident to ensure the correct liters and oxygen saturations. She stated she also expected staff to stop administering oxygen after an order to discontinue it.

Based on record reviews, interviews, and facility policy reviews, the facility failed to develop and implement a baseline care plan that included instructions needed to maintain hydration for 1 (Resident #3) of 7 residents reviewed. Specifically, the facility failed to develop and implement a baseline care plan for Resident #3 that included administration of water with bolus enteral feedings and failed to update the baseline care plan with Registered Dietitian (RD) #4's recommendations to increase fluids to maintain hydration. This failure resulted in Resident #3 passing away in the facility due to dehydration. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.21 (Comprehensive Resident Centered Care Plan) at a scope and severity of J. The IJ began on [DATE] when Resident #3 was admitted to the facility and the facility did not address hydration on the resident's baseline care plan which resulted in fluids not being provided as ordered. The Administrator and Director of Nursing (DON) were notified of the IJ on [DATE] at 2:12 PM and provided the IJ Template at 2:32 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on [DATE] at 2:45 PM. The IJ was removed on [DATE] at 7:00 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance remained at the lower scope and severity of D that was not immediate jeopardy for F655. Findings include: A review of the facility's policy, titled, Plan of Care Assessments, dated [DATE], indicated, Policy: Each resident will have a Plan of Care in order to receive the care necessary to enable the resident to achieve and/or maintain the highest practical physical, mental and psychological well-being. Procedure: A head-to-toe physical assessment of each resident will be completed on admission by an assigned Licensed Nurse with input from CNAs [certified nurse aides]. The baseline Plan of Care will be implemented within 48 hours of admission to ensure the resident receives the following necessary immediate care: Initial goal based on admission orders, Physician orders, Dietary orders, Therapy services, Social services and PASARR [Preadmission Screening and Resident Review] recommendations, if applicable. The Plan of Care will be completed with [the] MDS [Minimum Data Set] assessment and Care Area Assessments are completed by all disciplines. The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan will be developed within 48 hours of the resident's admission and meets all requirements. The facility will provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: a. The initial goals of the resident. b. A summary of the resident's medications and dietary instructions. Review of an Admission Record revealed the facility admitted Resident #3 on [DATE] with diagnoses that included traumatic subarachnoid hemorrhage (brain bleed), traumatic brain injury, acute respiratory failure, dysphagia, and fracture of the fifth and sixth cervical vertebrae and nasal bone. A review of Resident #3's Nursing Assessment, dated [DATE], revealed the resident had severely impaired cognitive skills for daily decision making. The assessment indicated the resident used a percutaneous endoscopic gastrostomy (PEG) feeding tube. The assessment indicated the resident had upper and lower extremity impairments on both sides. According to the assessment, Resident #3 had a sacral wound and was always incontinent of bowel and bladder. Review of Resident #'3s Baseline Care Plan, dated [DATE], revealed the resident's diet order was NPO (nothing by mouth), and the resident was to receive tube feedings for nutrition. The baseline care plan did not address hydration. A review of Resident #3's Nursing Home Instructions, within the hospital discharge summary dated [DATE], revealed Resident #3 was to receive 200 milliliters (mL) of water with each bolus tube feeding. The nursing home instructions were not added to the baseline care plan. A review of Resident #3's [DATE] physician orders indicated the resident was to receive enteral nutrition administered four times a day. There was no physician's order for the additional 200 mL of water, as recommended in the hospital discharge summary. A review of Resident #3's Enteral Nutrition Assessment, dated [DATE], revealed the resident was receiving bolus enteral nutrition, four times per day, due to dysphagia. The assessment indicated Resident #3 was receiving 608 cubic centimeters (cc) of fluid per day and the resident's estimated fluid requirement was 1950 cc per day. In the assessment, RD #4 suggested staff change Resident #3's bolus enteral feeding to a continuous enteral feeding at a rate of 55 cc per hour with water auto flushes at 40 cc per hour to provide 1980 kilocalories (kcal) and 84 grams (g) of protein per day with 1963 cc of free water. RD #4 also suggested adding 1 ounce (oz) of liquid protein daily for an additional 15g of protein, a multivitamin (MVI) with minerals to help with wound healing, weekly weights for four weeks, and baseline laboratory tests including a comprehensive metabolic panel (CMP) and prealbumin (PAB). Further review of the Baseline Care Plan revealed the RD recommendations were not added to Resident #3's baseline care plan. A review of Resident #3's Nurses Notes, dated [DATE] at 8:05 PM, revealed staff found Resident #3 unresponsive. The nurse noted Resident #3 was lying on the resident's back with no noted rise or fall of the chest. Staff were unable to obtain any vital signs. The note indicated cardiopulmonary resuscitation (CPR) was initiated twice by staff members and 911 was called due to the resident's full code status. According to the note, first responders and an emergency ambulance arrived; however, the resident remained unresponsive to CPR or other stimuli. The coroner was contacted by the staff for pronouncement of death. A review of a Forensic Autopsy Report, dated [DATE], revealed Resident #3's final cause of death was dehydration. The report indicated, Analysis of vitreous fluid (liquid from the eyeball) reveals the following: sodium = 140 mmol/L [millimoles per litre], urea nitrogen = 87 mg/dl [milligrams per decilitre], creatinine = 2.5 mg/dl, and glucose = 14.0 mg/dl, consistent with dehydration. The Resident Assessment Coordinator/MDS Nurse was not available for an interview regarding Resident #3's baseline care plan during the survey. During an interview on [DATE] at 12:40 PM, the Director of Nursing (DON) stated the floor nurses completed the new admission assessments if she or the unit manager were not in the facility and the floor nurses routinely completed the resident baseline care plans; otherwise, the MDS nurse completed them. The DON did not know why Resident #3's hydration needs were not assessed as she was not employed by the facility at the time of the resident's stay. The Administrator and DON were notified of the determination of IJ on [DATE] at 2:12 PM. A Removal Plan was requested. During an interview on [DATE] at 10:00 AM, the Medical Director said he started working at the facility in mid-October of 2022. He noted he was physically in the building once a week, and attended quality assurance (QA) meetings, which were held monthly. He indicated staff had been responsive and had updated him with any concerns or issues. He stated someone from the facility made him aware of the concerns which led to the IJ. He said he did not know the whole situation, but the facility was addressing the issues and he agreed with the plan. Removal Plan: The following IJ Removal Plan was provided by the facility and accepted by the State Survey Agency on [DATE] at 2:45 PM: Resident #3 did not have appropriate documentation completed in the baseline care plan (completed [DATE]) to reflect nutrition and hydration specific orders. Registered Dietitian (RD) recommendations were not implemented. This occurrence negatively impacted the resident and had the ability to affect all residents receiving enteral nutrition at that time. 1. A baseline care plan audit was completed on [DATE] by the Director of Nursing for six (6) residents with enteral feedings to ensure baseline care plans were specific to the residents and tube feeding orders for nutrition, hydration, and/or RD recommendations/interventions were included in the care plan. Six of six (,d+[DATE]) baseline care plans had dietary orders of 'NPO [nothing by mouth]' but have been corrected to include enteral nutrition and hydration orders. The Director of Nursing made this correction to ,d+[DATE] care plans. 2. Upon new admission of a resident receiving enteral feeding the Director of Nursing or designee will notify the RD via telephone call or email of the resident's physical arrival to the facility and review feeding orders to ensure appropriate nutrition and hydration for the resident. This notification will be documented in the progress notes by the notifier. Upon acceptance of a referral from the hospital and planned admission to the facility with discharge orders, the RD will be included in the notification email sent from the Marketing Liaison that is sent out to facility managers for anticipated admission. This is implemented as of [DATE]. This process will be audited by the Administrator within 24 hours of admission of a resident with a g-tube and will continue to be audited for three months to ensure compliance is achieved. If no recommendations are made at the time of admission notification, and there is no immediate concern, the RD will evaluate, remotely or in person, the resident's chart within 24 hours of admission and will document completion of the review in the progress notes. 3. The Administrator and Director of Nursing immediately on [DATE] educated facility RNs and LPNs [licensed practical nurse] in person, or via telephone, on baseline care plan completion and specificity to resident to properly address hydration and nutrition for enteral feeding patients. Physician orders will be included in the dietary section of baseline care plans. As of [DATE], 100% of RNs and LPNs have been informed of the baseline care plan completion process and will sign the in-service sheet on their next scheduled shift. Ten (10) licensed nursing staff were educated in person and nine (9) via telephone. The Director of Nursing will educate new RNs and LPNs hired after [DATE] at new hire orientation of baseline care plan completion process and documentation. The MDS Coordinator is responsible for completing the baseline care plan. The MDS Coordinator was educated on [DATE] of baseline care plan specifications, to include enteral nutrition and hydration orders under dietary. 4. All enteral orders for nutrition and hydration are reviewed weekly at RISK meetings with the interdisciplinary team. This meeting has been held weekly by the Administrator and the Director of Nursing since [DATE]. 5. Baseline care plan audits to be completed by the Director of Nursing with 72 hours of admission for residents with enteral feedings to ensure care plans are specific to resident and include feeding orders for nutrition, hydration, and/or RD recommendations. If negative findings or missing information is identified, the DON will correct at the time of discovery. Audits to be turned in to the Administrator on a weekly basis for three months, reviewed at weekly RISK meeting, and monthly Quality Assurance Meeting. Quality Assurance team members include the Administrator, Director of Nursing, Infection Prevention, Business Office, Social Services, Marketing, Therapy, Activities, Maintenance, Dietary, Medical Records, MDS, Wound Nurse and Human Services. The Medical Director and RD review meeting notes on their following visit. If errors in baseline care plan audits are identified, QA team will discuss an extension of the audits at month three completion. Twelve (12) Quality Assurance team members met at 4:40 PM on [DATE] to review Immediate Jeopardy concerns and action plan for removal of immediacy. Members present: Administrator, Social Services, Business Office, Director of Nursing, Human Resources, Medical Records, Wound Nurse, Therapy, Activities, Maintenance. Responsibilities of Administrator, Director of Nursing and Unit Manager for action plan audits were reviewed. QA team was educated that when an error or missing information is identified in baseline care plan audits, the DON will rectify at the time of discovery. 6. The Medical Director was informed of the Immediate Jeopardy and concern areas on [DATE]. The Medical Director was informed of the action plan for removal and agrees with the resolution plan. 7. All corrections were completed on [DATE]. 8. The immediacy of the IJ was removed on [DATE]. Onsite verification of Removal Plan: The IJ was removed on [DATE] at 7:00 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began at 2:45 PM on [DATE], when staff were informed the Removal Plan was accepted by the State Survey Agency. Verification of licensed staff education was performed. A total of 10 of the 19 staff (three day shift nurses; three evening shift nurses; two night shift nurses; and two other staff, non-nursing) were interviewed in person and/or via telephone. All staff who were interviewed stated they received education regarding ensuring baseline care plans were updated to reflect resident nutrition and hydration needs including physician orders for enteral nutrition and hydration and RD recommendations. Staff indicated that the DON and unit manager would be notified regarding order discrepancies. A review was completed of the facility's audit of six residents receiving enteral feedings for accuracy and appropriate nutrition and hydration interventions. The review revealed interventions were included in baseline and interdisciplinary care plans. A review was completed of the facility's attendance sheet for RISK meetings. Monthly audits of new admission orders and RD recommendations remains ongoing. The Medical Director was interviewed and confirmed he was informed of the IJ.

Based on record review, interviews, and facility policy review, it was determined that the facility failed to ensure 1 (Resident #3) of 7 residents reviewed for assisted nutrition and hydration received adequate fluid intake to maintain proper hydration. Specifically, the facility failed to transcribe discharge orders from the hospital for water with bolus enteral feedings for Resident #3 and failed to implement recommendations from Registered Dietitian (RD) #4 to increase Resident #3's fluids to maintain hydration. This failure resulted in Resident #3 passing away in the facility due to dehydration. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on [DATE] when Resident #3 was admitted to the facility and the hospital discharge orders were not transcribed accurately which resulted in fluids not being provided as ordered. The Administrator and Director of Nursing (DON) were notified of the IJ on [DATE] at 2:12 PM and provided the IJ Template at 2:32 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on [DATE] at 2:45 PM. The IJ was removed on [DATE] at 7:00 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance remained at the lower scope and severity of D that was not immediate jeopardy for F692. Findings included: A review of the facility's undated policy, titled, Resident Hydration and Prevention of Dehydration, indicated, The Dietitian will assess identified at risk residents for hydration adequacy as need [sic]. Minimum fluid needs will be calculated and documented, as appropriate, for at risk residents using current Standards of Practice. The policy indicated, Nursing will assess for signs and symptoms of dehydration during daily care. Another excerpt from the policy directed staff as follows: If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan. Activities of daily living (ADL) status, diagnosis, individual preferences, habits, and cognitive and medical status will be considered in all interventions. Physician will be notified. Additional guidance in the policy indicated, Laboratory tests may be ordered to assess hydration if intake and symptoms indicate possible significate dehydration. If laboratory results are consistent with actual dehydration, the Physician may initiate IV [intravenous] hydration. hospitalization will be recommended, as necessary. Nursing will monitor and document fluid intake and the Dietitian will be kept informed of status. Interdisciplinary team will update care plan and document resident response to interventions until team agrees that fluid intake and related factors are resolved. A review of the facility's policy, titled, Nasogastric/Gastrostomy Tube Feeding, that was last updated [DATE], indicated, Nasogastric/Gastrostomy feedings will be given as ordered by the physician. Nasogastric/Gastrostomy feeding will supply nutrition and medication to residents who are unable to take food by mouth or receive tube feeding to supplement their intake. The policy also included the following guidance, Additional water may be indicated to meet hydration needs. Check with physician and nutrition support specialist as needed. Review of an Admission Record revealed the facility admitted Resident #3 on [DATE] with diagnoses that included traumatic subarachnoid hemorrhage (brain bleed), traumatic brain injury, acute respiratory failure, dysphagia, and fracture of the fifth and sixth cervical vertebrae and nasal bone. A review of Resident #3's Nursing Assessment, dated [DATE], revealed the resident had severely impaired cognitive skills for daily decision making. The assessment indicated the resident used a percutaneous endoscopic gastrostomy (PEG) feeding tube. The assessment indicated the resident had upper and lower extremity impairments on both sides. According to the assessment, Resident #3 had a sacral wound and was always incontinent of bowel and bladder. Review of Resident #'3s Baseline Care Plan, dated [DATE], revealed the resident's diet order was NPO (nothing by mouth), and the resident was to receive tube feedings for nutrition. The baseline care plan did not address hydration. A review of Resident #3's Nursing Home Instructions, within the hospital discharge summary dated [DATE], revealed Resident #3 was to receive 200 milliliters (mL) of water with each bolus tube feeding. A review of Resident #3's [DATE] physician orders indicated the resident was to receive enteral nutrition administered four times a day. There was no physician's order for the additional 200 mL of water, as recommended in the hospital discharge summary. A review of Resident #3's [DATE] Medication Administration Record (MAR) revealed there was no order for the 200 mL of water with each tube feeding bolus, four times a day, and there was no documented evidence indicating the water was provided. A review of Resident #3's Enteral Nutrition Assessment, dated [DATE], revealed the resident was receiving bolus enteral nutrition, four times per day, due to dysphagia. The assessment indicated Resident #3 was receiving 608 cubic centimeters (cc) of fluid per day and the resident's estimated fluid requirement was 1950 cc per day. In the assessment, RD #4 suggested staff change Resident #3's bolus enteral feeding to a continuous enteral feeding at a rate of 55 cc per hour with water auto flushes at 40 cc per hour to provide 1980 kilocalories (kcal) and 84 grams (g) of protein per day with 1963 cc of free water. RD #4 also suggested adding 1 ounce (oz) of liquid protein daily for an additional 15g of protein, a multivitamin (MVI) with minerals to help with wound healing, weekly weights for four weeks, and baseline laboratory tests including a comprehensive metabolic panel (CMP) and prealbumin (PAB). A review of Resident #3's physician visit progress note, dated [DATE], revealed the physician recommended a complete blood count (CBC) laboratory test related to the resident's history of mild thrombocytosis (low blood platelet count) and leukocytosis (high white blood cell count). There was no concern related to Resident #3's hydration status indicated in the note and no recommendation related to the resident's hydration status. Review of the entire medical record, including progress notes from [DATE] through [DATE], indicated the facility did not implement the recommendations made by RD #4. A review of Resident #3's Nurses Notes, dated [DATE] at 8:05 PM, revealed staff found Resident #3 unresponsive. The nurse noted Resident #3 was lying on the resident's back with no noted rise or fall of the chest. Staff were unable to obtain any vital signs. The note indicated cardiopulmonary resuscitation (CPR) was initiated twice by staff members and 911 was called due to the resident's full code status. According to the note, first responders and an emergency ambulance arrived; however, the resident remained unresponsive to CPR or other stimuli. The coroner was contacted by the staff for pronouncement of death. A review of a Forensic Autopsy Report, dated [DATE], revealed Resident #3's final cause of death was dehydration. The report indicated, Analysis of vitreous fluid (liquid from the eyeball) reveals the following: sodium = 140 mmol/L [millimoles per litre], urea nitrogen = 87 mg/dl [milligrams per decilitre], creatinine = 2.5 mg/dl, and glucose = 14.0 mg/dl, consistent with dehydration. During an interview on [DATE] at 12:50 PM, Licensed Practical Nurse (LPN) #1 stated she cared for Resident #3 the day the resident died . She indicated Resident #3 was their usual self, lying in bed with their eyes open or closed, the resident did not speak or respond to stimuli, and required total assistance for all care. She said she administered medications for the resident through the gastrostomy tube around 5:00 PM or 5:30 PM and checked the gastrostomy tube for gastric residual volume. LPN #1 said she administered the medications and the resident's bolus feeding through the gastrostomy tube per gravity with no concerns. She noted that at 8:00 PM the certified nurse aide (CNA) reported to her that Resident #3 was not breathing. She and other staff started CPR and called 911. During an interview on [DATE] at 1:50 PM, CNA #7 stated she provided care for Resident #3 the day the resident died . She said Resident #3 required total assistance with all activities of daily living (ADLs). CNA #7 said she provided Resident #3 with incontinence care around 4:30 PM on [DATE]. She stated the resident's eyes were open, but did not respond when she explained what care she was going to provide, but that was not unusual. CNA #7 said that after she delivered room trays around 6:00 PM or 6:30 PM she was going to check on Resident #3, but bypassed Resident #3 because the nurse was in the room administering medications for the resident. She noted the next time she went to check on Resident #3 was at 8:00 PM. CNA #7 said at that time the resident felt cold and did not appear to be breathing, so she went to get the nurse and the nurse started CPR and called 911. During an interview on [DATE] at 2:15 PM, RD #4 stated she no longer worked for the facility. She said that when she made a recommendation, she would typically review it with the nurses because she was not allowed to write a physician's order. She said that while working for the facility in [DATE], she was not sure who she was supposed to notify in the facility of her recommendations because there was not a consistent unit manager or DON because of staff turnover. She stated she did not remember what recommendations were made for Resident #3 after she completed the resident's nutritional assessment on [DATE] or who in the facility she communicated with regarding her recommendations. She stated if she did not verbally communicate her recommendations, she would send the recommendations via fax or email. RD #4 could not provide written verification that she communicated her recommendations to the facility. During an interview on [DATE] at 4:58 PM, Resident #3's physician stated he no longer had any affiliation with the facility and had not worked for the facility since October of 2022. He said he no longer had access to Resident #3's information and could not answer any questions related to patient care. Three attempts to contact Resident #3's admitting registered nurse (RN) were made via telephone on [DATE] at 2:00 PM, on [DATE] at 3:44 PM, and on [DATE] at 7:24 PM. Messages were left each time, but the admitting RN did not return any of the calls. During an interview on [DATE] at 12:40 PM with the Administrator (ADM) and Director of Nursing (DON), they both stated they started working at the facility in [DATE]. The DON stated she was not aware of any care concerns related to Resident #3. The ADM said she became aware of concerns regarding Resident #3 after receiving multiple calls from Resident #3's family member but could not elaborate on the issues because she was not present when the resident was in the facility. The DON said that when a resident was admitted to the facility, the admitting nurse needed to verify the orders and have the physician review them. Then the unit manager or DON was responsible for entering the admission orders into the electronic record. She said the floor nurses completed the new admission assessment if she or the unit manager were not in the building. She said physician orders for the type of enteral formula needed to be in place. If there were concerns, then nursing staff contacted her directly. The DON said if a resident was receiving enteral nutrition, she would expect nursing staff to assess if the resident was tolerating the enteral feeding. The DON said she could not speak to what staff did regarding Resident #3's care in [DATE], because the DON and the ADM were not working at the facility at that time. The ADM and DON were notified of the determination of IJ on [DATE] at 2:12 PM. A Removal Plan was requested. During an interview on [DATE] at 10:00 AM, the Medical Director said he started working at the facility in mid-October of 2022. He noted he was physically in the building once a week, and attended quality assurance (QA) meetings, which were held monthly. He indicated staff had been responsive and had updated him with any concerns or issues. He stated someone from the facility made him aware of the concerns which led to the IJ. He said he did not know the whole situation, but the facility was addressing the issues and he agreed with the plan. Removal Plan: The following IJ Removal Plan was provided by the facility and accepted by the State Survey Agency on [DATE] at 2:45 PM: Discharge orders from the hospital were not properly transcribed at the time of admission for Resident #3. This negatively impacted the resident by failing to provide appropriate nutrition and hydration to the resident. Inaccurate order entry of enteral feeding orders had the ability to affect all residents receiving enteral nutrition at that time. 1. The Administrator and Director of Nursing immediately on [DATE] educated licensed RNs and LPNs, in person and via telephone, on the process of new admission orders being transcribed into the electronic medical record at the time of or prior to admission for residents admitted from the hospital. Facility policy created and implemented for medication admission orders, licensed RNs and LPNs educated on this policy. Policy created [DATE], titled, 'Medication Admission Orders.' Policy intent: It is the policy of [name of facility] to provide the pharmacy with current, accurate resident information upon admission to ensure legal and safe medication and enteral nutrition dispensing. Please reference this policy on pg. 3. As of [DATE], 100% of RNs and LPNs have been informed that the Director of Nursing transcribes hospital orders for new admissions. Ten (10) licensed nursing staff were educated in person and nine (9) via telephone. The Director of Nursing will educate new RNs and LPNs hired after [DATE] at new hire orientation of new admission orders. If the Director of Nursing is not present, the Unit Manager completes this. This is for all weekday, weekend, and off-hours admissions. 2. Licensed RNs and LPNs educated immediately on [DATE], in person and via telephone, on the process of receiving and implementation of Registered Dietician (RD) recommendations for current and new admitting resident with enter feed orders. Nursing staff educated that physician is notified of RD recommendations from the DON or Unit Manager at the time of receiving the recommendation. The RD turns in recommendations directly at the end of her weekly visit or communicates them via telephone or email for any immediate concerns. As of [DATE], 100% of RNs and LPNs have been informed that the Director of Nursing or Unit Manager informs the physician of RD recommendations at the time of receipt, and recommendations are received on a weekly basis or as needed. A progress note is entered by the Director of Nursing that the MD has been notified and new recommendation has been implemented. Ten (10) licensed nursing staff were educated in person and nine (9) via telephone. The Director of Nursing will educate new RNs and LPNs hired after [DATE] at new hire orientation of new admission orders. Licensed RNs and LPNs educated that if an order looks incorrect or insufficient regarding nutrition and hydration of residents with g-tubes, to immediately notify the Director of Nursing for clarification. 3. Audit completed on [DATE] of six (6) residents receiving enteral feedings by RD to ensure all residents are receiving adequate and appropriate nutrition and hydration via enteral feeding. One recommendation was made and given directly to the DON, who notified the physician and put new orders in the electronic medication administration record (EMAR). The DON documented recommendation receipt in the progress notes. The remaining five residents were noted to have orders for adequate nutrition, hydration, and energy for enteral feeding of residents. 4. All enteral orders for nutrition and hydration are reviewed weekly at RISK meetings with interdisciplinary team. This meeting has been held weekly by the Administrator and Director of Nursing since [DATE]. 5. New admission audits for residents on enteral feedings to be completed with 24 hours of admission by the Director of Nursing for three months to ensure orders are transcribed accurately. Audits to be turned in to the Administrator on a weekly basis, reviewed at weekly RISK meetings, and monthly Quality Assurance meetings. Quality Assurance team members include the Administrator, Director of Nursing, Infection Prevention, Business Office, Social Services, Marketing, Therapy, Activities, Maintenance, Dietary, Medical Records, MDS, Wound Nurse and Human Resources. The Medical Director and RD review meeting notes on their following visit. If negative findings or missing information is identified, the DON will correct at the time of discovery. If errors in admission orders audit are identified, QA team will discuss an extension of audits at month three completion. Twelve (12) Quality Assurance team members met at 4:40 PM on [DATE] to review Immediate Jeopardy concerns and action plan for removal of immediacy. Members present: Administrator, Social Services, Business Office, Director of Nursing, Human Resources, Medical Records, Wound Nurse, Therapy, Activities, Maintenance. Responsibilities of Administrator, Director of Nursing and Unit Manager for action plan audits were reviewed. QA team was educated that when an error or missing information is identified on admission orders or RD/Physician notification of recommendation, DON will rectify at time of discovery. 6. The Medical Director was informed of Immediate Jeopardy and concern areas on [DATE]. The Medical Director was informed of the action plan for removal and agrees with the resolution plan. 7. All corrections were completed on [DATE]. 8. The immediacy of the IJ was removed on [DATE]. Onsite verification of Removal Plan: The IJ was removed on [DATE] at 7:00 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began at 2:45 PM on [DATE], when staff were informed the Removal Plan was accepted by the State Survey Agency. Verification of licensed staff education was performed. A total of 10 of the 19 staff (three day shift nurses; three evening shift nurses; two night shift nurses; and two other staff, non-nursing) were interviewed in person and/or via telephone. All staff who were interviewed stated they received education regarding ensuring admission orders were transcribed accurately, RD recommendations were communicated to the DON and unit manager with follow-up with the physician for implementation, and order discrepancies were to be clarified with the DON and unit manager. A review was completed of the facility's Medication Admission Orders policy and verified the policy was created. A review was completed of the facility's audit of six residents receiving enteral feedings for accuracy of appropriate nutrition and hydration. It was verified that one recommendation was made and the DON notified the physician, put new orders into the EMAR, and documented in the progress notes. A review was completed of the facility's sign in sheet for the facility's RISK meetings. Monthly audits of new admission orders and RD recommendations remains ongoing. The Medical Director was interviewed and confirmed he was informed of the IJ.

Based on review of facility policy, record review, observations, and interviews, the facility failed to ensure that temperatures in resident rooms were maintained at a safe and comfortable range, in 1 of 3 resident units. Findings include: Review of the facility's undated policy titled Disaster and Emergency Preparedness Policy and Procedure revealed, In order to ensure the safety and security of all residents and staff during a disaster or emergency, RNC has defined the following policies and procedures, developed by an all hazards approach . The facility will ensure provision for the needs of staff and residents during disasters and emergencies, whether they evacuate or shelter in place. Specifically, natural disasters, man-made disasters, facility based emergencies, and emerging infectious diseases . On 07/29/2022 at an unspecified time, the State Agency received a complaint from Emergency Medical Technician (EMT) regarding the air conditioning (AC) being broken at the facility. EMT stated the temperatures were over 90 degrees Fahrenheit (F) and they were transporting a resident due to the facility being too hot. The State Agency contacted Fire Life Safety (FLS) to investigate this complaint. A follow up interview with the EMT was unsuccessful. On 07/29/2022 at an unspecified time, FLS was onsite at the facility. The State Agency received an update from FLS that the temperature was 85 degrees Fahrenheit (F) on one wing. FLS reported if the facility can not get the temperatures down, they have a plan to move the residents to a different wing or in the common area. The facility has ordered new AC units and compressors, which are enroute to the facility. A request was made to the Maintenance Director (MD) to send documentation of temperature logs every hour until the temperatures were below 82 degrees F and then submit temperature logs every six (6) hours. Review of the temperature logs dated 07/29/2022 thru 08/01/2022, revealed documented temperatures never exceeded 80 degrees F. A follow up email with FLS on 08/01/2022 regarding FLS's onsite visit on 07/29/2022 revealed, Yes temperatures were above 82 upon my arrival. The highest temperature that I had a reading of was 85 degrees. They were in the process of installing 5 window ac units and 2 portable units while I was on site . On 07/29/2022 at 9:40 PM the State Agency's Director of Nursing Home Oversight (DNHO) conducted a phone interview with a nurse working on Unit B of the facility, regarding the AC being fixed. The interview revealed, the unit is much cooler from earlier today and they are installing more AC units currently. On the morning of 07/31/2022 at an unspecified time, the State Agency continued to receive complaints regarding the AC unit being broken and temperatures in the facility were hot. A survey team was dispatched and arrived on site at approximately 1:30 PM. An interview with the Unit Supervisor (US) on 07/31/2022 at 1:35 PM revealed, the Director of Nursing and the Administrator were not available. An initial walkthrough of the facility on 07/31/2022 at 1:45 PM, revealed the air conditioner was still broken on Unit B. Unit B contained twenty one (21) resident rooms and one (1) resident therapy room. Observations revealed, an industrial fan/blower was set up at the entrance to Unit B, pointing down the hallway. Further observation revealed, six (6) resident rooms contained a window AC unit or a portable AC unit. Multiple resident rooms were observed to have fans. This surveyor along with the Maintenance Director (MD) observed temperatures of resident rooms on Unit B. The MD used a laser air temperature thermometer to measure the air temperature. The following rooms on Unit B had observed temperatures above the safe and comfortable regulated temperatures: Room 146 - 82.9 degrees Fahrenheit (F) Room 162 - 83.1 degrees F Room 166 - 84.2 degrees F Room 167 - 83.8 degrees F An interview with the MD on 07/31/2022 at 2:00 PM revealed, the MD did not take the temperatures in the resident rooms. The MD delegated this responsibility to the nursing staff. The MD further stated they never had temps over 80 degrees. An interview with multiple nursing staff on 07/31/2022 at varied times, revealed the AC has been broken for a few days. Nursing staff further stated that multiple residents have been complaining about how hot it is in their room. On 07/31/2022 at 4:40 PM, the US was notified of the survey team's concerns related to the AC being broken and the temperatures in resident rooms. The US called the Administrator and the survey team's concerns were addressed with the Administrator over the phone. The Administrator stated she was driving back from West Virginia and would not be able to make it to the facility, but did state she would give directions to the MD and US on how to fix the issue. A combined interview with the MD and US on 07/31/2022 at 4:43 PM revealed, the Administrator directed the MD to move a portable AC unit from the Therapy room to one of the resident rooms that was hot. And the US was instructed to go to the store and purchase more portable AC units for the other hot room. On 07/31/2022 at approximately 8:00 PM, the US returned to the facility with more window AC units. The MD received them and begin installing the window AC units in the designated rooms. On 07/31/2022 at approximately 9:30 PM the survey team had to exit the facility due to following COVID protocol. The survey team was not able to complete the survey. On 08/01/2022 at 12:45 PM another survey team entered the facility. On 08/01/2022 at 12:45 PM a walk through was conducted with MD on Unit B to obtain room temperatures. The hallway on Unit B was 81 degrees F. The following room temperatures on Unit B were above the safe and comfortable regulated temperature: Room 146 - 84 degrees F Room 161 - 82.8 degrees F Therapy room - 87 degrees F Review of the outside temperatures, provided by Accuweather.com, revealed the following: 07/29/2022 - high of 95 degrees F, with a low of 78 degrees F 07/30/2022 - high of 96 degrees F, with a low of 79 degrees F 07/31/2022 - high of 97 degrees F, with a low of 79 degrees F 08/01/2022 - high of 97 degrees F, with a low of 77 degrees F An observation and interview with Resident (R)1 in room 162 on 08/01/22 at 1:30 PM, revealed a window AC unit and room temperature was 81.1 degrees F. R1 states the AC unit has been broken about a month. R1 states that the unit was placed in the window last night 7/31/22 at around 10:00 PM. The temperature is getting better, but the room has been hot for a while. An observation and interview with R2 in room 166 on 08/01/2022 at 1:35 PM revealed, a window AC unit and room temperature was 79.9 degrees F. R2 states that it has been hot as h*** in the room, until last night. R2 stated that he did not know what the facility was waiting on to get the unit fixed but it has been very uncomfortable. An observation and interview with R3 in room 146 on 08/01/2022 at 1:40 PM revealed, a window AC unit and a fan blowing directing on R3 and room temperature was 84 degrees F. R3 states she was admitted to facility on Wednesday 7/27/22 and the air was off when she got to her room. R3 further stated she has been hot in her room until last night when she received the window AC unit. An observation and interview with R4 in room 167 on 08/01/2022 at 1:45 PM revealed, a window AC unit and room temperature was 73.9 degrees F. R4 states the temperature has gotten a little better, but it has been hot in his room since last Wednesday. R4 further stated he received his window AC unit today. An interview with the MD on 08/01/2022 at 1:55 PM revealed, the AC unit has been broken since Friday 07/29/2022 and [NAME]-Chase HVAC Company was notified and they have been working on the unit since. Review of an e-mail correspondence between [NAME]-Chase HVAC and the Administrator confirmed that appointments were made with [NAME]-Chase heating and Air on Tuesday 07/19/2022, Tuesday 07/26/2022, Friday 07/29/2022, Sunday 07/31/2022 and Monday 08/01/2022. Review of invoices revealed that [NAME]-Chase HVAC performed service on the AC unit on 07/19/2022 and 07/26/2022. On 08/01/2022 at 3:40 PM the CMS Immediate Jeopardy Template was presented to the Administrator regarding the broken AC unit affecting Unit B of the facility. Four (4) rooms were observed to have temperatures above the safe and comfortable regulated range. On 08/01/2022 at approximately 10:00 PM the survey team had to exit the facility due to following COVID protocol. The survey team was not able to complete the survey. On 08/02/2022 at an unspecified time the Administrator emailed the State Agency an acceptable removal plan related to the IJ. The removal plan included the following: What Corrective action will be accomplished for the residents found to have been affected by the deficient practice? 1. F584 states that residents have the right to a safe, clean comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely, including comfortable temperature. [NAME]-Chase HVAC Company came to the facility on [DATE] & changed out the capacitor on the outside unit to provide a safe, comfortable, cool environment. At the time of arrival, [NAME]-Chase determined the motor was bad from the factory on the outdoor unit. [NAME]-Chase was able to get the unit running without the new motor. They had overnighted the motor & it arrived & was installed on 8/2/22. The unit began cooling down the B wing below 81 degrees Fahrenheit immediately. All rooms have split units running. Additional window air conditioning units & fans placed in rooms are running to assist with the cool down. A commercial fan was placed at the end of the unit to assist with cooling. 2. [NAME]-Chase contacted Sunbelt rentals for a 12-ton portable air conditioning unit to be deployed if the current facility outdoor unit were to fail. [NAME]-Chase performed a site visit to see what materials needed to be acquired if the need for the 12-ton rental unit would be needed. All materials were acquired by [NAME]-Chase in preparation of the rental unit if needed. [NAME]-Chase was on stand-by. If the facility unit were to fail, the Maintenance Director/Nurse on B Wing would call the Administrator who will then notify [NAME]-Chase to have the rental unit deployed to our facility. Sunbelt would deploy the unit at that time & [NAME]-Chase would come to the facility to immediately install it. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 1. All resident rooms on B Wing have the potential to be affected. All resident rooms on B Wing had a temperature check between 3 pm & 4 pm on 8/1/22. Room 146 had an ambient air temperature of 81.2 degrees, Room 153 had an ambient air temperature of 81.3 degrees, Room 162 had an ambient air temperature of 81.9 degrees & Room 167 had an ambient air temperature of 81.3 degrees. 2. The 4 rooms: 146, 153, 162 & 167 all had fans repositioned & window air conditioning units were ensured to be running on high. The Room temperatures were retaken 15 minutes later & the room temps at that time were: Room 146- 80 degrees, Room 153- 80.6 degrees, Room 162- 81 degrees & Room 167- 80.4 degrees. What measures will be put in place or what systemic changes will be made to ensure that the deficient practice will not reoccur? 1. The Maintenance Director/ Nurse on B Wing continued taking ambient air room temperatures on B Wing hourly until the motor for the outside air conditioning unit was installed to ensure a comfortable environment would be obtained & maintained. The Maintenance Director/ Designee will continue to take ambient air temperatures in at least 3 rooms & record the results daily & ongoing. 2. A preventative maintenance plan for the air conditioner on Bwing will be initiated & will have the unit serviced quarterly to reduce the risk of the air conditioner unit failing again. The initial preventative maintenance will be performed on 8/10/22. 3. The Administrator has educated the Maintenance Director/ Nurse on B Wing to immediately notify her if the ambient air temperatures in any resident room exceeds 81 degrees Fahrenheit. 4. Any resident noted to be in a room with an ambient air temperature greater than 81 degrees will be relocated to a cooler area in the facility, such as the dining room, until his/her room is 81 degrees or cooler. 5. Residents were offered cold water or juice, in addition to their pitcher of water at bedside, hourly to provide comfort & to prevent dehydration. 6. All residents on B Wing had their temperatures taken every 4 hours until the motor was installed to ensure they did not become overheated & a comfortable environment was maintained. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. 1. An Audit will be conducted by the Administrator of resident room temperatures taken by the Maintenance Director/Nurse on B Wing every hour while the room temperatures are 81 degrees or above and every 4 hours once all room temperatures are at 80 degrees or below until the new motor is installed on the outside facility unit for B Wing. Audit of B Wing room temperatures will then be daily x 7 days, weekly x 4 weeks & monthly x 3 months. Date of Completion: August 4, 2022 Due to the State Agency not having available surveyors due to following COVID protocol a survey team was not able to enter the facility until 08/08/2022. On 08/08/2022 at 1:47 PM another survey team was sent to the facility. The survey team was able to verify the removal of immediacy of the IJ by verifying resident room temperatures were at a safe and comfortable level. Additionally, the survey team was able to verify the AC unit was fixed.

Based on review of facility policy, record review, observations, and interviews, the facility failed to maintain essential, safe operating equipment, in 1 of 3 resident units. Findings include: Review of the facility's undated policy titled Disaster and Emergency Preparedness Policy and Procedure revealed, In order to ensure the safety and security of all residents and staff during a disaster or emergency, RNC has defined the following policies and procedures, developed by an all hazards approach . The facility will ensure provision for the needs of staff and residents during disasters and emergencies, whether they evacuate or shelter in place. Specifically, natural disasters, man-made disasters, facility based emergencies, and emerging infectious diseases . On 07/29/2022 at an unspecified time, the State Agency received a complaint from Emergency Medical Technician (EMT) regarding the air conditioning (AC) being broken at the facility. EMT stated the temperatures were over 90 degrees Fahrenheit (F) and they were transporting a resident due to the facility being too hot. The State Agency contacted Fire Life Safety (FLS) to investigate this complaint. A follow up interview with the EMT was unsuccessful. On 07/29/2022 at an unspecified time, FLS was onsite at the facility. The State Agency received an update from FLS that the temperature was 85 degrees Fahrenheit (F) on one wing. FLS reported if the facility can not get the temperatures down, they have a plan to move the residents to a different wing or in the common area. The facility has ordered new AC units and compressors, which are enroute to the facility. A request was made to the Maintenance Director (MD) to send documentation of temperature logs every hour until the temperatures were below 82 degrees F and then submit temperature logs every six (6) hours. Review of the temperature logs dated 07/29/2022 thru 08/01/2022, revealed documented temperatures never exceeded 80 degrees F. A follow up email with FLS on 08/01/2022 regarding FLS's onsite visit on 07/29/2022 revealed, Yes temperatures were above 82 upon my arrival. The highest temperature that I had a reading of was 85 degrees. They were in the process of installing 5 window ac units and 2 portable units while i was on site . On 07/29/2022 at 9:40 PM the State Agency's Director of Nursing Home Oversight (DNHO) conducted a phone interview with a nurse working on Unit B of the facility, regarding the AC being fixed. The interview revealed, the unit is much cooler from earlier today and they are installing more AC units currently. On the morning of 07/31/2022 at an unspecified time, the State Agency continued to receive complaints regarding the AC unit being broken and temperatures in the facility were hot. A survey team was dispatched and arrived on site at approximately 1:30 PM. An interview with the Unit Supervisor (US) on 07/31/2022 at 1:35 PM revealed, the Director of Nursing and the Administrator were not available. An initial walkthrough of the facility on 07/31/2022 at 1:45 PM, revealed the air conditioner was still broken on Unit B. Unit B contained twenty one (21) resident rooms and one (1) resident therapy room. Observations revealed, an industrial fan/blower was set up at the entrance to Unit B, pointing down the hallway. Further observation revealed, six (6) resident rooms contained a window AC unit or a portable AC unit. Multiple resident rooms were observed to have fans. This surveyor along with the Maintenance Director (MD) observed temperatures of resident rooms on Unit B. The MD used a laser air temperature thermometer to measure the air temperature. The following rooms on Unit B had observed temperatures above the safe and comfortable regulated temperatures: Room 146 - 82.9 degrees Fahrenheit (F) Room 162 - 83.1 degrees F Room 166 - 84.2 degrees F Room 167 - 83.8 degrees F An interview with the MD on 07/31/2022 at 2:00 PM revealed, the MD did not take the temperatures in the resident rooms. The MD delegated this responsibility to the nursing staff. The MD further stated they never had temps over 80 degrees. An interview with multiple nursing staff on 07/31/2022 at varied times, revealed the AC has been broken for a few days. Nursing staff further stated that multiple residents have been complaining about how hot it is in their room. On 07/31/2022 at 4:40 PM, the US was notified of the survey team's concerns related to the AC being broken and the temperatures in resident rooms. The US called the Administrator and the survey team's concerns were addressed with the Administrator over the phone. The Administrator stated she was driving back from West Virginia and would not be able to make it to the facility, but did state she would give directions to the MD and US on how to fix the issue. A combined interview with the MD and US on 07/31/2022 at 4:43 PM revealed, the Administrator directed the MD to move a portable AC unit from the Therapy room to one of the resident rooms that was hot. And the US was instructed to go to the store and purchase more portable AC units for the other hot room. On 07/31/2022 at approximately 8:00 PM, the US returned to the facility with more window AC units. The MD received them and begin installing the window AC units in the designated rooms. On 07/31/2022 at approximately 9:30 PM the survey team had to exit the facility due to following COVID protocol. The survey team was not able to complete the survey. On 08/01/2022 at 12:45 PM another survey team entered the facility. On 08/01/2022 at 12:45 PM a walk through was conducted with MD on Unit B to obtain room temperatures. The hallway on Unit B was 81 degrees F. The following room temperatures on Unit B were above the safe and comfortable regulated temperature: Room 146 - 84 degrees F Room 161 - 82.8 degrees F Therapy room - 87 degrees F Review of the outside temperatures, provided by Accuweather.com, revealed the following: 07/29/2022 - high of 95 degrees F, with a low of 78 degrees F 07/30/2022 - high of 96 degrees F, with a low of 79 degrees F 07/31/2022 - high of 97 degrees F, with a low of 79 degrees F 08/01/2022 - high of 97 degrees F, with a low of 77 degrees F An observation and interview with Resident (R)1 in room 162 on 08/01/22 at 1:30 PM, revealed a window AC unit and room temperature was 81.1 degrees F. R1 states the AC unit has been broken about a month. R1 states that the unit was placed in the window last night 7/31/22 at around 10:00 PM. The temperature is getting better, but the room has been hot for a while. An observation and interview with R2 in room 166 on 08/01/2022 at 1:35 PM revealed, a window AC unit and room temperature was 79.9 degrees F. R2 states that it has been hot as h*** in the room, until last night. R2 stated that he did not know what the facility was waiting on to get the unit fixed but it has been very uncomfortable. An observation and interview with R3 in room 146 on 08/01/2022 at 1:40 PM revealed, a window AC unit and a fan blowing directing on R3 and room temperature was 84 degrees F. R3 states she was admitted to facility on Wednesday 7/27/22 and the air was off when she got to her room. R3 further stated she has been hot in her room until last night when she received the window AC unit. An observation and interview with R4 in room 167 on 08/01/2022 at 1:45 PM revealed, a window AC unit and room temperature was 73.9 degrees F. R4 states the temperature has gotten a little better, but it has been hot in his room since last Wednesday. R4 further stated he received his window AC unit today. An interview with the MD on 08/01/2022 at 1:55 PM revealed, the AC unit has been broken since Friday 07/29/2022 and [NAME]-Chase HVAC Company was notified and they have been working on the unit since. Review of an e-mail correspondence between [NAME]-Chase HVAC and the Administrator confirmed that appointments were made with [NAME]-Chase heating and Air on Tuesday 07/19/2022, Tuesday 07/26/2022, Friday 07/29/2022, Sunday 07/31/2022 and Monday 08/01/2022. Review of invoices revealed that [NAME]-Chase HVAC performed service on the AC unit on 07/19/2022 and 07/26/2022. On 08/01/2022 at 3:40 PM the CMS Immediate Jeopardy Template was presented to the Administrator regarding the broken AC unit affecting Unit B of the facility. Four (4) rooms were observed to have temperatures above the safe and comfortable regulated range. On 08/01/2022 at approximately 10:00 PM the survey team had to exit the facility due to following COVID protocol. The survey team was not able to complete the survey. On 08/02/2022 at an unspecified time the Administrator emailed the State Agency an acceptable removal plan related to the IJ. The removal plan included the following: What Corrective action will be accomplished for the residents found to have been affected by the deficient practice? 1. The regulation requires that facilities maintain all mechanical, electrical and patient care equipment in safe operating condition. [NAME]-Chase HVAC Company came to the facility today & changed out the capacitor on the outside unit to address the essential equipment & ensure that it is in operating condition. At that time of arrival today, [NAME]-Chase determined the motor was bad from the factory on the outdoor unit. They have the unit running currently. They have overnighted the motor & it is anticipated to be here tomorrow & it will be installed at that time. The unit is cooling down to be below 81 degrees Fahrenheit. All rooms have split units running on cool. Additional window air conditioning units & fans placed in rooms are running to assist with the cool down. A commercial fan was placed at the end of the unit to assist with cooling. 2. [NAME]-Chase contacted Sunbelt rentals for a 12-ton portable air conditioning unit to be deployed if the current facility outdoor unit were to fail. [NAME]-Chase performed a site visit to see what materials needed to be acquired if the need for the 12-ton rental unit would be needed. All materials were acquired by [NAME]-Chase in preparation of the rental unit if needed. [NAME]-Chase is on stand-by. If the facility unit were to fail, the Maintenance Director/Designee is to call the Administrator who will then notify [NAME]-Chase to have the rental unit deployed to our facility. Sunbelt will deploy the unit at that time & [NAME]-Chase will come to the facility to immediately install it. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 1. All resident rooms on B Wing have the potential to be affected. All resident rooms on B Wing had a temperature check between 3pm & 4pm today. Room 146 had an ambient air temperature of 81.2, Room 153 had an ambient air temperature of 81.3 degrees, Room 162 had an ambient air temperature of 81.9 degrees & Room 167 had an ambient air temperature of 81.3 degrees. 2. The 4 rooms 146, 153, 162 & 167 all had fans repositioned & window air conditioning units were ensured to be running on high. The Room temperatures were retaken 15 minutes later & the room temps at that time were: Room 146- 80 degrees, Room 153- 80.6 degrees, Room 162- 81 degrees & Room 167- 80.4 degrees. What measures will be put in place or what systemic changes will be made to ensure that the deficient practice will not reoccur? 1. The Maintenance Director/ Nurse on B Wing will continue taking ambient air room temperatures on B Wing hourly until the motor for the outside air conditioning unit is installed and then he will continue to take ambient air temperatures in at least 3 rooms & record the results daily & ongoing. 2. A preventative maintenance plan for the air conditioner on B wing will be initiated & will have the unit serviced quarterly to reduce the risk of the air conditioner unit failing again. 3. The Administrator has educated the Maintenance Director/ Nurse on B Wing to immediately notify her if the ambient air temperatures in any resident room exceeds 81 degrees Fahrenheit. 4. Any resident noted to be in a room with an ambient air temperature greater than 81 degrees will be relocated to a cooler area in the facility, such as the dining room, until his/her room is 81 degrees or cooler. 5. Residents will be offered cold water or juice, in addition to their pitcher of water at bedside, hourly to provide comfort & to prevent dehydration. 6. All residents on B Wing will have their temperature taken every 4 hours to ensure they are not overheated. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained 1. An Audit will be conducted by the Administrator of resident room temperatures taken by the Maintenance Director/Nurse on B Wing every hour while the room temperatures are 81 degrees or above and every 4 hours once all room temperatures are at 80 degrees or below until the new motor is installed on the outside facility unit for B Wing. Audit of B Wing room temperatures will then be daily x 7 days, weekly x 4 weeks & monthly x 3 months. Due to the State Agency not having available surveyors due to following COVID protocol a survey team was not able to enter the facility until 08/08/2022. On 08/08/2022 at 1:47 PM another survey team was sent to the facility. The survey team was able to verify the removal of immediacy of the IJ by verifying resident room temperatures were at a safe and comfortable level. Additionally, the survey team was able to verify the AC unit was fixed.

Based on observations, interviews, record reviews, and review of the facility's policy titled, Exit Seeking/Elopement, the facility failed to provide adequate supervision for 1 of 1 resident reviewed for accidents related to wandering. Resident (R)1 had a successful elopement on 4/2/22 at approximately 3:30 AM and was found by a facility agency staff member, 1.3 miles away from the facility on North [NAME] Smart Boulevard, in front of the Piggly Wiggly store. R1 was returned to the facility at approximately 5:34 AM. R1 obtained a skin tear to his right great toe. R1 was wearing a white tee shirt and blue sweatpants and no shoes, and the outside temperature was around 54 degrees Fahrenheit. On 4/5/22 at 12:40 PM, an Immediate Jeopardy (IJ) template was provided to the Administrator, notifying her IJ existed at F689 due to the facility's failure to adequately monitor R1, who has wandering behaviors, with an effective date of 4/2/22. On 4/5/22 at approximately 4:40 PM, the facility provided an acceptable IJ Removal Plan related to F689. The IJ was lowered to a scope and severity of D. Additionally, the failure constituted substandard quality of care, warranting the completion of an extended survey. The facility's removal plan for F689 included: 1) Clinical Leadership will ensure that appropriate interventions are in place for each resident by reviewing physician orders and updating care plans to reflect wandering/elopement risk. 2) Administrator initiated education on exit seeking/elopement policy with all-staff inserviced. 3) Ongoing education will be provided by Clinical Leadership for all new hires during orientation. 4) Regular elopement drills will be held weekly on all shifts to reduce the risk of elopement. 5) Kennedy Controls to go to the facility to evaluate all other exit doors in facility that do not have alarm enunciator and to install enunciators as soon as possible. 6) Additional staff person will be added to the 11-7 shift to continuously walk the halls observing all exit doors and residents with exit-seeking behaviors until the enunciators have been successfully installed on each exit door. Implementation of the removal plan was verified through observations, staff interviews, and record reviews. Observation verified that all doors were functioning successfully with the wanderguards being used in the facility. Documentation review revealed that staff was educated with demonstration check offs on the use of wanderguards, immediacy on responding to door alarms, and following the elopement policy and procedures. These trainings were conducted on 04/04/22. Findings include: R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to: unspecified dementia without behavioral disturbances and alcohol dependency. Review of the Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 01/13/22 revealed, R1 was not cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) score 00 out of 15. R1 requires assistance from one staff member for some Activities of Daily Living (ADLs). The facility submitted a 24 hour report via facsimile to the State Agency on 04/02/22 indicating that around 4:24 AM on 04/02/22, staff started their rounds and noted that R1 was not in his room. Staff immediately began searching the facility and could not locate R1. An agency staff member saw R1 down the street, in front of the Piggly Wiggly, and asked R1 to get into her car to go home. R1 got into the car and was back at the facility at approximately 5:34 AM on 04/02/22. R1 was assessed and a skin tear was noted to exist under R1's right great toe and voiced complaint of slight lower back discomfort. R1's family and physician were left voice messages by the nurse. A record review of R1's progress note dated 4/2/22 states; At approximately 04:45 AM staff could not locate R1. All staff in the building alerted and all rooms were searched. Resident was not located in the facility. Administrator was made aware and 911 called. R1 was found by an agency staff member walking on the sidewalk on N [NAME] Smart Boulevard, in front of the Piggly Wiggly store. Resident was returned back to the facility by agency staff. Record review of R1's care plan with a creation date of 1/19/22 revealed he requires assistance with activities of daily living, has a diagnosis of dementia, history of right [CONDITION(S)], alcohol dependence, frequent falls and malnutrition. He experiences weakness and has a poor sense of safety. He has a history of wandering and exit seeking. It was updated on 4/5/22 to include his recent elopement on 4/2/22. Review of the monthly orders dated April 2022 revealed a wanderguard was added to R1's Physician orders as of 4/5/22. During the investigation on 04/05/22 at 1:10 PM, the Director of Nursing (DON) reported being aware of what door R1 exited and a tour was conducted of the facility with the DON. During the tour of 04/05/22 at 1:13 PM, the DON demonstrated the use of the door and held the bar down 15 seconds and it alarmed. The sound was not as loud as the other doors in the facility. The DON reported this door is not equipped with a sensor for the wanderguard, due to the low volume of the alarm, staff could not hear it alarming. During the investigation on 04/05/22 at 1:15 PM, the Maintenance Supervisor reported he checks the alarm on the door weekly and reported he does not have any paperwork to support this. He further reported that the facility requested a quote to update the alarm and this too, he did not have any paperwork to support. Review of the facility's policy Exit Seeking/Elopement Policy and Procedure, without date, revealed the facility is to provide a course of action by the staff in the event a resident has displaced exit seeking behaviors or leaves the premises without notifying staff or their intention to do so. During an interview on 04/05/22 at 9:30 AM, the Administrator stated she received a call from staff on 04/02/22 at 3:40 AM reporting that R1 was not in the facility and was last seen between 3:15 AM - 3:30 AM, when he was put in bed with a tee shirt and wearing a brief. When staff started rounds at 4:24 AM, R1 was not in his room. Staff began to look for R1 in rooms and then went outside and this is when they heard the back service door alarm going off and reports the alarm was not heard prior to going outside to look for R1, as that alarm is not very loud. The door is equipped with a 15-minute egress alarm and R1 knows if he pushes on it, it will open. The Administrator reported that R1 was not on 1:1 and is normally very accommodating, but at nights he does wander. R1 is ordered to have a wander guard and the Administrator reported that he was wearing it, but the door that he left out of does not have a sensor for the wander guard on it. R1 was wearing a white tee shirt and blue sweatpants and no shoes, and the outside temperature was around 54 degrees Fahrenheit. A staff member was driving around the area by the local Piggly Wiggly store which is 1.3 miles away from the facility. The store is on a two-lane highway and staff saw R1 and asked him to get in her car and she drove R1 back to the facility. When R1 was assessed by the nurse he was found to have skin tear to his right great toe and no other injuries. During an interview on 04/05/22 at 9:40 AM, the Director of Nursing (DON) stated that he was not on duty during R1's elopement. He reported R1 was found that Monday morning. He reports that R1 can answer questions and stays in his room during the day, but during second and third shift, R1 reports he must go to work, and he tries everything he can to get out of the building. R1 has successfully gotten off his wing, but this is the first time he has gotten out of the facility. The DON reported that R1 does have a wanderguard on and to his knowledge, he was wearing it when he left the facility. On 04/05/22 at 12:10 PM, attempts were made made to contact the agency nurse Licensed Practical Nurse (LPN) 1 with no success. On 04/05/22 at 12:12 PM, Registered Nurse (RN)1 stated on 04/02/22 she got a call from LPN 1 stating that one of the residents cannot be located and she did not know what to do. RN1 stated she asked LPN1 if the Administrator and the police were contacted and the LPN said no. RN1 stated she advised LPN1 to contact the Administrator and police. RN1 stated she was provided the name of the resident that was missing, and since she does not live very far from the facility, she got in her car to drive around to look for R1. RN1 reported she saw R1 walking on the sidewalk so she had to turn the car around and went to ask him if he could get in her car and he did. RN 1 stated that she works at the facility and knows the residents. RN1 reported he looked confused but complied and got in the car. She reported she found him around 5:00 AM - 5:15 AM and he was wearing blue sweatpants and a white shirt and no shoes. She was not able to recall the outside temperature but reported it was not cold. RN1 reported that R1 had a scratch to his right foot but was otherwise ok. RN1 reported she got R1 back to the facility, the nurse assessed him for injuries, and the Administrator showed up and she left. RN1 reported that R1 is a major elopement risk due to the facility not having a dementia unit and he was able to get out this morning. On 04/05/22 at 12:27 PM, Certified Nursing Assistant (CNA)1 reported on 04/02/22 R1 was up until 1:00 AM and they last placed him in bed after 2:00 AM when they turned the lights off and went back to check on him at 4:00 AM and he was missing. CNA1 reported that they all started to look for him in rooms then they started looking outside and still could not find him. CNA1 reported everyone started to panic and she called the facility's prior DON and told her. The previous DON was called due to CNA1 not having anyone else phone number and everyone there was agency staff. CNA1 stated the previous DON asked her if we had called the Administrator and the police? CNA1 reported the double doors were closed and did not recall hearing an alarm. CNA1 reported R1 was found walking but did not know location or distance or the outside temperature. CNA1 reported R1 was brought back to the facility and was checked out by the nurse. On 04/05/22 at 12:20 PM, CNA2 reported on 04/02/22 R1 had been trying to get out of the facility during second and third shift and he does this a lot. She reported that at 3:30 AM, R1 was taken to the bathroom and was put in bed. At 4:24 AM, she and other staff started rounds and did not find R1 in his room, so they looked for him on Units A and B. CNA2 stated she looked out Unit B's door that was closed by housekeeping and the alarm was going off. She reported that the nurse went out for break at 4:10 AM and at that time, there was no alarm sounding. The nurse told her she was going on break and would be sitting in her car. CNA2 reported that R1 was not seen leaving the facility and this was the first time he got out of the facility but had previously got off his unit. CNA2 reported she called her boss and she got in her car and went driving around and found him. On 04/05/22 at 1:38 PM, R1 was observed in bed wearing a tee shirt and blue sweatpants. An interview with R1 revealed he had been in the facility for 1 month and he had a house, but came here so he could help keep others. R1 stated his son is in the process of getting things lined up for him to go home. R1 reported he is treated well, getting medications on time and is good. When R1 was asked if he had ever left the facility to go to work or home, he reported that he has never tried to leave and did not know what I was talking about. R1 was asked if he has a device on his ankle and he pulled down socks of both feet and no wander guard was in place. On 04/05/22 at 2:00 PM, an interview with the DON confirmed R1 did not have a wanderguard in place and one was then added. On 04/05/22 at 4:18 PM, an interview with the brother for R1 reported that R1 was taken home by another brother for a visit on 3/30/22 and per conversation with his brother, R1 did not want to return to the facility, but was told he had to return.

Based on observation, interview, record review, and facility policy, the facility neglected to provide adequate supervision to prevent successful elopement for 1 of 3 residents reviewed Resident (R) 1. This failure placed R1 at risk for serious harm, injury, or death. Resident (R)1 had a successful elopement on 04/02/22 at approximately 3:30 AM and was found by an agency staff member, 1.3 miles away from the facility on North [NAME] Smart Boulevard in front of the Piggly Wiggly store. R1 was returned to the facility at approximately 5:34 AM. R1 obtained a skin tear to his right great toe. R1 was wearing a white tee shirt and blue sweatpants and no shoes, and the outside temperature was around 54 degrees Fahrenheit. On 4/5/22 at 12:40 PM, an Immediate Jeopardy (IJ) template was provided to the Administrator, notifying IJ existed at F600 due to the facility's neglect to adequately monitor R1, who has wandering behaviors, with an effective date of 04/02/22. On 04/05/22 at approximately 4:40 PM the facility provided an acceptable IJ Removal Plan related to F600. The IJ was lowered to a scope and severity of D. The facility's removal plan for F600 included: 1) Clinical Leadership will ensure that appropriate interventions are in place for each resident by reviewing physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) Administrator initiated education on exit seeking/elopement policy with all-staff inserviced. 3) Regular elopement drills will be held weekly on all shifts to reduce the risk of elopement. 4) Kennedy Kontrols to go to the facility to evaluate all other exit doors in facility that do not have alarm enunciator and to install enunciators as soon as possible. 5) Additional staff person will be added to the 11-7 shift to continuously walk the halls observing all exit doors and residents with exit-seeking behaviors until the enunciators have been successfully installed on each exit door. Implementation of the removal plan was verified through observations, staff interviews, and record reviews. Observation verified that all doors were functioning successfully with the wanderguards being used in the facility. Documentation review revealed that staff were educated with demonstration check offs on the use of wanderguards, immediacy on responding to door alarms, and following the elopement policy and procedures. These trainings were conducted on 04/04/22. Findings include: Review of the facility's policy titled Abuse/Neglect Policy and Procedure last revised May 2000, revealed that it is the policy of the facility that abuse/neglect whether physical or verbal will not be tolerated. This includes the resident, employee, family members, visitor or resident to resident. Review of the Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 01/13/22, revealed the facility admitted R1 to the facility on [DATE]. R1 was not cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) score of 00 out of 15. R1's pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During the investigation on 04/05/22 at 1:10 PM, the Director of Nursing (DON) reported being aware of what door R1 exited and a tour was conducted of the facility with the DON. During the tour of 04/05/22 at 1:13 PM, the DON demonstrated the use of the door and held the bar down 15 seconds and it alarmed. The sound was not as loud as the other doors in the facility. The DON reported this door is not equipped with a sensor for the wanderguard, due to the low volume of the alarm, staff could not hear it alarming. During the investigation on 04/05/22 at 1:15 PM, the Maintenance Supervisor reported he checks the alarm on the door weekly and reported he does not have any paperwork to support this. He further reported that the facility requested a quote to update the alarm and this too, he did not have any paperwork to support. Record review of R1's care plan with a creation date of 1/19/22 revealed he requires assistance with activities of daily living, has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He experiences weakness and has a poor sense of safety. He has a history of wandering and exit seeking. It was updated on 4/5/22 to include his recent elopement on 4/2/22. Review of the monthly orders dated April 2022 revealed a wanderguard was added to R1's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 04/05/22 at 9:30 AM, the Administrator stated she received a call from staff on 04/02/22 at 3:40 AM reporting that R1 was not in the facility and was last seen between 3:15 AM - 3:30 AM, when he was put in bed with a tee shirt and wearing a brief. When staff started rounds at 04:24 AM, R1 was not in his room. Staff began to look for R1 in rooms and then went outside and this is when they heard the back service door alarm going off and reports the alarm was not heard prior to going outside to look for R1, as that alarm is not very loud. The door is equipped with a 15-minute egress alarm and R1 knows if he pushes on it, it will open. The Administrator reported that R1 was not on 1:1 and is normally very accommodating, but at nights he does wander. R1 is ordered to have a wander guard and the Administrator reported that he was wearing it, but the door that he left out of does not have a sensor for the wander guard on it. R1 was wearing a white tee shirt and blue sweatpants and no shoes, and the outside temperature was around 54 degrees Fahrenheit. A staff member was driving around the area by the local Piggly Wiggly store which is 1.3 miles away from the facility. The store is on a two-lane highway and staff saw R1 and asked him to get in her car and she drove R1 back to the facility. When R1 was assessed by the nurse he was found to have skin tear to his right great toe and no other injuries. During an interview on 04/05/22 at 09:40 AM, the Director of Nursing (DON) stated that he was not on duty during R1's elopement. He reported R1 was found that Monday morning. He reports that R1 can answer questions and stays in his room during the day, but during second and third shift, R1 reports he must go to work, and he tries everything he can to get out of the building. R1 has successfully gotten off his wing, but this is the first time he has gotten out of the facility. The DON reported that R1 does have a wanderguard on and to his knowledge, he was wearing it when he left the facility. On 04/05/22 at 12:10 PM, attempts were made made to contact the agency nurse Licensed Practical Nurse (LPN) 1 with no success. On 04/05/22 at 12:12 PM, Registered Nurse (RN)1 stated on 04/02/22 she got a call from LPN 1 stating that one of the residents cannot be located and she did not know what to do. RN1 stated she asked LPN1 if the Administrator and the police were contacted and the LPN said no. RN1 stated she advised LPN1 to contact the Administrator and police. RN1 stated she was provided the name of the resident that was missing, and since she does not live very far from the facility, she got in her car to drive around to look for R1. RN1 reported she saw R1 walking on the sidewalk so she had to turn the car around and went to ask him if he could get in her car and he did. RN 1 stated that she works at the facility and knows the residents. RN1 reported he looked confused but complied and got in the car. She reported she found him around 5:00 AM - 5:15 AM and he was wearing blue sweatpants and a white shirt and no shoes. She was not able to recall the outside temperature but reported it was not cold. RN1 reported that R1 had a scratch to his right foot but was otherwise ok. RN1 reported she got R1 back to the facility, the nurse assessed him for injuries, and the Administrator showed up and she left. RN1 reported that R1 is a major elopement risk due to the facility not having a dementia unit and he was able to get out this morning. On 04/05/22 at 12:27 PM, Certified Nursing Assistant (CNA)1 reported on 04/02/22 R1 was up until 1:00 AM and they last placed him in bed after 2:00 AM when they turned the lights off and went back to check on him at 4:00 AM and he was missing. CNA1 reported that they all started to look for him in rooms then they started looking outside and still could not find him. CNA1 reported everyone started to panic and she called the facility's prior DON and told her. The previous DON was called due to CNA1 not having anyone else phone number and everyone there was agency staff. CNA1 stated the previous DON asked her if we had called the Administrator and the police? CNA1 reported the double doors were closed and did not recall hearing an alarm. CNA1 reported R1 was found walking but did not know location or distance or the outside temperature. CNA1 reported R1 was brought back to the facility and was checked out by the nurse. On 04/05/22 at 12:20 PM, CNA2 reported on 04/02/22 R1 had been trying to get out of the facility during second and third shift and he does this a lot. She reported that at 3:30 AM, R1 was taken to the bathroom and was put in bed. At 4:24 AM, she and other staff started rounds and did not find R1 in his room, so they looked for him on Units A and B. CNA2 stated she looked out Unit B's door that was closed by housekeeping and the alarm was going off. She reported that the nurse went out for break at 4:10 AM and at that time, there was no alarm sounding. The nurse told her she was going on break and would be sitting in her car. CNA2 reported that R1 was not seen leaving the facility and this was the first time he got out of the facility but had previously got off his unit. CNA2 reported she called her boss and she got in her car and went driving around and found him. On 04/05/22 at 1:38 PM, R1 was observed in bed wearing a tee shirt and blue sweatpants. An interview with R1 revealed he had been in the facility for 1 month and he had a house, but came here so he could help keep others. R1 stated his son is in the process of getting things lined up for him to go home. R1 reported he is treated well, getting medications on time and is good. When R1 was asked if he had ever left the facility to go to work or home, he reported that he has never tried to leave and did not know what I was talking about. R1 was asked if he has a device on his ankle and he pulled down socks of both feet and no wander guard was in place. On 04/05/22 at 2:00 PM, an interview with the DON confirmed R1 did not have a wanderguard in place and one was then added. On 04/05/22 at 4:18 PM, an interview with the brother for R1 reported that R1 was taken home by another brother for a visit on 3/30/22 and per conversation with his brother, R1 did not want to return to the facility, but was told he had to return.

Based on observation, record review, interviews, and review of facility policy the facility failed to provide effective and individualized interventions for the prevention of accidents for two (2) of four (4) sample residents (Resident #2 and Resident #4) reviewed for accidents. Resident #4 experienced 28 falls resulting in fractures to the anterior and posterior walls of the left maxillary sinus (sinus located near the nose), left lateral orbital wall and left orbital floor (breaks in the eye socket). The facility failed to ensure Resident #2's siderail was functioning properly to prevent entrapment. Findings include: 1. Resident #4 was admitted to the facility on [DATE] and the [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of zero (0) indicating severe cognitive impairment. The resident had hallucinations and delusions and rejected care one to three (1-3) days of the seven (7) day observation period. The resident required limited assistance with bed mobility and eating, required extensive assistance of one (1) staff with walking, locomotion, dressing, toilet use and personal hygiene and required extensive assistance of two (2) staff with transfers. The resident utilized a walker and wheelchair and the resident was not steady and was only able to stabilize with staff assistance with moving from a seated to standing position, walking, turning around, moving on and off the toilet and surface to surface transfers. The MDS documented the resident had two (2) or more falls since the last assessment. The resident did not receive therapy or restorative services and utilized a wander alarm daily. The Fall Care Area Assessment (CAA) dated 1/18/19 revealed the resident was a risk for falls related to cognitive loss, impaired mobility and incontinence. Review of the care plan revealed the fall interventions in place on 2/24/19, (the first fall reviewed): Encourage resident to allow staff to pack belongings for any upcoming outings; staff to monitor resident frequently when in his/her room; staff to attempt to keep resident in group areas during times of confusion; (cognitively impaired) resident educated to lock wheelchair when he/she stops and call for assistance to change his/her footwear; staff to monitor frequently for needs; wheelchair cushion fashioned with Velcro to ensure it remains in place; non-skid socks applied to resident feet and updated to Task List in computer; attempt to dress resident as he/she wishes at all times; bring to monitored areas as needed; foot wear reviewed for safety to notify responsible party to remove footwear with backs out, for safety; spouse encourage to increase frequency of visits during waking hours; clip belt to wheelchair to deter self-transfers; staff to remind/encourage spouse to call for assist with resident toileting; staff to keep resident in view during times of agitation/anxiety and waking hours; Occupational Therapy (OT) and Physical Therapy (PT) evaluation and treat three (3) times a week for four (4) weeks; staff will assist with activities of daily living (ADLs) as needed and encourage resident to participate as appropriate; and staff will ensure call light is within reach and functioning properly. Review of the Fall Risk Assessments scoring revealed a score of ten (10) or above represented the resident at a high fall risk. Review of the assessments completed quarterly from 3/14/19 to 8/24/20 scored the resident from 15 to 18, indicating the resident was a high fall risk. Review of the Investigation Reports and the Care Plan revealed the following 28 falls and the interventions since 2/24/19: -2/24/19 at 6:39 a.m. - staff found the resident with knees on floor and body across roommate's bed -2/26/19 at 5:00 p.m. - a visitor found the resident on the floor, with the interventions for staff to assist with activities of daily living (ADLs) as needed and encourage resident to participate as appropriate -2/27/19 at 2:24 p.m. - found on floor in front of recliner -2/27/19 at 10:30 p.m. - found sitting on the floor with the intervention for a clip belt when in the wheelchair with a Pommel cushion -2/28/19 at 5:12 p.m. - another resident told staff the resident was on the floor; staff were educated on proper use of clip belt and the Pommel cushion was ordered -2/28/19 at 7:30 p.m. - found on floor next to bathroom -3/3/19 at 12:03 p.m. - found on floor by nurses' desk, safety precautions reinforced -3/4/19 at 7:35 a.m. - slid out from under clip belt at nurses' desk, the resident requires frequent rounding -3/4/19 at 7:45 a.m. - found on floor in room, had removed clip belt -3/4/19 at 7:55 a.m. - found on floor in room, had removed clip belt, with the intervention for a Geriatric chair with soft waist restraint to deter self-transfers with falls. -4/22/19 at 9:24 a.m. - spouse assisted resident to bathroom and resident found on floor, (spouse) was instructed to call staff for assist. Quarter side rail times one (1) for positioning and safety and bed against wall on left side initiated. -6/9/19 at 12:18 p.m. - found on floor in room in front of recliner, reminders given to (cognitively impaired) resident to call for assistance, staff to keep well- lit lighting and room free of clutter -6/28/19 at 7:10 p.m. - found on floor after being placed in bed for the night. Resident transferred to the hospital and the computer tomography (CT) revealed fractures to the anterior and posterior walls of the left maxillary sinus, left lateral orbital wall and left orbital floor, hemorrhage filled the left maxillary sinus and a left cheek/periorbital hematoma. -7/19/19 at 10:00 a.m. - found on floor, was previously in bed. -8/2/19 at 8:19 a.m. - found on floor in room, resident had disconnected the bed alarm -10/11/19 at 4:00 p.m. - found on floor, transferred to hospital for complaint of pain. No fracture sustained and therapy screen requested -2/2/2020 at 10:07 p.m. - found on floor in bathroom -4/8/2020 at 9:37 p.m. - found on floor in room, (cognitively impaired) resident instructed to call for assistance and staff to make sure bed alarm is in place and functioning and respond to bed alarm quickly. Skin tears to left elbow sustained. -4/9/2020 at 2:26 p.m. - found resident on floor in room -4/19/2020 at 12:12 p.m. - found the resident had slid under the waist restraint and was sitting on the floor in his/her room. A skin tear was noted to the right arm -5/12/2020 at 2:17 p.m. - found resident on floor in room beside the bathroom with his/her pants around his/her ankles. -5/16/2020 at 9:59 p.m. - found sitting on floor in doorway, staff instructed to keep bed alarm box out of resident's reach -5/30/2020 at 1:07 p.m. - found on floor beside bed after responding to bed alarm, staff instructed to make sure shoes or non-skid socks are on when resident is out of bed -7/1/2020 at 10:10 a.m. - found on floor next to his/her chair with the alarm going off, resident sustained [REDACTED]. -7/12/2020 at 9:30 a.m. - found on floor in room, resident had slid under the lap belt (physical restraint) staff instructed to monitor the resident more frequently -7/16/2020 at 10:50 a.m. - resident found on floor in room -7/17/2020 at 2:39 p.m. - found on floor beside the bed, staff instructed to make sure bed alarm is intact and check resident upon rising, after meals and at bedtime for toileting -7/19/2020 at 8:26 a.m. - found on floor in front of bathroom, bed alarm going off Review of the 28 falls revealed 27 of the falls were unwitnessed by staff and all of those 27 falls occurred in the resident's room. Further review of the falls revealed, while the resident received physical therapy from 10/10/19 to 2/27/2020, the resident only had two (2) falls. Review of the facility's Fall Investigations lacked this track and trending of the falls, what was occurring prior to the falls and the root cause analysis of the falls. There was a lack of evidence the facility analyzed the falls to determine if there were any patterns to the falls. There was a lack of evidence the facility developed interventions based on the root cause analysis of the falls. The care plan lacked individualized and effective interventions for the prevention of falls. Furthermore, the risk of the lap belt restraint was not evaluated as an accident hazard even though the resident sustained [REDACTED]. Review of the Physical Therapy (PT) Discharge Summary revealed the resident received therapy from 10/10/19 to 2/27/2020. Upon discharge the resident was able to ambulate 150 feet with a front wheeled walker and minimum assist. The resident had excellent prognosis to maintain clinical level of function. Observation on 8/23/2020 at 5:06 p.m. revealed the resident sat in a wheelchair with a waist restraint tied to the lower bars on the back of the wheelchair. The resident wheeled him/herself up and down the hall. Observation on 8/24/2020 at 10:03 a.m. revealed the resident sat in his/her room in a wheelchair with the tied waist restraint on. Observation on 8/24/2020 at 11:58 a.m. revealed the resident sat in a wheelchair in his/her room. The resident slid partially down in the wheelchair and the tied waist restraint was positioned under her armpits. The room was slightly dark and the room lights were not on and it was rainy and cloudy outside. Staff came and repositioned the resident. Observation on 8/25/2020 at 10:40 a.m. revealed the resident lying in bed on his/her left side and the bed pressure alarm in place. Observation on 8/25/2020 at 12:46 p.m. revealed the resident sat in the wheelchair with the tied waist restraint on. The resident was eating his/her lunch. Observation on 8/26/2020 at 5:25 p.m. revealed the resident sat in the wheelchair with the tied waist restraint on. The resident was eating his/her dinner and staff were sitting with him/her. Interview with Certified Nurse Aide (CNA) #1 on 8/25/2020 at 10:40 a.m. revealed the fall interventions for Resident #4 consisted of a bed alarm and a belt around the waist when in the wheelchair. Interview with the Occupational Therapist (OT) on 8/26/2020 at 3:45 p.m. revealed he/she 8/26/2020 reviewed the falls every morning and evaluate to see if it warrants an evaluation. For Resident #4 we have tried a bed alarm and a clip belt. Interview with Licensed Practical Nurse (LPN) #1 on 8/26/2020 at 2:01 p.m. revealed Resident #4 gets up unassisted and falls. The facility tried a chair alarm but with the waist restraint it was considered a double restraint so we removed the chair alarm. LPN #1 further stated the resident had a bed alarm and staff allow the resident to wheel in the halls, help him/her do a puzzle or offered the resident a snack. Staff sometimes will walk him/her to the bathroom but the resident in not on a restorative program or a set ambulation schedule. Further interview with CNA #1 at on 8/26/2020 at 2:37 p.m. revealed the resident had the restraint because of all the falls. He/she further stated that therapy or the restorative aide would walk with the residents. The CNAs did not walk Resident #4. Interview with the Director of Nursing (DON) on 8/26/2020 at 2:51 p.m. revealed the department heads met every week and review the falls since the last meeting and decide what interventions were needed. The DON stated that sometimes the staff walked Resident #4 to the bathroom but did not walk with him/her any other time. The DON stated sometimes the staff sat with the resident for a few minutes but could not sit with him/her for an hour or so. Review of the undated Fall Prevention Policy included the intervention for staff to provide assistance with transfers, mobility and toileting as needed and the Interdisciplinary Team will review falls weekly and make recommendations for individual fall prevention. The facility failed to provide effective, timely and individualized interventions for this resident with 28 falls and who had sustained several fractures. 2. Resident #2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) Assessment, dated 8/6/2020 revealed bed rails had not been utilized on the bed for Resident #2 during the review period. A Restraint/Positioning Device Quarterly Assessment was completed on 8/6/2020. Although the resident was assessed to not utilize siderails on the bed during the review period, it was determined they would be used to assist the resident with positioning during times when the resident became agitated. The assessment indicated Resident #2's responsible party (RP) had been notified of the decision. Review of physician's orders [REDACTED].#2 to utilize one full length siderail for bed positioning and define parameters, every shift, for safety. Resident #2 was observed on 8/23/2020 at 3:30 p.m. to be lying in bed with her entire body covered, including head, with a blanket. A full length siderail was observed to be up on the left side of the bed. The bed was in a low position and a fall mat was on the floor beside the bed on the side where the siderail was noted. Resident #2 was observed on 8/24/2020 at 10:39 a.m. to be lying in bed with a full length siderail up on the left side of the bed. The resident was noted to have her back to the siderail and was facing the wall. The bed continued to be in a low position and a fall mat was positioned on the floor. Resident #2 was observed on 8/25/2020 at 12:03 p.m. to be lying in bed on her right side. A full length siderail was observed to be up and the resident's back was facing the siderail. The siderail was observed to have detached from the bed and there was a gap of approximately 6 to 9 inches between the mattress and the siderail. CNA #3 had been observed exiting the resident's room approximately 10 minutes before the observation of a safety hazard regarding the siderail being detached and the safety risk for entrapment for Resident #2 was observed at 12:03 p.m. Interview was conducted with the Registered Nurse (RN) Supervisor on 8/25/2020 at 12:25 p.m. who was requested by the surveyor to accompany her to the room of Resident #2. The RN Supervisor stated she had not been made aware of the siderail being detached, creating an entrapment space between the mattress and siderail. The RN Supervisor agreed the placement of the siderail created an increased risk for an accident for Resident #2. CNA #3 was already in the room setting up a meal tray when the RN Supervisor was requested to enter the resident's room. Interview was conducted with CNA #3 on 8/25/2020 at 12:30 p.m. The CNA indicated she had not noticed the siderail being detached. The CNA stated Resident #2 had been walked by therapy earlier and afterwards had become agitated. CNA #3 stated she had assisted Resident #2 earlier with getting in the bed and had put the siderail up. The CNA indicated he/she was preparing to get the resident up into a bedside chair to assist him/her with eating lunch. A request was made on 8/25/2020 at 12:35 p.m. for the Administrator to go to the room of Resident #2. The Administrator, after noting the siderail was detached, confirmed the resident was at an increased danger of an entrapment accident. The Administrator indicated the Maintenance Director would be notified immediately. Staff were to remain with the resident until the equipment could be repaired or the bed replaced.

Based on observation, interview, and record review the facility failed to ensure appropriate services and assistance was provided to maintain or improve ambulation ability for three (3) of 17 sampled residents (Residents #2, #11, and #17). Residents #2, #11, and #17 were discontinued from skilled therapy services with a care plan developed for each resident to receive assisted ambulation services through the facility's restorative nursing program. The facility failed to ensure each resident received the planned restorative ambulation program, in an attempt to maintain each resident's maximum practicable level of independence. The failure to provide Resident #2 with the planned ambulation program resulted in the resident experiencing a decline in the ability to walk. Findings include: Review of a policy titled Restorative Nursing Program (no date) revealed a statement When it is determined by the doctor, nursing, or therapist that a patient is in need of restorative nursing care, the therapist will write a functional maintenance program for that patient. The therapist will inform and instruct all appropriate staff members on the need for restorative care and the nature of restorative program for that particular patient. Procedures outlined for implementation of the policy included the therapist providing written instructions that outlined the restorative plan of care and the plan was placed in a Restorative Nursing Program (RNP) book. The Restorative Technician was to document daily checks and weekly notes in the electronic medical record after a resident received restorative services. It was the responsibility of nursing and therapy to ensure the restorative program was carried out according to the plan. The policy specified both therapy and nursing would oversee the restorative nursing program. Programs were to be updated and revised as needed. All residents were to have doctor's orders to perform under the restorative nursing program. 1. Resident #2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set (MDS) Assessment, dated 2/17/2020 revealed Resident #2 was severely impaired in cognitive skills for daily decision making. The resident was assessed to require the extensive assistance of one person with walking in room and walking in corridor. The resident required the extensive assistance with locomotion both on and off the unit. The MDS assessment indicated the resident used the mobility devices of a wheelchair and a walker. Review of a Quarterly MDS assessment dated [DATE] revealed Resident #2 had improved in locomotion both on and off the unit. The resident was assessed to require limited assistance with the Activities of Daily Living (ADL) function of locomotion. This MDS assessment demonstrated the resident was showing improvement while receiving Physical Therapy services. Review of the medical record revealed Skilled Therapy Notes indicating Resident #2 was evaluated for Physical Therapy (PT) services on 3/16/2020 and a determination was made the resident could benefit from receiving a Physical Therapy treatment program. PT services were initiated on 3/17/2020. Gait training with emphasis on increasing safety and performance within the facility was initiated as part of the PT services. PT services included strengthening exercises until 3/30/2020 when the Physical Therapy Aide (PTA) documented the resident ambulated 15 feet, twice, with a four-wheel walker and moderate assistance. Resident #2 continued to receive PT services until being discharged on [DATE]. The PT Discharge Summary, dated 6/4/2020, noted the resident's baseline for ambulation at the start of the therapy program had been 0 feet and total dependence without attempts to initiate. On the PT Discharge Summary it was noted the resident could ambulate 100 feet with minimal assistance. A PT discharge recommendation was made for Resident #2 to continue with a Restorative Nursing Program to facilitate maintaining the current level of performance and to prevent decline. A care plan was developed with the interdisciplinary team (IDT) to address the need to implement the restorative nursing ambulation plan. Review of the medical record revealed Resident #2 had a physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of a restorative nursing care plan revealed on 6/8/2020 planned interventions were developed with the objective to maintain Resident #2's ambulatory status. Ambulation frequency was to be five times each week with minimal assistance. Devices to be used were a four-wheel walker, gait belt, and follow with a wheelchair. The goal was for the resident to ambulate 50 feet each day. Review of documentation of the implemented ambulatory restorative nursing plan for Resident #2 revealed for the week of 6/21/2020 - 6/27/2020, the resident was not provided ambulation assistance the entire week. For the week of 6/28/2020 - 7/4/2020, the ambulation program was provided three (3) times. For the week of 7/5/2020 -7/11/2020, the ambulation program was provided once. For the week of 7/12/2020 - 7/18/2020, the ambulation program was provided three (3) times; For the week of 7/26/2020 - 8/1/2020, the ambulation program was provided once. For the week of 8/2/2020 - 8/8/2020, the ambulation program was provided three (3) times. For the week of 8/9/2020 - 8/15/2020, the ambulation program was provided twice. For the week of 8/15/2020 - 8/22/2020, the ambulation program was provided four (4) times. Interview was conducted on 8/25/2020 at 12:25 p.m. with the Restorative Nurse Aide (RNA) who provided restorative services for Resident #2. The RNA stated he/she had provided Resident #2 with ambulation earlier that day. The RNA indicated the resident had walked from his/her bedroom to the nurses' station, which was approximately 50 feet. The RNA stated he/she provided ambulation assistance approximately three (3) times each week, not the care planned five (5) times. The RNA stated he/she worked different shifts as a Certified Nursing Assistant (CNA) and couldn't implement the restorative nursing care plan as written for Resident #2. According to the RNA, Resident #2 was stiff when he/she tried to walk him/her because he/she (resident) did not get enough exercise. Interview was conducted on 8/26/2020 at 10:50 a.m. with a Physical Therapy Aide (PTA) who was observed providing Resident #2 with ambulation assistance that morning. The PTA stated he/she had worked with Resident #2 when the resident was receiving Physical Therapy services. The PTA stated at the end of the physical therapy program, Resident #2 could ambulate 100 feet to the therapy gym and back to his/her room with minimal assistance, a roller walker, gait belt, and wheelchair following. The PTA stated he/she noticed a decline in the resident's activity tolerance while providing him/her with ambulatory assistance earlier. Additionally, the resident could not stand as straight as he/she had achieved while receiving physical therapy. The PTA stated Resident #2 could benefit and demonstrate improvement if the ambulatory rehab nursing program was consistently implemented in accordance with the plan of care. The PTA stated Resident #2 might also benefit from a rescreen by Physical Therapy. Interview was conducted via telephone on 8/26/2020 at 4:55 p.m. with the responsible party (RP) for Resident #2. The RP stated the facility had conducted a care plan conference earlier in the month and he/she (RP) had participated via telephone. The RP stated he/she was not aware Resident #2 was supposed to be receiving a restorative nursing program to maintain his/her ambulation ability. Ambulation was not part of the discussion during the care plan conference. The RP was aware the resident had received Physical Therapy services and the RP had seen Resident #2 walking down the hallway at that time. The RP stated Resident #2 also received arm exercises as part of Physical Therapy. The RP was concerned when he/she was notified that physical therapy services were being discontinued because he/she felt the service had helped Resident #2 to maintain strength. Resident #2 was observed on 8/26/2020 at 10:26 a.m. to be ambulating in the hallway with the assistance of the Physical Therapy Assistant (PTA), a four-wheel walker, gait belt, and wheelchair pulled behind the resident. Resident #2 was noted to be approximately 30 feet from his/her bedroom doorway when the resident stated, I've got to sit down. The PTA assisted Resident #2 to sit down in the wheelchair. The resident was wheeled back to his/her room where he/she informed the PTA that he/she had to go to the bathroom. The PTA assisted the resident with transferring from the wheelchair to the commode. Upon exiting the bathroom, the PTA assisted Resident #2 with standing at the wash basin to wash his/her hands. The resident was noted to be bent over at the waist and was saying I can't do this anymore. Resident #2 sat back down in the wheelchair and was wheeled into him/her room by the PTA. The failure to implement a restorative nursing program for ambulation as ordered by the physician and planned in the restorative nursing care plan resulted in Resident #2 experiencing a decline in the ability to ambulate. 2. Resident #11 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) Assessment, dated 6/10/2020, revealed the resident required limited assistance of one person with ambulation. The Quarterly Assessment did not identify Resident #11 to be receiving skilled therapy services or restorative nursing services. Resident #11 had a physician's orders [REDACTED]. The order specified the resident should ambulate 50 feet with a four-wheeled walker and gait belt, followed by a wheelchair. The ambulation program was to be implemented five (5) times each week, for six (6) months. Review of a restorative nursing care plan, dated 6/10/2020, for Resident #11 revealed an ambulation plan was developed to maintain the resident's ambulation ability. The care plan specified minimum assistance should be provided with a four-wheel walker, gait belt, followed by a wheelchair. The plan specified the intervention should be implemented five (5) times each week and the resident should ambulate a total of 50 feet. Review of Resident #11's ambulation program documentation from 6/21/2020 - 8/22/2020 revealed the program had not been provided as ordered or care planned. Resident #11 was not provided the ambulation program at all for the week of 6/21/2020 - 6/27/2020. The resident was provided the ambulation program three times the week of 6/27/2020 - 7/4/2020; one time the week of 7/5/2020 -7/11/2020; three (3) times the week of 7/12/2020 - 7/18/2020; zero times the week of 7/19/2020 - 7/25/2020; once the week of 7/26/2020 - 8/1/2020; three (3) times the week of 8/2/2020 - 8/8/2020; twice the week of 8/9/2020 - 8/15/2020; and four (4) times the week of 8/16/2020 -8/22/2020. 3. Resident#17 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set, dated dated [DATE], coded the resident as having severely impaired cognition. The MDS also coded the resident as needing extensive assistance with one person for ambulation on and off the unit. The resident was also coded as using a walker for mobility. Resident #17 had a physician's orders [REDACTED]. The order specified the resident was to ambulate fifty feet with a front wheeled walker and gait belt. Review of a Physical Therapy Discharge Summary for Resident#17, dated 6/8/2020, revealed Physical Therapy services were provided from 5/19/2020 to 6/4/2020. The Discharge Summary indicated Resident #17 could ambulate up to 20 feet when Physical Therapy services were initiated. At the time services were discontinued, the resident could ambulate up to 40 feet. The resident's prognosis to maintain the current level of function was excellent with participation in a restorative nursing program. The resident was discharged to the restorative nursing program to facilitate the resident maintaining the current level of performance and to prevent decline. The Discharge Summary indicated a plan of care for ambulation was developed and completed with the interdisciplinary team (IDT). Review of documentation of the ambulation program for Resident #17 from 6/10/2020 - 8/25/2020 revealed the program was not provided as ordered. For the month of June 2020: The week of 6/07/2020 - 6/13/2020, the resident was seen three (3) times. The week of 6/14/2020 - 6/20/2020, the resident was seen five (5) times. The week of 6/21/2020 - 6/27/2020, the resident was not seen at all. The week of 6/28/2020-7/4/2020 the resident was seen three (3) times. The month of July 2020: The week of 7/5/2020- 7/11/2020, the resident was seen one time. 7/12/2020 - 7/18/2020, the resident was seen four (4) times, 7/19/2020- 7/25/2020 the resident was seen one time. 7/26/2020-7/31/2020, the resident was seen one time. The month of August 2020: 8/2/2020-8/8/ , the resident was seen three (3) times. The week of 8/9/2020-8/15/2020 the resident was seen three (3) times. The week of 8/16/2020-8/22/2020 the resident was seen four (4) times. Interview was conducted on 8/25/2020 at 12:25 p.m. with the Restorative Nurse Aide (RNA) who provided restorative services for Resident #11, #13, and #17. The RNA stated, that due to also being assigned to work shifts providing care as a CNA, he/she could not consistently implement the restorative nursing program for each resident whose care plan specified an ambulation program. According to the RNA there were currently no other staff providing restorative services for residents. Interview was conducted on 8/25/2020 at 2:07 p.m. with the Director of Nursing (DON) who also served as the Registered Nurse (RN) over the facility's restorative nursing program. The DON stated the Restorative Nurse Aide (RNA) was responsible for reporting to him/her if a resident had experienced a decline or if the planned restorative program was not being implemented. The DON stated he/she had received no reports regarding the residents not receiving assistance with ambulation as outlined in each of their restorative nursing care plans. The DON stated he/she did not review documentation to confirm a resident's restorative nursing care plan was being implemented. The DON stated the facility had a risk management meeting every Thursday and residents receiving physical and occupational therapy were discussed, as well as all residents who were receiving a restorative nursing program. The DON stated there had been no mention of care planned ambulation programs not being implemented. Interview was conducted on 8/26/2020 at 1:05 p.m. with the Director of the Therapy Department. The Director stated it was a collaborative effort between nursing and therapy to make decisions regarding who would benefit from a Functional Management Program and this included restorative nursing services. The Director stated however, it was a nursing responsibility to oversee the restorative program and make sure the program was being implemented.

Based on observation, record review and interview the facility failed to prevent misappropriation of resident property for 1 of 3 residents sampled for Personal Funds. The findings included: The facility admitted Resident #1 on or about 12/27/2017 with [DIAGNOSES REDACTED]. July 17, 2018 record review revealed the facility reported that on 02/07/18 that a report was filed with the local Police Department by an elderly victim after information was received from his/her bank that a total of 9 checks, totaling $1700, had been presented against his/her account bearing fraudulent signatures between December 27, 2017 and January 20, 2018. A review of surveillance footage and banking records identified Certified Nursing Assistant (CNA) #1 as the person responsible. A police report obtained on 07/18/18 from the investigating police department revealed the department obtained a subpoena and received photos/video of CNA #1 at the drive-thru window on 01/16/18 and at the ATM on 01/27/18 of the Bank #2. Further review of the police report revealed the following statement from the investigating officer: On February 7, 2018, (this officer) met with (Resident Representative) in reference to forged checks cashed against Resident #1's bank account (Bank #1). (Resident Representative) helps care for his/her father who is ill and is currently at the Ridgeland Nursing Home. S/he provided copies of checks number 1799, 1800, 1801, 1802, 1820, 1821, 1822, 1823, 1824, s/he states that the checks were forged. S/he provided a written statement that the handwriting on the checks was not her/his or her/his father's. The checks were made out to CNA #1 who signed his/her name on the back of the checks. Two of the checks (1799, 1800) were cashed at Bank #1. S/he provided her/his SC DL and her/his thumb print for identification. Two of the checks (1801, 1802) were deposited at Bank #2 (CNA #1's bank). The remaining checks (1820, 1821, 1822, 1823, 1824) were endorsed and per information from the bank the checks had been deposited through a mobile device. The Representative was issued a victims form. The statement continues, We then traveled to dispatch and were able to obtain a suspect identification of CNA #1 from the drivers license information that was written on checks 1799 and 1800. We then traveled to Bank #1 who confirmed that CNA #1 cashed checks 1799 and 1800 in person at the Ridgeland location. The tellers confirmed s/he provided a SC driver's license as positive identification. The bank has video footage of the suspect cashing the checks, but requires a subpoena to obtain it .(subpoena drafted). We then traveled to Bank #2 who confirmed that CNA #1 is an account holder at Bank #2. They also confirmed checks 1801 and 1802 were deposited at the Ridgeland ATM. They also stated that a subpoena was required to obtain the ATM footage. Bank #2 provided us information that the remaining checks had been deposited into CNA #1's account by use of mobile deposit software. Based on information collected, enough probable cause exists to obtain warrants charging CNA #1 with 9 counts of Forgery . Review of the employee records on July 18, 2018, revealed Certified Nursing Assistant #1 was hired by the facility on 10/31/2017 and terminated on 02/08/18 due to failure to report to work. Background checks included a State Law Enforcement Department database check which revealed No Arrest Data and the Nurse Aide Testing Credential Management System which revealed a certificate in good standing with no substantiated findings of abuse, neglect or misappropriation of property on file with the South Carolina Nurse Aide Registry. CNA #1 completed Orientation at the facility including a video on Abuse/Neglect and signed documentation of doing so on 10/31/17. CNA #1 signed the facility policy entitled Abuse/Neglect Policy and Procedure which states, it is the policy of this facility that Abuse/Neglect, whether physical, verbal, emotional, or financial will not be tolerated. This includes residents, employees, family members, visitors or resident to resident. Time clock and task assignment records show CNA #1 worked in the facility December 27 - 29, 31, January 2, 5-8, 13, 19, 27, February 2 and 3, 2018 on the B-wing where Resident #1 resided upon admission to the facility. Attempts to make phone contact with CNA #1 on 07/18/18 and 07/19/18 were unsuccessful. In an interview on 07/18/18 at 12:30 PM the Director of Nursing (DON) reviewed the statement provided with the facility's investigation report and provided the following information. Resident #1's representative came to the facility and dropped off a police department form to be notarized when the Human Resources officer recognized the name on the report as that of a facility employee. DON stated the facility informed both law enforcement and the family member. The DON stated that when Resident #1 went to the hospital on [DATE] s/he was asked whether to lock of his/her belongings but Resident #1 wanted to take them along to the hospital. The DON stated the family member stated no recollection of Resident #1 having a check book in his/her possession. Review of the list of Resident #1's belongings at admission included a wallet and a blue see-through bag. Attempts to reach the family on 07/18/18 revealed the local family member did not wish to speak with the surveyor. Attempts to reach the Resident Representative who resides in Alaska on 07/18/18 and 07/19/19 were unsuccessful. Review of a letter provided by Bank #1 on 07/24/18 revealed restitution in the amount of $1700 was made to Resident #1 by the banking institution on 04/16/18.

Based on observation, record review and interview the facility failed to develop/implement abuse policies for 1 of 3 residents sampled for Personal Funds. The findings included: The facility admitted Resident #1 on or about 12/27/2017 with [DIAGNOSES REDACTED]. July 17, 2018 record review revealed the facility reported that on 02/07/18 that a report was filed with the local Police Department by an elderly victim after information was received from his/her bank that a total of 9 checks, totaling $1700, had been presented against his/her account bearing fraudulent signatures between December 27, 2017 and January 20, 2018. A review of surveillance footage and banking records identified Certified Nursing Assistant (CNA) #1 as the person responsible. A police report obtained on 07/18/18 from the investigating police department revealed the department obtained a subpoena and received photos/video of CNA #1 at the drive-thru window on 01/16/18 and at the ATM on 01/27/18 of the Bank #2. Further review of the police report revealed the following statement from the investigating officer: On February 7, 2018, (this officer) met with (Resident Representative) in reference to forged checks cashed against Resident #1's bank account (Bank #1). (Resident Representative) helps care for his/her father who is ill and is currently at the Ridgeland Nursing Home. S/he provided copies of checks number 1799, 1800, 1801, 1802, 1820, 1821, 1822, 1823, 1824, s/he states that the checks were forged. S/he provided a written statement that the handwriting on the checks was not her/his or her/his father's. The checks were made out to CNA #1 who signed his/her name on the back of the checks. Two of the checks (1799, 1800) were cashed at Bank #1. S/he provided her/his SC DL and her/his thumb print for identification. Two of the checks (1801, 1802) were deposited at Bank #2 (CNA #1's bank). The remaining checks (1820, 1821, 1822, 1823, 1824) were endorsed and per information from the bank the checks had been deposited through a mobile device. The Representative was issued a victims form. The statement continues, We then traveled to dispatch and were able to obtain a suspect identification of CNA #1 from the drivers license information that was written on checks 1799 and 1800. We then traveled to Bank #1 who confirmed that CNA #1 cashed checks 1799 and 1800 in person at the Ridgeland location. The tellers confirmed s/he provided a SC driver's license as positive identification. The bank has video footage of the suspect cashing the checks, but requires a subpoena to obtain it .(subpoena drafted). We then traveled to Bank #2 who confirmed that CNA #1 is an account holder at Bank #2. They also confirmed checks 1801 and 1802 were deposited at the Ridgeland ATM. They also stated that a subpoena was required to obtain the ATM footage. Bank #2 provided us information that the remaining checks had been deposited into CNA #1's account by use of mobile deposit software. Based on information collected, enough probable cause exists to obtain warrants charging CNA #1 with 9 counts of Forgery . Review of the employee records on July 18, 2018, revealed Certified Nursing Assistant #1 was hired by the facility on 10/31/2017 and terminated on 02/08/18 due to failure to report to work. Background checks included a State Law Enforcement Department database check which revealed No Arrest Data and the Nurse Aide Testing Credential Management System which revealed a certificate in good standing with no substantiated findings of abuse, neglect or misappropriation of property on file with the South Carolina Nurse Aide Registry. CNA #1 completed Orientation at the facility including a video on Abuse/Neglect and signed documentation of doing so on 10/31/17. CNA #1 signed the facility policy entitled Abuse/Neglect Policy and Procedure which states, it is the policy of this facility that Abuse/Neglect, whether physical, verbal, emotional, or financial will not be tolerated. This includes residents, employees, family members, visitors or resident to resident. Time clock and task assignment records show CNA #1 worked in the facility December 27 - 29, 31, January 2, 5-8, 13, 19, 27, February 2 and 3, 2018 on the B-wing where Resident #1 resided upon admission to the facility. Attempts to make phone contact with CNA #1 on 07/18/18 and 07/19/18 were unsuccessful. In an interview on 07/18/18 at 12:30 PM the Director of Nursing (DON) reviewed the statement provided with the facility's investigation report and provided the following information. Resident #1's representative came to the facility and dropped off a police department form to be notarized when the Human Resources officer recognized the name on the report as that of a facility employee. DON stated the facility informed both law enforcement and the family member. The DON stated that when Resident #1 went to the hospital on [DATE] s/he was asked whether to lock of his/her belongings but Resident #1 wanted to take them along to the hospital. The DON stated the family member stated no recollection of Resident #1 having a check book in his/her possession. Review of the list of Resident #1's belongings at admission included a wallet and a blue see-through bag. Attempts to reach the family on 07/18/18 revealed the local family member did not wish to speak with the surveyor. Attempts to reach the Resident Representative who resides in Alaska on 07/18/18 and 07/19/19 were unsuccessful. Review of a letter provided by Bank #1 on 07/24/18 revealed restitution in the amount of $1700 was made to Resident #1 by the banking institution on 04/16/18.

Based on review of facility files and interviews, the facility failed to ensure that each resident remained free from abuse. Certified Nursing Assistant (CNA) #1 physically abused Resident #1 when the resident attempted to leave the table on the facility sun porch. One of three residents reviewed for abuse. The findings included: The facility reported an allegation of physical abuse for Resident #1 by CNA #1 to the State Agency on 6/20/17. Review of the facility's Five-Day Follow-Up Report dated 6/20/17 indicated video of the incident did substantiate the abuse allegation. On 6/19/17, the Social Services Director was alerted by an anonymous phone call to check the suggestion box. In the box was a letter stating that CNA #1 slapped a resident after the resident slapped him/her. The letter suggested the video should be watched and that the incident had been reported to the charge nurse. Review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 9. The Quarterly MDS coded the resident as requiring extensive assistance for transfers, dressing, hygiene, and bed mobility. Resident #1 was coded as having other behaviors occurring 1-3 days during the assessment period. Review of the Nurses' Notes dated 6/16/17 revealed there was no documentation related to the incident on 6/16/17. A Nurses' Note dated 6/20/17 at 10:13 AM indicated a call was placed to the resident's responsible party with information regarding the resident's incident on Friday. Review of the letter left in the suggestion box indicated (CNA #1) hit (Resident #1) on 6/17/17 because s/he hit him/her. It's on the film on B wing. Nurse (Licensed Practical Nurse (LPN) #1) is aware and did not turn it in. (Resident #1) did hit him/her first. Check the film. Concerned employee There was no facility-obtained statement for LPN #1. In an interview with the surveyor on 7/5/17 at approximately 5:10 PM, LPN #1 stated that the nurse on the other unit told him/her about the incident that evening. The nurse said s/he heard somebody say CNA #1 hit Resident #1. The nurse told LPN #1 in the evening around 8:00 or 9:00. CNA #1 was still working at the time. LPN #1 asked the nurse what s/he was supposed to do. The nurse said it was hearsay, s/he didn't see it so s/he didn't know what happened. LPN #1 stated s/he did not talk to Resident #1 because s/he was already asleep when s/he found out about the incident. CNA #2's facility-obtained statement dated 6/19/17 indicated s/he was sitting at the nurses' desk when Resident #1 came off the sun porch crying and stated somebody help me that girl hit me. CNA #2 got up and went on the sun porch and asked CNA #1 to leave because Resident #1 said s/he hit him/her. CNA #1 said yeah, I hit him/her because s/he hit me first. In an interview with the surveyor on 7/5/17 at approximately 6:50 PM, CNA #2 stated s/he worked the night of the incident. S/he was at the Nurses' desk and Resident #1 came off the sun porch and s/he was crying. CNA #2 asked Resident #1 what was wrong and s/he said that girl hit me. CNA #2 and LPN #1 asked who and Resident #1 said the girl on the porch. CNA #2 went to the sun porch and asked CNA #1 if s/he hit Resident #1 and s/he said hell yeah, the [***] hit me and I hit the [***] back. CNA #1 said let's trade, I'll take the sun porch. CNA #1 went to the main dining room and told CNA #3 that s/he hit Resident #1 because s/he hit him/her. CNA #3's facility-obtained statement dated 6/19/17 indicated s/he was sitting at the nurses' station charting when CNA #1 came off the sun porch and stated that Resident #1 had hit him/her twice. CNA #3 said I hope s/he calms down before bedtime because I have him/her tonight. In the dining room, another CNA asked him/her how things were going on B wing. CNA #3 said things were good aside from Resident #1 getting upset and hitting CNA #1. The CNA said I hope s/he didn't hit the resident back. CNA #3 said I hope not either. In an interview with the surveyor on 7/5/17 at approximately 7:30 PM, the DON (Director of Nursing) and administrator were interviewed. The DON stated at approximately 3:45 PM the social services director received a phone call that said to check the comment box. They got the letter that is in the investigation file. After they read the letter, they pulled up the video to see if anything was there. They found the incident the letter referred to on 6/16/17 at 1733. The administrator stated they have a copy of the incident on a flash drive. The DON talked with CNA #1 before watching the video, and s/he said there was no incident. The resident had slapped him/her and s/he just put his/her hand on top of the resident's hand and asked them not to slap him/her. CNA #1 did not give a written statement. The DON stated that CNA #1 was working on 6/19/17 when they were notified about the incident from 6/16/17. The administrator stated they reported the incident to the ombudsman. The ombudsman talked with the resident who said s/he had no recollection of the incident. The ombudsman was at the facility on 6/29/17 to follow up on the incident. The administrator stated they did not report the incident to the police. The DON talked with the staff who were working on the unit at the time of the incident. On the video, there were no staff witnesses. There were some other residents on the sun porch, but no one who could be interviewed. The DON stated Resident #1 had wheeled him/herself to the sun porch, s/he was put at the end of the table. On the video, you see Resident #1 leave the sun porch and then come back. On the video, you see CNA #1 push the resident to the table and see the resident push back from the table. On the video, you see Resident #1's hands pushing away from the table and CNA #1 trying to keep the resident at the table. On the video, you can see CNA #1 hit Resident #1 twice on the hand. You can tell CNA #1 was upset with the resident. The DON stated LPN #1 didn't know anything about the incident until someone said something to him/her. The staff that the DON talked to said they didn't know anything about the incident until they heard about it from other people.

Based on review of facility files and interview, the facility failed to ensure that all alleged violations involving abuse are reported immediately. Resident #1 reported an allegation of physical abuse by Certified Nursing Assistant (CNA) #1 to Licensed Practical Nurse (LPN) #1 and CNA #2. The allegation was not reported to administration timely and CNA #1 continued to work at the facility after hitting a resident. One of three residents reviewed for abuse. The findings included: The facility reported an allegation of physical abuse for Resident #1 by CNA #1 to the State Agency on 6/20/17. Review of the facility's Five-Day Follow-Up Report dated 6/20/17 indicated video of the incident did substantiate the abuse allegation. On 6/19/17, the Social Services Director was alerted by an anonymous phone call to check the suggestion box. In the box was a letter stating that CNA #1 slapped a resident after the resident slapped him/her. The letter suggested the video should be watched and that the incident had been reported to the charge nurse. Review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 9. The Quarterly MDS coded the resident as requiring extensive assistance for transfers, dressing, hygiene, and bed mobility. Resident #1 was coded as having other behaviors occurring 1-3 days during the assessment period. Review of the Nurses' Notes dated 6/16/17 revealed there was no documentation related to the incident on 6/16/17. A Nurses' Note dated 6/20/17 at 10:13 AM indicated a call was placed to the resident's responsible party with information regarding the resident's incident on Friday. Review of the letter left in the suggestion box indicated (CNA #1) hit (Resident #1) on 6/17/17 because s/he hit him/her. It's on the film on B wing. Nurse (LPN #1) is aware and did not turn it in. (Resident #1) did hit him/her first. Check the film. Concerned employee There was no facility-obtained statement for LPN #1. In an interview with the surveyor on 7/5/17 at approximately 5:10 PM, LPN #1 stated that the nurse on the other unit told him/her about the incident that evening. The nurse said s/he heard somebody say CNA #1 hit Resident #1. The nurse told LPN #1 in the evening around 8:00 or 9:00. CNA #1 was still working at the time. LPN #1 asked the nurse what s/he was supposed to do. The nurse said it was hearsay, s/he didn't see it so s/he didn't know what happened. LPN #1 stated s/he did not talk to Resident #1 because s/he was already asleep when s/he found out about the incident. CNA #2's facility-obtained statement dated 6/19/17 indicated s/he was sitting at the nurses' desk when Resident #1 came off the sun porch crying and stated somebody help me that girl hit me. CNA #2 got up and went on the sun porch and asked CNA #1 to leave because Resident #1 said s/he hit him/her. CNA #1 said yeah, I hit him/her because s/he hit me first. In an interview with the surveyor on 7/5/17 at approximately 6:50 PM, CNA #2 stated s/he worked the night of the incident. S/he was at the Nurses' desk and Resident #1 came off the sun porch and s/he was crying. CNA #2 asked Resident #1 what was wrong and s/he said that girl hit me. CNA #2 and LPN #1 asked who and Resident #1 said the girl on the porch. CNA #2 went to the sun porch and asked CNA #1 if s/he hit Resident #1 and s/he said hell yeah, the [***] hit me and I hit the [***] back. CNA #1 said let's trade, I'll take the sun porch. CNA #1 went to the main dining room and told CNA #3 that s/he hit Resident #1 because s/he hit him/her. CNA #3's facility-obtained statement dated 6/19/17 indicated s/he was sitting at the nurses' station charting when CNA #1 came off the sun porch and stated that Resident #1 had hit him/her twice. CNA #3 said I hope s/he calms down before bedtime because I have him/her tonight. In the dining room, another CNA asked him/her how things were going on B wing. CNA #3 said things were good aside from Resident #1 getting upset and hitting CNA #1. The CNA said I hope s/he didn't hit the resident back. CNA #3 said I hope not either. In an interview with the surveyor on 7/5/17 at approximately 7:30 PM, the DON (Director of Nursing) and administrator were interviewed. The DON stated at approximately 3:45 PM the social services director received a phone call that said to check the comment box. They got the letter that is in the investigation file. After they read the letter, they pulled up the video to see if anything was there. They found the incident the letter referred to on 6/16/17 at 1733. The administrator stated they have a copy of the incident on flash drive. The DON talked with CNA #1 before watching the video, and s/he said there was no incident. The resident had slapped him/her and s/he just put his/her hand on top of the resident's hand and asked them not to slap him/her. CNA #1 did not give a written statement. The DON stated that CNA #1 was working on 6/19/17 when they were notified about the incident from 6/16/17. The administrator stated they reported the incident to the ombudsman. The ombudsman talked with the resident who said s/he had no recollection of the incident. The ombudsman was at the facility on 6/29/17 to follow up on the incident. The administrator stated they did not report the incident to the police. The DON talked with the staff who were working on the unit at the time of the incident. On the video, there were no staff witnesses. There were some other residents on the sun porch, but no one who could be interviewed. The DON stated Resident #1 had wheeled him/herself to the sun porch, s/he was put at the end of the table. On the video, you see Resident #1 leave the sun porch and then come back. On the video, you see CNA #1 push the resident to the table and see the resident push back from the table. On the video, you see Resident #1's hands pushing away from the table and CNA #1 trying to keep the resident at the table. On the video, you can see CNA #1 hit Resident #1 twice on the hand. You can tell CNA #1 was upset with the resident. The DON stated LPN #1 didn't know anything about the incident until someone said something to him/her. The staff the DON talked to said they didn't know anything about the incident until they heard about it from other people. Review of the Staff Schedule Report revealed CNA #1 worked on 6/17/17 from 3:12 PM to 11:05 PM, on 6/18/17 from 3:00 PM to 11:17 PM, and on 6/19/17 from 3:05 PM to 5:45 PM. Review of the Employee Counseling Form dated 6/20/17 revealed a written warning for LPN #1. The reason for counseling indicated Resident #1 reported to LPN #1, charge nurse on Friday 6/16/17, that s/he had been slapped/hit by a CNA. The incident was not documented, reported, or followed up on. Abuse was substantiated on 6/19/17. Mandatory requirement for nurses in the state of South Carolina. Review of the facility's Reportable Accidents/Incidents Policy and Procedures revealed mistreatment of [REDACTED]. Physical abuse was noted to be non-accidental physical force that results in injury, physical pain, or impairment. The policy and procedure included reports of being hit, slapped, kicked or mistreated. Reporting procedure included to report knowledge (witnessed, hearsay, suspect) of violation to nursing supervisor immediately. Report violation to Administrator or designated representative. Investigate violation promptly. Protect resident from further violation.

Based on record review and interview the facility failed to notify the physician that Resident #1 failed to have a bowel movement for at least seven days, 1 of 3 residents sampled related to constipation. The findings included: Cross refer to F-309 as it relates to the failure of the facility to notify Resident #1's physician when s/he failed to have a bowel movement for 7 days between 07/13/2014 and 07/19/2014. Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] coded him/her with a BIMs (brief interview of mental status) of 9. S/he was coded as always incontinent of bowel and totally dependant for toileting. Review of the Nurse's Notes (Progress Notes) for July 2014 revealed no documentation that the physician was called regarding Resident #1 not having a bowel movement from from 07/13/2014 through 07/19/2014 (7 days). The notes documented on 07/24/2014 at 10:14 AM "Per resident s/he has not had a bowel movement in 3 weeks... Abdomen is distended and bowel sounds hypoactive. Enema administered x 1. Awaiting to evaluate if enema effective." No additional documentation was found regarding the results of the enema. The next note at 1600 stated, "Resident abdominal distended, MD called Magnesium [MEDICATION NAME] 30 cc Po (by mouth) x 1 now given per MD order. Resident with small amount of BM. Resident stated that s/he feels like s/he has to have more BM; 1800 Resident stated that s/he wanted to go to the hospital, called MD, s/he stated to send him/her to the hospital. Personal Care Ambulance Services called." On 07/25/2014 at 3:27 AM the facility called the hospital to check on the resident and was told s/he was admitted with a bowel obstruction. Review of Resident #1's Toileting documentation for July 2014 revealed that s/he had a medium bowel movement on 07/12/2014, seven days later on 07/20/2014 s/he had a medium bowel movement. The Toileting documentation indicated the resident had a medium bowel movement on 07/24/2014, this was not documented in the Nurse's Note that indicated the resident complained of not having a bowel movement on 07/24/2014. In a telephone interview with the surveyor on 01/27/2015 at 9:30 AM Licensed Practical Nurse #1 stated that s/he was told when s/he came to work (07/24/2014) that Resident #1 was distended and had received an enema. S/he stated that when s/he assessed the resident s/he was still distended and uncomfortable. S/he called the physician and s/he ordered Magnesium [MEDICATION NAME], which was given with very little effect. Resident #1 stated, "I guess I need to go to the hospital". "S/he wanted to go out for his/her stomach." Licensed Practical Nurse #1 stated that s/he looks at the CNA (certified nurse aides) toileting record to make sure resident's are having regular bowel movements, "I work on both units not always on the same unit." In a telephone interview with the surveyor on 01/27/2015 at approximately 2:30 PM the physician confirmed s/he was not aware the resident had not had a bowel movement for seven days in July and stated s/he should have been called.

Based on record review and interview the facility failed to provide needed care and services to Resident #1, 1 of 3 residents sampled related to constipation. Resident #1 had a bowel movement (BM) on 7/12/2014 his/her next bowel movement was 7/20/2014, seven days later. The medical record revealed no information that the physician was notified regarding the residents failure to have a bowel movement. The BM on 7/20/2014 was documented on the Certified Nurse Aide (CNA) tracking tool as medium. Resident #1 complained of not having a bowel movement on 7/24/2014 and an enema was administered with no documented results. The physician was notified that the resident's abdomen was distended and s/he had hypoactive bowel sounds, magnesium [MEDICATION NAME] was given resulting in a small bowel movement. The resident was still uncomfortable and asked to be sent to the hospital. The resident was admitted to the hospital on [DATE] with a bowel obstruction. The findings included: Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. There was no documentation in the resident's medical record of a history of constipation. The Quarterly Minimum (MDS) data set [DATE] coded him/her with a BIMs (brief interview of mental status) of 9. S/he was coded as always incontinent of bowel and totally dependant for toileting. Review of the Nurse's Notes (Progress Notes) for July 2014 revealed documentation on 07/24/2014 at 10:14 AM "Per resident s/he has not had a bowel movement in 3 weeks... Abdomen is distended and bowel sounds hypoactive. Enema administered x 1. Awaiting to evaluate if enema effective." No additional documentation was found regarding the results of the enema. The next note at 1600 stated, "Resident abdominal distended, MD called Magnesium [MEDICATION NAME] 30 cc Po (by mouth) x 1 now given per MD order. Resident with small amount of BM. Resident stated that s/he feels like s/he has to have more BM; 1800 Resident stated that s/he wanted to go to the hospital, called MD, s/he stated to send him/her to the hospital. Personal Care Ambulance Services called." On 07/25/2014 at 3:27 AM the facility called the hospital to check on the resident and was told s/he was admitted with a bowel obstruction. Review of Resident #1's Toileting documentation for July 2014 revealed that s/he had a medium bowel movement on 07/12/2014, seven days later on 07/20/2014 s/he had a medium bowel movement. The Toileting documentation indicated the resident had a medium bowel movement on 07/24/2014, this was not documented in the Nurse's Note. Review of the Medication Administration Record [REDACTED]. The documentation on the MAR indicated [REDACTED]. Order date 07/24/2014..." In a telephone interview with the surveyor on 01/27/2015 at 9:30 AM Licensed Practical Nurse #1 stated that s/he was told when s/he came to work (07/24/2014) that Resident #1 was distended and had received an enema. S/he stated that when s/he assessed the resident s/he was still distended and uncomfortable. S/he called the physician and s/he ordered Magnesium [MEDICATION NAME], which was given with very little effect. Resident #1 stated, "I guess I need to go to the hospital". "S/he wanted to go out for his/her stomach." Licensed Practical Nurse #1 stated that s/he looks at the CNA (certified nurse aides) toileting record to make sure resident's are having regular bowel movements, "I work on both units not always on the same unit." In a telephone interview with the surveyor on 01/27/2015 at approximately 2:30 PM the physician confirmed s/he was not aware the resident had not had a bowel movement for seven days in July. S/he stated that s/he was notified that the resident was distended on 07/24/2014 and orders were given for an enema and later for magnesium [MEDICATION NAME]. S/he confirmed s/he should have been called when the resident was having problems with constipation earlier in July.