Every finding on record at Ridgeway Manor Healthcare Center

Based on observation, record review, staff interview, facility policy review, and Ecolab email, the facility failed to ensure the low-temperature dishwasher maintained the required final rinse temperature of at least 120 degrees Fahrenheit to ensure proper sanitization of dishware and utensils and reduce the potential for foodborne illness transmission. This deficient practice was identified in 1 of 1 main kitchens. Findings Include: Facility Policy: Dishwasher Temperature, Policy: It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures. Policy Explanation and Compliance Guidelines: 4. For low temperature dishwashers (chemical sanitization):a. The wash temperature shall be 120 degrees Fahrenheit.b. The sanitizing solution shall be 50ppm (parts per million) hypochlorite (chlorine on dish) surface in final rinse. An observation on 4/29/26 revealed a low temperature dishwasher temperature at 90 degrees Fahrenheit after wash and rinse. The sanitizer test strip was 100 ppm. A record review on 04/29/26 revealed:Supervisor's Daily Report/AM Shift 630/300Dish Machine Wash Temp (degrees Fahrenheit)04/01/2026 11604/02/2026 9604/03/2026 10004/04/2026 9204/05/2026 9404/06/2026 9504/07/2026 10004/08/2026 9804/19/2026 10104/10/2026 11004/11/2026 9504/12/2026 9804/13/2026 9404/14/2026 10004/15/2026 9204/16/2026 9804/17/2026 9804/18/2026 9204/19/2026 10004/20/2026 9904/21/2026 9604/22/2026 9804/23/2026 9704/24/2026 9804/25/2026 9004/26/2026 9704/27/2026 9604/28/2026 9804/29/2026 95 An interview on 04/29/26 at approximately 2:15 PM with the Certified Dietary Manager (CDM), revealed the dishwasher had been operating at low temperatures for approximately one month. She reported staff had continued documenting the temperatures and had notified management, maintenance, and the Ecolab Manufacturer. The CDM further stated Ecolab had previously evaluated the dishwasher and replaced the thermostat in an attempt to correct the issue; however, the dishwasher continued to register low temperatures. She indicated Ecolab was scheduled to return, coincidentally, on today's date 4/29/26 for further assessment/resolution. When asked, the CDM stated she would provide copies of the temperature logs reflecting the low readings. An interview on 04/29/26 at 2:41 PM with the Maintenance Director revealed he was aware the kitchen dishwasher was not reaching its temperature. It was verbally reported to him. He said it was like that for about one (1) month. An interview on 04/29/26 at approximately 4:07 PM, with Ecolab Territory Representative, revealed the facility's water heater is unable to keep up with demand. He recommended installation of an additional water heater, potentially on the dirty side, to prevent the facility from running out of hot water. He indicated the issue may be related to the age of the building and stated that Ecolab does not provide this type of equipment. The representative further stated he would document his recommendations and provide a copy to the facility. An interview on 04/30/26 at 11:10 AM with the Administrator revealed she was just made aware on yesterday, 04/29/26, that the dishwasher was not reaching the required temperature. If she had known a month ago when the problem first occurred, she would have notified the Regional Maintenance Director and [NAME] President of Operations, to correct the problem. Her expectation is better communication skills, and the appropriate people being notified of the issue and the progress, to be included on emails sent by department head, to be privy to the information and educate the department head on equipment function.

Based on record reviews and interviews, the facility failed to ensure that one Certified Nursing Assistant (CNA) received a performance evaluation in 2025, for 1 of 5 direct-care staff records reviewed.Findings include:The Staffing Coordinator stated that the facility currently does not have a facility policy on performance evaluation expectations.Review of CNA1 staff file indicated a hire date of February 2023.Review of CNA1 staff file indicated that the last performance evaluation was completed on 01/15/25.In an interview on 04/30/26 at approximately 2:35 PM, the Director of Nursing (DON) stated that she is still learning the performance evaluation process, as she is new to the position at the facility. The DON stated that her expectation is for CNA performance evaluations to be conducted within 90 days of hire and annually thereafter. She reported that approximately one week ago, she completed three performance evaluations for nurses; however, no evaluations were completed for CNAs. The DON stated that a performance evaluation should have already been completed for CNA1 for the 2025-2026 evaluation period and that she plans to complete an audit to verify future compliance for CNA1 and for all other CNAs.In an interview on 04/30/26 at approximately 3:15 PM, the Administrator stated that Human Resources typically generates notifications when annual CNA performance evaluations are due. The Administrator stated that this may have been overlooked during the period when the facility did not have a DON, although she was not certain. She further stated that she is not very familiar with the CNA who has not received an evaluation; however, no concerns regarding the CNA's performance or behavior have been brought to her attention. The Administrator confirmed that her expectation is that CNA1 should have had a performance evaluation completed for the 2025-2026 evaluation period.

Based on review of the facility policy, observations, and interviews, the facility failed to ensure an excessive amount of lint was removed from lint screens for 2 of 2 commercial clothes dryers in the main laundry room. Findings include:Review of the facility document titled, Direct Supply TELS indicated, lint catchers should be cleaned AFTER EACH LOAD.Review of facility policy titled Laundry , revised 12/23/2025, states the following:5. Laundry equipment will be used and maintained according to the manufacturer's instructions.Review of dryer manufacturer's instructions titled, Tumble Dryers, Operation/Maintenance, March 2021, pg. 22 states the following:2. End of day: a. Clean lint filter to maintain proper airflow and avoid overheating.An observation on 04/29/26 at 9:06 AM of two lint screens below the two dryers revealed the lint screens were excessive with lint. The Laundry Assistant (LA) was present during the observation. An observation on 04/29/26 at 1:15 PM of two lint screens below the two dryers, noted with excessive lint, and the walls and floor below the dryer with no lint present.During an interview on 04/29/26 at approximately 1:55 PM with the Housekeeping Director (HD) and LA revealed they both were unaware there were lint screens below the dryers.During an interview on 04/29/26 at approximately 2:05 PM, the HD stated, I did not know the dryer lint screens existed. I will contact the Maintenance Director and have him educate us on how to remove lint screens, and clean lint screens properly starting today. The HD stated he uses a wet/dry vac to clean the walls, the floors beneath dryers, and behind the dryers, but he has never cleaned the lint screens. The HD also reported he will be using a new lint log that includes cleaning the lint screens.During an interview on 04/30/26 at approximately 8:10 AM, the HD stated he and the LA were educated yesterday by the Maintenance Director on how to remove and clean lint screens. The HD stated he has implemented new lint logs that include cleaning lint screens as well as the floors, the walls, and behind the dryers.

Based on record review and interviews, the facility failed to ensure that one Certified Nursing Assistant (CNA) received 12 hours of annual in-service training, for one of 5 direct-care staff records reviewed.Findings include:The Staffing Coordinator stated that the facility currently does not have a facility policy on annual training expectations.Review of CNA1 staff file indicated a hire date of February 2023.Review of CNA1 staff file indicated that a total of 8.5 hours of annual training was completed via Relias in 2025.In an interview on 04/30/2026 approximately 2:45 PM, the Director of Nursing (DON) stated that that she was not aware of the 12-hour minimum annual training requirement due to being new to the DON position. However, a Performance Improvement Plan (PIP) will be initiated to address the concern. She indicated that she is currently in the process of implementing a skills fair, and that she previously conducted an in-service for direct care staff upon assuming her role, which included topics such as dignity, respect, and resident rights. She further stated that her expectation of moving forward is to implement additional training through Relias, along with monthly in-services, annual performance evaluations, and a skills fair to ensure that Certified Nursing Assistant (CNA) staff are meeting the 12-hour minimum of annual training that is required.In an interview on 04/30/26 at approximately 3:30 PM, the Administrator stated that the expectation is for each CNA to complete a minimum of 12 hours of training annually. Staff are assigned 12 hours of training in Relias by Human Resources, which is divided into approximately 2-3 hours per month until the 12-hour requirement is met. She stated that the facility transitioned to in-service training due to staff not consistently completing the assigned Relias modules. She indicated that staff could access and complete Relias training at any time; however, completion does not consistently occur without constant prompting.

Based on observation, record review, and interview, the facility failed to use its resources effectively and efficiently related to suspension of food service delivery, suspension of oxygen supply, and suspension of linen orders, and an incomplete facility assessment. This inaction in administering the facility had the potential to affect all residents living in the facility. Findings include:Review of an undated and unsigned policy titled, Business Continuity revealed, Policy: This facility plans for continuity of operations in the case of an emergency or disaster. Policy Explanation and Compliance Guidelines . 5. Critical resources have been identified. The facility maintains contracts with various vendors for obtaining supplies and materials in case of an emergency. a. Contracts with two or more vendors are maintained in case primary vendors are also affected. b. The facility has a means of communication with local/state Incident Command Center to relay needs in case of a prolonged event. c. Designated storage areas hold emergency supplies at established par levels . 8. In the case of sheltering in place, ongoing evaluation of the facility's capabilities to safely maintain operations will include evaluation of the following: a. Communication b. Resources (medical/non-medical supplies and equipment) c. Utilities d. Staff e. Food and water f. Safety and security. Review of an undated and unsigned policy titled, Compliance and Ethics Program revealed, Policy: This facility is committed to compliance and has designed, implemented, and enforced a compliance and ethics program for promoting quality of care and preventing and detecting criminal, civil and administrative violations . 4. Components of the facility's compliance and ethics program include: . a. Written compliance and ethics standards, policies, and procedures. b. Assigned individuals within the high-level personnel of the facility with the overall responsibility to oversee compliance with the facility's compliance and ethics program standards, policies and procedures. c. Sufficient resources and authority to reasonably assure compliance . 6. The facility reviews the compliance and ethics program annually, revising as needed to: a. Reflect changes in applicable laws or regulations within the organization. b. Improve performance in deterring, reducing and detecting violations. c. Promoting quality care. During the initial tour of the kitchen on 02/10/26 at 2:05 PM, the freezer, cold, and dry storage areas were observed and revealed more than 90% of products with a food delivery date of 02/10/26. The Dietary Manager (DM) produced photos on a cellular phone of the same areas observed being empty or nearly empty, containing between zero and four individual items. The photos were dated 02/10/26 between 6:00 AM and 8:00 AM. During the initial tour on 02/10/26 at 10:30 AM, there was a framed sign in the foyer titled, Mainstay Senior Living which indicated a purpose and core values of Purpose: To enrich the lives and be faithful stewards of all entrusted to us. Core Values: Integrity. Creating equal environments. Stewardship. Create raving fans through emotional connection. Improving quality of life through vertical integration. During a tour of the laundry building on 02/11/26 at 8:55 AM, it was noted to have covered racks of clothing awaiting distribution, personal clothing items in bins awaiting being folded and hung, and no linens were observed awaiting distribution to the buildings. The rooms containing the washers and dryers had bins of dirty linens awaiting laundering. There was no emergency supply of linens observed. Review of communications between Medical Supplies (MS) Clerk 1 and a representative of [NAME] Gas & Equipment, Inc., a supplier of oxygen, revealed the facility's account was on hold for being over the credit limit on the following dates: 04/04/25, 05/02/25, 11/20/25, and 01/02/26. Accounting statements were attached to each correspondence. Review of receipts for food purchased at local vendors on 02/03/26, 02/05/26, and 02/09/26, which revealed items on the schedule menu were purchased. Review of a documented titled, Payment Details from U.S. Foods was reviewed, showing a payment processed date of 02/10/26 in the amount of $45,631.08 for 15 charges dated back to 12/26/25. This affected two deliveries, 02/03/26 and 02/06/26. Review of a documented titled, Payment Details from U.S. Foods was reviewed showing a payment processed date of 12/23/25 in the amount of $57,260.72 for 20 charges dated back to 10/17/25. The facility's U.S. Foods account was suspended for nonpayment. Review of a documented titled, Payment Details from U.S. Foods was reviewed showing a payment processed date of 11/07/25 in the amount of $59,040.28 for 22 charges dated back to 08/29/25. The facility's U.S. Foods account was suspended for nonpayment. Review of invoices from Progressive Medical Concepts were reviewed showing orders for towels, washcloths, and sheets. Each of these orders was due within 30 days. It was unclear if and/or when the invoices were paid. The invoices were dated: 02/21/25, 04/15/25, 07/14/25, 08/21/25, 09/11/25, and 10/16/25. Another order was placed on 02/12/26. Review of the Facility assessment dated [DATE], revealed it was not signed and was reviewed with the QAA Committee on 04/10/25. Several sections were blank or incomplete, and many had no supporting documentation. Review of a document titled Profit & Loss Budget Overview January 2026 and dated 02/12/26 was reviewed revealing a net income of $-6,131.57. Review of a document titled U.S. Foods Customer Account Application was provided in response to a request for the facility's contract with U.S. Foods. The document was dated 06/07/23 and revealed, in part, .4. Payment of the purchase price for goods and/or services acquired from Seller shall be made pursuant to the terms set forth on each invoice, and Applicant agrees to pay all charges according to the payment terms established in said invoice. The entire outstanding balance due to Seller on all invoices shall become due in full immediately . During an interview on 02/10/26 at 9:45 AM, the Administrator and the Assistant Director of Nursing (ADON) stated they assumed that this surveyor was there about the food delivery and said this had been the second time that the food delivery was cut off for non-payment on 01/30/26, adding, We got word yesterday that we were able to order a truck again because he had paid the bill, and the regular service arrived today. When asked how meals were prepared without food delivery, the Administrator stated she and the Regional Director of Operations (RDO) used their corporate petty cash 'BizNow' cards to purchase food from local suppliers. They also used all the emergency food supplies, adding that they had just recently experienced a significant winter storm during the last two weeks. The Administrator stated there is no policy or procedure or process for this type of situation, they just did the best we could, and it worked. During an interview with the Dietary Manager (DM) on 02/10/26 at 10:05 AM, she stated, This is the third time this has happened. We got lucky on that last order before they cut us off because they allowed us to order an emergency truck because of the winter storm. She said that food deliveries are typically twice per week, on Tuesdays and Fridays. The DM stated that the last food delivery (before 02/10/26) was made on 01/30/26, and the facility's U.S. Foods account was suspended for nonpayment, causing two regular orders/deliveries to be missed on 02/03/26 and 02/06/26. During an interview with the DM on 02/10/26 at 12:35 PM, she said lunch is usually served around 12:00 PM, but with the delivery truck having just arrived and having to piece together a menu, things were running a little behind. During an interview on 02/10/26 at 4:30 PM, the RDO was asked what the biggest barrier was to getting bills paid, especially the food delivery. He replied, He just got behind on the payments. It's a small company; there are two nursing homes in this state and two in Alabama, for a total of four in the company, and he has about 50 ALFs (Assisted Living Facilities). We get a 10-day notice. The owner is old school and signs the checks himself, and he is hard to track down at times or when he does not want to be. He is in Florida. When asked if he understands and communicates the gravity of the situations to the owner, the RDO stated he understands, but he was unsure if the owner understands the gravity of the situation. During an interview with the Administrator on 02/11/26 at 10:50 AM, she stated, They reloaded my card today. Mine and [RDO]'s cards were maxed. I never know how much they are going to put on the card. He (the owner) is hard to get ahold of, but he always pulls us out at the last minute. But, if there is an emergency, I'm not confident we'd be able to get through it. During an interview with the MS on 02/11/26 at 11:20 AM, revealed she is in charge of central supply to include linen inventory and ordering linens and other medical supplies. She said that she will frequently order items, and they just won't get delivered. When I order, they don't tell me, it just doesn't come. When I call to follow up, they tell me that it needs to be paid. When there is an outstanding invoice, I report it to Accounts Payable (AP) person. I ask when they are going to pay it so I can order again. She said this happens several times per year. She said nursing has enough supplies, but she does not keep up with the emergency supply of linens. She said if the facility needs something immediate, the AP will do an ACH payment. If it is not needed immediately, they'll send a check. Any disruption in service because of late payment. She said when they cannot order supplies, they can get it from the store or the administrator will order from Amazon or somewhere else. She stated they have gone through several vendors because they won't pay the bills. During an interview with the RDO on 02/11/26 at 1:20 PM, revealed the facility does not have a governing board. The RDO stated, We don't really have a governing board. There are no names to give. We had all that before. [Owner] told me that 'Mainstay' (the corporate entity) is the governing body. The RDO said the owner's sister-in-law is the person in charge of accounts payable (AP). When asked about the corporate compliance program, bylaws and/or operating policy to include evidence of ownership and officers, the RDO stated, I will bring the policy. I do not yet have a response from the owner. He is hard to get a hold of. He's always busy or off doing something. [Owner] is the 100% owner. There is no operations policy. Our policies come from the compliance store. When asked about emergency situations and planning, the RDO responded, We have plenty on our corporate cards for any back up needs. Our regional maintenance person has access to nearly unlimited money at a moment's notice. During an interview with the RDO on 02/11/26 at 2:30 PM, he stated there were no bylaws or operating policy. He said, Continuity of business is based on disaster preparedness. That's how we do it. During an interview with the RDO on 02/11/26 at 3:45 PM, the words on the framed sign in the foyer titled, Mainstay Senior Living, were read to the RDO, and this surveyor asked, How does staff having to worry about feeding the residents or having enough supplies affect residents? to which he answered, Staff should have never known. We should have managed it. This surveyor then asked about the findings regarding linens, and the RDO stated, I thought you meant the food. It shouldn't. They cannot provide care without the necessary supplies. It has the potential to affect morale and patient care.

Based on observation, record review, and interview, the facility failed to provide evidence of having a governing body, ensuring a facility assessment was complete to assess the overall management and operation of the facility, a failure to develop and implement bylaws and operational policies for the facility which resulted in a failure to ensure facility's Ethics and Compliance Program was implemented. These failures resulted in vendors not getting paid and a disruption in delivery of food and supplies to residents and had the potential to affect all residents living in the facility. Findings include:Review of an undated and unsigned policy titled Compliance and Ethics Program revealed, Policy: This facility is committed to compliance and has designed, implemented, and enforced a compliance and ethics program for . preventing and detecting . administrative violations . c. Sufficient resources and authority to reasonably assure compliance . Review of a document titled U.S. Foods Customer Account Application was provided in response to a request for the facility's contract with U.S. Foods. The document was dated 06/07/23 and revealed, in part, . 4. Payment of the purchase price for goods and/or services acquired from Seller shall be made pursuant to the terms set forth on each invoice, and Applicant agrees to pay all charges according to the payment terms established in said invoice. The entire outstanding balance due to Seller on all invoices shall become due in full immediately . Telephonic and electronic communication was attempted with both Owner and Accounts Payable (AP) Clerk 2 on 02/12/26, and no return communication was received. Review of the Facility assessment dated [DATE], revealed it was not signed and was reviewed with the QAA Committee on 04/10/25. Several sections were blank or incomplete, and many had no supporting documentation. Review of a document titled Profit & Loss Budget Overview January 2026 and dated 02/12/26, was reviewed revealing a net income of $-6,131.57. During an interview with the Regional Director of Operations (RDO) on 02/11/26 at 1:20 PM, revealed the facility does not have a governing board. The RDO stated, We don't really have a governing board. There are no names to give. We had all that before. [Owner] to [sic] me that 'Mainstay' is the governing body. The RDO said the owner's sister-in-law is the person in charge of accounts payable (AP). When asked about the corporate compliance program, bylaws and/or operating policy to include evidence of ownership and officers, the RDO stated, I will bring the policy. I have not received a response from the owner. [Owner] is the 100% owner. There is no operating policy. Our policies come from compliance store. When asked about emergency situations and planning, the RDO responded, We have plenty on our corporate cards for any back up needs. Our regional maintenance person has access to nearly unlimited money at a moment's notice. During an interview with the RDO on 02/11/26 at 2:30 PM, he stated there were no bylaws or operating policy. He said, Continuity of business is based on disaster preparedness. That's how we do it.

Based on observation, record review, and interview, the facility failed to ensure the facility assessment was complete and to identify all necessary resources to attain and maintain resident needs, and failed to ensure active involvement of required participants. This inaction in administering the facility had the potential to affect all residents living in the facility. Review of the Facility assessment dated [DATE] revealed it was not signed and was reviewed with the QAA Committee on 04/10/25. Several sections were blank or incomplete, and many had no supporting documentation. There was no signature page or other documentation to identify the participating members included in the development of the assessment. During an interview with the Administrator and Regional Director of Operations on 02/11/26 at 4:30 PM, revealed that the facility assessment provided was the only facility assessment available for review.

Based on observation, record review, and interview, the facility failed to provide a sufficient amount of bath and bed linens, in good condition, in 2 of 2 linen closets reviewed out of a total of 2 linen closets in The Home building. This had the potential to affect 58 of 58 residents residing in The Home building in a total facility census of 92.Findings include:During the initial facility tour on 2/10/26 at 10:30 AM, with the Assistant Director of Nursing (ADON), the facility was observed to be comprised of two separate buildings. The two buildings were referred as The Home and The Manor. The Home building had three hallways (100, 200, and 300). The 100 and 200 hallway each had one linen closet. The 300 hallway had no linen closet. During a facility tour on 2/10/26 at 3:00 PM, linen closets were observed within the 100 and 200 hallways. Both linen closets were noted to contain fewer than 10 of each of the following: towels, washcloths, fitted sheets, flat sheets, and pillowcases. A washcloth was randomly selected from the closet which was thin and torn at the seam on one of the four sides of the cloth. During a facility tour on 2/11/26 at 8:45 AM, linen closets were observed within the 100 and 200 hallways. Both linen closets were noted to contain fewer than 10 of each of the following: towels, washcloths, fitted sheets, flat sheets, and pillowcases. The flat sheets and fitted sheets in the closet were noted to be worn and thin. During a tour of the laundry building on 02/11/26 at 8:55 AM, no linens were observed awaiting distribution to the buildings. The rooms containing the washers and dryers had bins of dirty linens awaiting laundering. There was no emergency supply of linens observed. Invoices from Progressive Medical Concepts were reviewed showing orders for towels, washcloths, and sheets. Each of these orders was due within 30 days. It was unclear if and/or when the invoices were paid. The invoices were dated: 02/21/25, 04/15/25, 07/14/25, 08/21/25, 09/11/25, and 10/16/25. Another order was placed on 02/12/26. During an interview with the Administrator on 02/10/26 at 2:55 PM, she agreed the linen closets observed within the 100 and 200 hallways were low on linens, containing fewer than 10 of each type of linen item. A washcloth was pulled from the closet and was noted to have large shredded-type tears along the seam, and the Administrator agreed washcloths in that condition should not be used to bathe residents nor be found in linen closets. During an interview with Certified Nurse Aide (CNA)2 on 02/10/26 at 3:00 PM, she stated, Some mornings we don't have much (linens). They (laundry workers) make a delivery around breakfast and sometimes two or three times a day. The condition of the linens is 'not ok,' and it has been like that since I've been here; about two years. CNA2 was referencing the tears and thin and/or worn conditions of the linens being observed. When asked how that affected her job and how it affected the residents, she stated, It slows it down, and some of them don't get out of bed when they want to. During an interview with CNA3 on 02/10/26 at 3:05 PM, revealed that she has worked at the facility for about six months and has been a CNA for 21 years. She said there are not enough linen supplies to do her job properly, especially washcloths and towels in the mornings. She said this slows down or delays patient care, and sometimes they don't get a bath because it's been delayed by not having the supplies we need. During an interview with Housekeeping Supervisor (HKS) on 02/10/26 at 4:00 PM, he stated he is new to his role. He stated that the laundry/housekeeping workers are responsible for ensuring both closets have the same amount of all linens including clothing protectors. He said, When we see that they are running low, they wash all day, but they have been short on supplies frequently. He said he has been unable to get any orders for the last couple months, because they would not send them because the bill was not paid. They usually keep them in central supply and take them out as needed. He said, When I'm down to the last three bundles, then I try to put in an order. He said the process is that he will place an order with the Medical Supplies (MS) clerk, and then she sends it out to the supplier to order. He said sometimes they have to shop at a local supplier to get last-minute supplies because orders are unable to be placed, adding, the facility does not currently, nor do they usually have any emergency supplies of linens in the supply room. During an interview with the Administrator on 02/10/26 at 4:15 PM, she stated, We do not have an emergency supply of linens. We have to order them as needed because the bill doesn't get paid or takes a long time to get paid. It is very frustrating. She stated that corporate is responsible for paying the bills, but they are difficult to reach, adding, When we're really desperate and make a big deal about it, sometimes things will get paid at the last minute before they cut us off or the day that they cut us off. When asked how the lack of linens affects the residents, she said it can delay their care and cause stress on the CNAs. During an interview with Resident (R)10 on 02/12/26 at 2:00 PM, he stated several times he has to wait to be bathed, . because the CNAs don't have enough supplies.

Based on observation, interview, and record review, the facility failed to completely and accurately document the suspected cause of a fracture for 1 (Resident (R)3) of 3 residents reviewed for accidents. Findings include:Review of an undated facility policy titled Documentation in Medical Record revealed, Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines . 4. Principles of documentation include but are not limited to . b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care . Review of R3's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/27/25, revealed a Brief Interview for Mental Status (BIMS) score of 0 out of 15; the resident was unable to complete the BIMS.Review of R3's Significant Change MDS with an ARD of 07/31/25 revealed a BIMS score of 99, indicating R3 was unable to complete the interview. Review of R3's Quarterly MDS with an ARD of 10/30/25 revealed a BIMS score of 99, indicating the resident was unable to complete the interview. Review of a progress note dated 06/24/25 at 10:38 AM, by Social Worker (SW) indicated a BIMS should be conducted and, Record response (day): No response Resident was unable to complete the interview. BIMS NOTE: [R3] is alert oriented to self with impaired decision-making skills as well as, Speech is mumbled also, needs are anticipated via Staff. N Adv - BIMS Summary score: 0.0. A BIMS score of 0 indicates severe cognitive impairment. Review of progress notes within R3's medical record was initially reviewed for the month of July 2025 related to the resident's hip fracture. Upon review of the entire month of July, beginning on 07/1/25, progress notes revealed several occurrences documenting buddy taping of the right ring and middle fingers and the resident's removal of the same which continued through 07/14/25. Review of two progress notes dated 07/01/25 were reviewed. The first was at 2:17 AM, wherein Registered Nurse (RN)1 documented, . Continues to remove buddy tape after applied to middle finger. No s/sx of pain or discomfort noted . The second progress note documented by Licensed Practical Nurse (LPN)1 at 7:12 AM revealed, Keep right ring finger buddy taped to middle finger for stability and healing every shift for fracture for 3 weeks. This finding prompted a review of June 2025 progress notes revealing the resident sustained a fracture to his right middle ring finger on 06/25/25; however, there was no corresponding documentation to identify the cause of the fracture. Review of a progress note dated 06/24/25 at 1:10 PM was reviewed wherein RN2 documented, Entered room where staff was trying to change resident's brief and clothing but he began to fight, yelling, climbing on top of bed, standing on bed, striking at staff . Resident was reaching out to things not there, becoming more agitated as staff tried to keep resident safe. [Medical Director] was notified and order received for 5 mg IM Haldol. IM was administered and staff continued to watch resident for his safety until he settled down . Review of a progress note dated 06/24/25 at 6:49 PM, RN2 documented, Resident on 1:1, continuing to constantly try to get up from gerichair and bed. Becomes very agitated and belligerent when he is sat back down. Resident is very unsteady and weak . often appears to be experiencing visual hallucinations . Review of a progress note by LPN2 dated 06/25/25, at 1:17 PM, revealed, Noted with Bruising to right ring finger with swelling, resident has been noted with combative/aggressive behaviors this am, requiring redirection and one and one care. MD aware orders for Ativan as well as Tylenol, Xray also to be obtained, attempted to contact PR no answer, unable to leave message. Review of a progress note dated 06/25/25 at 4:12 PM, by LPN1 revealed, Xray tech here and performed X-ray of resident's hand and finger, resident currently shows no signs of pain or discomfort at this time. Review of a progress note dated 06/25/25 at 7:15 PM, was reviewed wherein LPN1 documented, X-Ray results received through Fax machine, call made to [Medical Director] and notified of results, Md [sic] states he would like a ortho referral and a appointment for the patient, Supervisor called and notified of X-ray results, resident has been bending and using finger and hand today with no signs and symptoms of pain or discomfort noted will continue to monitor. Review of a progress note dated 06/25/25 at 7:33 PM, the Assistant Director of Nursing (ADON) documented, Notified of xray results via primary nurse. [Medical Director] stated that he would prefer a second opinion due to uncertainty of xray results. Will attempt to follow up with ortho on next business day and notify RP. Nurse on shift reports resident using fingers/hands without s/sx of pain or discomfort at this time. Review was made of two x-ray reports for R3 with an exam date of 06/25/25 at 3:35 PM. The report signed by the reviewing physician on 06/25/25 at 4:43 PM revealed, . Exam Description: Xray finger 2 views . Findings: 2 views right digit. No prior study for comparison. No oblique view. Small ossific fragment adjacent to the middle phalanx is only seen on the AP. Joint spaces narrowed. Osteopenia. Follow-up standard imaging. Impression: Correlate clinically for middle phalanx fracture by 2 views. The report signed by a different physician at 9:05 PM revealed, . Exam Description: Rt x-ray, hand; minimum of 3 views. Right hand. Findings: here is no evidence of dislocation or osseous lesion. Carpal and metacarpal bone alignment is normal. Narrowing of the interphalangeal joints. Oblique lucency in the ulnar base of the middle phalanx of the fourth digit with surrounding soft tissue swelling. Impression: Acute nondisplaced fracture of the middle phalanx of the ring finger. The report signed at 4:43 PM did not identify which finger or a fracture. The report signed at 9:05 PM identified a fracture of the fourth/ring finger. Review of the orthopedic consult obtained on 06/27/25, revealed an order from the consulting physician to keep ring finger buddy taped to middle finger x3 weeks. The last documentation of buddy taping was made on 07/14/25, as noted above. During an interview with the ADON on 02/12/26 at 2:24 PM, she stated Medical Supplies (MS) Clerk 1 had witnessed R3 punching the wall that morning before morning meeting, on 06/25/25, adding that the MS is also a Certified Nurse Aide (CNA) who was helping R3's assigned CNA get him dressed. She said, The nurse was also trying to obtain a urine sample, and he had been having a lot of behaviors, and he did end up having a UTI. The ADON stated, We were on our way to morning meeting at that time, and when we came back through to check on him, we noticed his finger was red. An x-ray was ordered, and two conflicting reports came back, so the doctor wanted a second opinion, and he ordered an orthopedic consultation. When asked the reason there was no documentation related to R3 punching the wall, she said his behaviors had been documented that day but did not specifically include him punching the wall. When asked if this was important to determine whether an injury was known or unknown, she indicated by nodding her head up and down that she agreed, and then stated, yes. During an interview with RN2 on 02/12/26 at 2:55 PM, she stated, I reviewed my notes, and I do remember that day now. I had to give him Haldol because he just couldn't calm down. He was jumping on his bed and hitting the walls. She did not know why it was not specifically documented that [R3] was hitting the walls, but she did express the documentation of his notable behaviors, but that could have been the cause of his fractured finger. During an interview with MS Clerk on 02/12/26 at 3:00 PM, she stated she is also a CNA and had gone to help CNA10 with R3 on the morning of 06/15/25. The MS stated, [R3] was standing on his bed reaching for his watch. He was hallucinating. He was flailing his arms. When we got him down, he kept flailing his arms and legs and hitting the walls. [RN2] had to give him Haldol to calm him down. I helped [CNA10] get him changed and dressed. I did not notice his finger at the time, and he did not show any signs of pain, but he usually doesn't anyway. During an interview on 02/12/26 at 3:59 PM, with the former Director of Nursing (DON) working at the facility on 06/15/25, stated that she and the ADON were going to morning meeting and noticed the MS was helping CNA10 with R3 and he was being combative and staff were attempting to obtain a urine sample to test for a suspected urinary tract infection which may have been a cause of the increase agitation and other behaviors. They checked on him on the way back from the morning meeting and noticed his finger was red and an x-ray was ordered. She remembers there being conflicting radiology reports, one indicating a fracture and one not indicating a fracture, and the doctor wanted to get a second opinion. She believed he had been witnessed punching the wall during his agitation and aggressive behaviors, and that was a likely cause of the fracture.

Based on review of facility policies, observations, and interviews, the facility failed to ensure that all mechanical, electrical, and patient-care equipment was maintained in safe operating condition. Specifically, on 12/08/25, the facility's Heating, Ventilation, and Air Conditioning (HVAC) systems serving the 200 and 300 halls and the lobby were inoperable and/or unable to provide adequate heat, resulting in an inability to maintain required ambient temperatures for residents. This failure placed residents at risk for cold-related discomfort and adverse health outcomes.Findings include: Review of the facility policy titled HVAC Systems, last revised on 06/22/22, revealed, This facility maintains an HVAC system in a manner that protects resident health and safety from fire and extreme temperatures. Policy Explanation and Compliance Guidelines: 1. Documentation regarding the facility's HVAC system is maintained by the Maintenance Director. 2. HVAC installation and maintenance shall be in accordance with the manufacturer's specifications and the Life Safety Code (2012 version: 18.5.2.1 and 9.2) . 6. Documentation of all inspections, tests, and maintenance shall be maintained by the Maintenance Director. During a facility walkthrough on 12/10/25 at 1:30 PM, observations of the 100, 200, and 300 halls and the lobby revealed no residents on the 300 halls, temperatures in the lobby unit were below 71 degrees Fahrenheit, and multiple rooms on the 200 hall were without a working HVAC system. During an interview on 12/10/25 at 12:40 PM, the Facility Administrator (FA) revealed residents were moved from the 300 halls due to the HVAC system being out. The FA stated phone calls were made to the affected residents and/or their representatives. The FA states the HVAC system went out on Monday. During an interview on 12/10/25 at 1:18 PM, the Regional Director of Operations (RDO) revealed the facility uses Broom Heating and Air, and they have contacted them twice this week for service. Broom was out here on Monday and Tuesday of this week. The RDO stated the HVAC on the 300 hall needs to be replaced, and the other units need parts. During an interview on 12/10/25 at 4:06 PM, the FA was unable to state how often the facility provides maintenance on the HVAC system and deferred to the Maintenance Director. During an interview on 12/10/25 at 4:16 PM, the Regional Maintenance Director (RMD) stated that they change the filters on the systems once a month. He further stated that he used to keep documentation for the HVAC system, but honestly, he has not. The RMD reports, if necessary, they call any issues in to outside companies.

Based on interview, record review, and facility policy review, the facility failed to monitor, protect, and prevent misappropriation of narcotic medication for 1 of 3 residents (Resident (R)8) reviewed for misappropriation out of a total sample of 21 residents. This failure had the potential to place all residents receiving narcotic pain medication at risk of serious harm of uncontrolled pain due to drug diversion. Cross-Reference: F755 Pharmacy Services. The facility's failure to ensure prevention of misappropriation of property related to narcotic drug diversion had the potential to cause serious harm. Immediate Jeopardy was identified on 03/03/25 and was determined to exist on 02/26/25 in the area of S483.12 Misappropriation F602 at a scope and severity (S/S) of J. The Administrator was notified of the Immediate Jeopardy on 03/03/25 at 8:35 PM. The facility was notified that an acceptable plan of removal had been accepted on 03/04/25 at 7:38 PM. The survey team validated implementation of the removal plan through observations, staff interviews, and review of resident records and facility training records and the Immediate Jeopardy was removed on 03/05/25 at 1:50 PM. After removal of the Immediate Jeopardy, the deficiency remained at a D scope and severity for an isolated incident of potential harm. An extended survey was conducted in conjunction with the Recertification Survey for non-compliance at F602, constituting substandard quality of care. Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised 2024, revealed, . It is the policy of this facility to provide protections for the health. welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . 'Misappropriation of Resident property' means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent . Review of R8's Face Sheet, located in the resident's electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE], with diagnoses including but not limited to: breast cancer, chronic pain, major depressive disorder, affective mood disorder, and anxiety disorder. Review of R8's Quarterly Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 12/23/24, and located in the Aspen MDS viewer, revealed R8 scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. It was recorded R8 received scheduled and as needed (PRN) pain medications, stated her pain was moderate, and occasionally affected her sleep. It was recorded R8 stated she occasionally had pain. Review of R8's Order Summary, located under the Orders tab of the EMR, revealed on 01/30/25, R8 had physician orders for oxycodone, a narcotic pain medication, five (5) milligrams (mg) one tablet every four hours while awake. Review of R8's narcotic count sheets, provided by the facility and dated 01/30/25, revealed R8 received six blister packs of oxycodone 5mg, with each pack containing 30 tablets, for a total of 180 tablets. Review of a Prescriptions Delivered to [NAME] Manor sheet, provided by the facility, revealed 180 tablets of oxycodone 5mg were delivered for R8 at 1:47 PM on 01/30/25. Review of R8's Medication Administration Records (MARs), dated 01/30/25 and 01/31/25, and located under the Orders tab of the EMR, revealed documentation indicating R8 received a total of eight oxycodone 5mg tablets from 4:00 PM on 01/30/25 through 8:00 PM on 01/31/25. Review of R8's MARs, dated 02/01/25 through 02/21/25 at 12:00 PM, revealed R8 received one oxycodone 5mg tab every four hours while awake a total of 115 tabs (eight times documented as asleep, one time documented as other see progress notes). It was recorded that R8's order was changed to oxycodone 5mg one tab twice daily on 02/21/25, and R8 received 10 oxycodone 5mg tablets from 02/21/25 at 9:00 PM through 02/26/25 at 9:00 AM. This was a total of 133 oxycodone 5 mg tablets R8 received from 02/01/25 through 02/26/25 at 9:00 AM. Review of R8's Controlled Medication Utilization Record [narcotic count sheet], dated 02/25/25, revealed two oxycodone 5mg tablets were destroyed. Review of R8's clinical record revealed no documentation as to when administration of the oxycodone tablets delivered on 01/30/25 was started. If the administration was started on 01/30/25 at 4:00 PM (after the medications were delivered at 1:47 PM), a total of 133 tablets were administered per documentation, leaving 47 tablets. Two tablets were destroyed on 02/25/25, which would leave 45 tablets. There was no documentation of administration of these 45 tablets. Review of the narcotic count sheets showed that R8 received the medications from blister pack number 2 on 02/03/25 through 02/09/25. It was recorded R8 received the medications from blister pack number 3 on 02/09/25 through 02/14/25. There were no narcotic count sheets for blister packs number 1, 4, 5, or 6. Review of a facility investigative file revealed the following: Statement from Registered Nurse (RN)1, dated 02/26/25, documented . On Monday, February 24th, I commenced my employment at Ridegeway Manor. My understanding was that [R8]'s prescription for oxycodone 5mg was [every four hours] PRN pain. On Tuesday, February 25th, [LPN1] brought to my attention a discrepancy in [R8]'s medication orders. A review revealed that the prescription had been altered on February 21st, changing [R8]'s oxycodone regimen to twice daily . for a five-day period (February 21st -27th). This change, while documented in the electronic medical record, was not accurately reflected in the hard-copy narcotics book . [LPN1] identified the discrepancy on Tuesday morning. Following this, my manager [Unit Manager (UM)] and I reconciled [R8]'s medication record. A corrected medication administration record (MAR) was created and placed in the narcotics book to prevent further errors. A total of six oxycodone 5gm [sic] tablets accounted for. Three of the six oxycodone 5mg tablets were secured. One tablet was dispensed for [LPN1]'s 9 PM shift, leaving two tablets for the morning and evening of February 26th. However, following shift change and after reconciliation with [LPN1], an additional decided to waste the other two tablets. [LPN1] and I signed a documented account of this discrepancy which was then placed in the designated management review folder. The discrepancy was rectified following review of this report . Statement from LPN1, dated 02/26/25, documented . On 02/25/25 I relieved 7a-7p nurse when I opened the narcotic box I saw a pill pack with 3 small pills in it. The nurse informed me that the pills were for resident in [R8's room]. She showed me the narcotic sheet that it belong [sic] to. I informed the nurse that we had to waste those pills. I did use the 9p dose and she and I wasted the 9a and 1p dose. When my 7a-7p nurse came and we counted the narcotic box she asked where were [sic] [R8]'s oxycodone I informed her that we wasted the pills and that she could get the card from the unit manager . Statement from LPN2, dated 02/26/25, documented . When I came in this am, I was counting with [LPN1]. I asked where is [R8]'s oxys [oxycodone]. She said girl you don't want to know. She then tells me that when she came in last night the off going nurse showed her a pill crusher pouch with 2 or 3 pills in it [and] states [UM] said that was [R8]'s oxy for tonight [and] in the morning. [LPN1] said she did not feel comfortable with that [and] she wanted to waste them in which they did. Off going nurse then texted [UM] to let her know. I had to go to [UM] to get this mornings [sic] dose. She brought me the card [and] punched out one oxy for me to give this am and said I'll sign it out. She then said she was keeping them in her office because some of the nurses where [sic] giving the 4xday order instead of holding like the order stated for 4 days. She said she was going to run out of oxy if that kept going on, she . took meds back to her office . Review of a Facility Reported Incident report, dated 02/26/25, revealed, . The Narcotic count for [R8] was not correct. The Director of Nursing (DON) contacted the pharmacy to verify the last date of delivery and count filled. Based on the information provided and number of pills on hand, it was determined that medications were likely missing. The Unit Manager (UM), was asked to come to the DON's office to discuss this issue and instead of coming to the office she left the facility grounds and quit. The Administrator contacted the UM and informed her that they were investigating the missing medications and that is when the UM informed them that she quit. She returned to the facility and gave her statement and produced a blister pack of [R8]'s oxycodone with two pills left in it that she had in her possession. Local County Sheriff department notified . During an interview on 03/01/25 at 6:43 PM, Registered Nurse (RN) 1 stated that on 02/25/25, The [UM] gave me three pills in a plastic crush pouch. She told me one was for 9:00 PM that night for [R8], and the other two were for 9:00 AM and 1:00 PM tomorrow. I think there were around 14-16 pills left because if you add up the dosages according to her medication administration record (MAR), then that would account for the discrepancy and add up to her old oxycodone order. During an interview on 03/02/25 at 10:50 AM, R8 stated she took pain medication. R8 stated, I don't know if I get them all or not unless I start hurting, but I'm hurting all the time it seems. I can only take bed baths. Sometimes it's just too painful to take a shower. R8 stated, I have caner in the brain, have breast cancer, but now it's all over and in my brain, so I can't remember some things now. During an interview on 03/02/25 at 3:56 PM, the Director of Nursing (DON), stated, I was made aware [of the incident on 02/25/25] when the day shift [LPN] informed me the night shift nurse told her of the incident with the medication of three pills in a plastic crush bag. She told me she didn't have any oxycodone for the resident. I let the Administrator know and report it to the local sheriff department. [UM] returned to the facility, attempted to go into her office, but it was locked, and then pulled a blister pack containing two pills from her purse and turned them in. I did a narcotic reconciliation on all the carts and educated day shift on making sure that the narcotic book always matched the MAR and to only give meds according to what the MAR says and not the narcotic book because sometimes the pink change stickers don't get put on the narcotic sheets and they give the wrong dose. We also educated them on never removing narcotics from their med cart, always keeping the narcotic sheets in the narcotic book, and never give your keys up to anyone. The Administrator had to leave for an appointment, but I kept her updated via text. The Regional Clinical Director arrived and reported it to the state. During an interview on 03/02/25 at 4:43 PM, the DON stated, I have an issue with the statement that [RN1] wrote. She told me she saw on the blister pack [R8]'s name and the medication name but did not see how many pills were left. I don't know how many pills were missing and that UM returned the blister pack with two pills remaining. During a telephone interview on 03/03/25 at 2:35 PM, local County Sheriff Sergeant stated, I filed two warrants for her [UM] arrest, I do not know if she has turned herself in. I've done my part of the investigation. The County Sheriff Sergeant stated, Facility staff told me the 14 pills were missing. I took pictures [of the blister pack] and gave them back. According to the police report, there is a discrepancy of 14 oxycodone pills missing. During an interview on 03/03/25 at 2:50 PM, the Administer stated, We can't provide the other blister packs or narcotic sheets, because they are missing. The DON told me she discovered it during the investigation. We don't know what happened to them. The entire blister packs of pills are missing. During an interview on 03/03/25 at 3:40 PM, the DON stated, No that's incorrect, we are not missing any narcotic blister packs. They were all given. We are just missing the narcotic sheets. The UM took the one narcotic sheet, but we don't know where the others are or who took them. We don't have the blister packs so they were given and all I can say is that the narcotic sheets are missing. The DON was not able to answer how she knew the oxycodone was given if she did not have the narcotic sheets to show they were given. The DON responded, because it says they were in the electronic medical record (EMR). On 03/03/25 at 4:15 PM, the Administrator reported that she was incorrect in her statement that there were missing narcotics. She stated just the narcotic sheets were missing. On 03/04/25 at 7:38 PM, the facility submitted an acceptable removal plan, which included the following: The resident's medications were replaced and the MAR show's no doses of the medication were missed. An audit of all narcotic medications and controlled substance count forms was conducted on 3/2/25. No other issues were identified. Policies and procedures were reviewed on 3/3/25 to identify any necessary revisions to aid in control of narcotic diversion. The facility reported the nurse to LLR on 3/2/25. F602 does not state the time frame for reporting to LLR. On 2/6/25 education for all staff was initiated on resident abuse, neglect, and misappropriation of property. This education includes the need for immediate reporting of suspicious behavior in relation to narcotic medications and is being provided to staff from all shifts and PRN and agency staff as well and will be conducted prior their next shift. This education will be completed on or before 3/5/25. All new hires will receive this education during their orientation, prior to resident contact. Policies and procedures were reviewed by the Admin, DON, RDO, and RNC, on 3/3/25 to identify any necessary revisions to aid in control of narcotic diversion. As a result of the review updates on the narcotic count sheet process and accounting were revised on the policy tilted Controlled Substance Administration and Accountability. These changes included updating of the how the total number of meds is noted on the sheets and it now requires two nurses' signatures to add or removed medications. The diverted medications were identified as actually missing at approx. 3pm on 2/26/25 and the 2-hour report was sent to the state agency at 4:57 pm which was within the 2-hour window. All reportable events will be reviewed monthly by the QAPI Committee to ensure timely reporting is accomplished. The facility reported the nurse to LLR on 3/2/25. F602 does not state the time frame for reporting to LLR. All allegations requiring reporting to LLR will be reported with the initial report to the state agency hence forth. The controlled substance card count sheet was updated to include a full count off on hand medications. With two nurse's signatures required to add or remove medications from the cart. The DON and/or Admin will audit narcotic counts and medications will be conducted three times weekly until no further instances of non-compliance are found to exist. Once compliance is achieved the audits will be conducted weekly going forward. All audit results will be provided the facility QAPI committee for review. The facility QAPI committee will review the narcotic count audits monthly times three months of audits showing no issues. All reportable events will be reviewed monthly by the QAPI Committee to ensure timely reporting is accomplished.

Based on interview, record review, and facility policy review, the facility failed to provide and maintain pharmaceutical services for the receipt, disposition, reconciliation, and control of narcotic medication for 1 of 3 residents (Resident (R)8) reviewed for medications out of a total sample of 21 residents. This failure had the potential to place all residents receiving narcotic pain medication at risk of serious harm of uncontrolled pain due to drug diversion. Cross Reference: F602 Misappropriation. The facility's failure to ensure pharmaceutical services were provided to meet the needs of each resident had the potential to cause serious harm. Immediate Jeopardy was identified on 03/03/25 and was determined to exist on 02/26/25, in the area of S483.45 Pharmacy Services F755 at a scope and severity (S/S) of J. The Administrator was notified of the Immediate Jeopardy on 03/03/25 at 8:35 PM. The facility was notified that an acceptable plan of removal had been accepted on 03/04/25 at 7:38 PM. The survey team validated implementation of the removal plan through observations, staff interviews, and review of resident records and facility training records and the Immediate Jeopardy was removed on 03/05/25 at 1:50 PM. After removal of the Immediate Jeopardy, the deficiency remained at a D scope and severity for an isolated incident of potential harm. Findings include: Review of the facility's policy titled, Medication Administration, revised 2022, revealed, . Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . Review of R8's Face Sheet located in resident's electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE], with diagnoses which included breast cancer, chronic pain, major depressive disorder, affective mood disorder, and anxiety disorder. Review of R8's quarterly Minimum Data Set (MDS),'' with an Assessment Reference Date (ARD) of 12/23/24 and located in the Aspen MDS viewer, revealed R8 scored 13 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. It was recorded R8 received scheduled and as needed (PRN) pain medications, stated her pain was moderate, and occasionally affected her sleep. It was recorded R8 stated she occasionally had pain. Review of R8's Order Summary, located under the Orders tab of the EMR, revealed on 01/30/25, R8 had physician orders for oxycodone, a narcotic pain medication, five (5) milligrams (mg) one tablet every four hours while awake. Review of R8's narcotic count sheets, provided by the facility and dated 01/30/25, revealed R8 received six blister packs of oxycodone 5mg, with each pack containing 30 tablets, for a total of 180 tablets. Review of a Prescriptions Delivered to [NAME] Manor sheet, provided by the facility, revealed 180 tables of oxycodone 5mg were delivered for R8 at 1:47 PM on 01/30/25. Review of R8's Medication Administration Records (MARs), dated 01/30/25 and 01/31/25 and located under the Orders tab of the EMR, revealed documentation R8 received a total of eight oxycodone 5mg tablets from 4:00 PM on 01/30/25 through 8:00 PM on 01/31/25. Review of R8's MARs, dated 02/01/25 through 02/21/25 at 12:00 PM, revealed R8 received one oxycodone 5mg tab every four hours, for a total of 115 tabs (eight times documented as asleep, one time documented as other see progress notes). It was recorded that R8's order was changed to oxycodone 5mg one tab twice daily on 02/21/25, and R8 received 10 oxycodone 5mg tablets from 02/21/25 at 9:00 PM through 02/26/25 at 9:00 AM. This was a total of 133 oxycodone 5 mg tablets R8 received from 02/01/25 through 02/26/25 at 9:00 AM. Review of R8's Controlled Medication Utilization Record [narcotic count sheet], dated 02/25/25, revealed two oxycodone 5mg tablets were destroyed. Review of R8's clinical record revealed no documentation as to when administration of the oxycodone tablets delivered on 01/30/25 was started. If the administration was started on 01/30/25 at 4:00 PM (after the medications were delivered at 1:47 PM), a total of 133 tablets were administered per documentation, leaving 47 tablets. Two tablets were destroyed on 02/25/25, which would leave 45 tablets. There was no documentation of administration of these 45 tablets. Review of the narcotic count sheets showed that R8 received the medications from blister pack number 2 on 02/03/25 through 02/09/25. It was recorded R8 received the medications from blister pack number 3 on 02/09/25 through 02/14/25. There were no narcotic count sheets for blister packs number 1, 4, 5, or 6. Review of a Facility Reported Incident report, dated 02/26/25, revealed, . The Narcotic count for [R8] was not correct. The Director of Nursing (DON) contacted the pharmacy to verify the last date of delivery and count filled. Based on the information provided and number of pills on hand, it was determined that medications were likely missing. The Unit Manager (UM), was asked to come to the DON's office to discuss this issue and instead of coming to the office she left the facility grounds and quit. The Administrator contacted the UM and informed her that they were investigating the missing medications and that is when the UM informed them that she quit. She returned to the facility and gave her statement and produced a blister pack of [R8]'s oxycodone with two pills left in it that she had in her possession. Local County Sheriff department notified . During an interview on 3/01/25 at 6:43 PM, Registered Nurse (RN) 1 stated that on 02/25/25, The UM gave me three pills in a plastic crush pouch. She told me one was for 9:00 PM that night for R8], and the other two were for 9:00 AM and 1:00 PM tomorrow. I think there were around 14-16 pills left because if you add up the dosages according to her medication administration record (MAR), then that would account for the discrepancy and add up to her old oxycodone order. During an interview on 3/02/25 at 3:56 PM, Director of Nursing (DON), stated, I was made aware [of the potential drug diversion] [on 02/26/25] when the day shift [Licensed Practical Nurse] informed me the night shift nurse told her the incident of the medication of 3 pills in a plastic crush bag. She told me she didn't have any oxycodone for the resident. I let the Administrator know and report it to the local sheriff department. [UM] returned to the facility, attempted to go into her office, but it was locked, and then pulled a blister pack containing two pills from her purse and turned them in. I did a narcotic reconciliation on all the carts and educated day shift on making sure that the narcotic book always matched the MAR and to only give meds according to what the MAR says and not the narcotic book because sometimes the pink change stickers don't get put on the narcotic sheets and they give the wrong dose. We also educated them on never removing narcotics from their med cart, always keeping the narcotic sheets in the narcotic book, and never giving your keys up to anyone. Continuing with the interview on 03/02/25 at 3:56 PM, the DON stated, No we don't require two nurses to put narcotics away or remove them from the med cart. We don't need two nurses to sign off on them to put them in the DON office because they are locked up and no one touches them. We don't need to reconcile them because again, no one touches them. The DON stated that the UM should not have been removing them and taking them to her office, so no double signature would have been needed. During an interview on 3/02/25 at 4:43 PM, Director of Nursing (DON), stated, I have an issue with the statement that [Registered Nurse 1] wrote. She told me she saw on the blister pack [R8]'s name and the medication name, but did not see how many pills were left. I don't know how many pills were missing and that [UM] returned the blister pack with two pills remaining. During an interview on 03/03/25 at 12:30 PM, the Pharmacy Technician (PT) stated that when narcotic medications were delivered to the facility, the nurse would take the medications to her cart and put them away. The PT stated the signature of two nurses was not required for the receipt of narcotic medications. During a telephone interview on 3/03/25 at 2:35 PM, the local County Sheriff [NAME] stated, Facility staff told me the 14 pills were missing. I took pictures [of the blister pack]and gave them back. According to the police report there is a discrepancy of 14 oxycodone pills missing. During an interview on 3/03/25 at 2:50 PM, the Administer stated, We can't provide the other blister packs or narcotic sheets, because they are missing. The DON told me she discovered it during the investigation. We don't know what happened to them. The entire blister packs of pills are missing. During an interview on 3/03/25 at 3:40 PM, Director of Nursing (DON), stated, No that's incorrect, we are not missing any narcotic blister packs. They were all given. We are just missing the narcotic sheets. The UM took the one narcotic sheet, but we don't know where the other sheets are or who took them. We don't have the blister packs so they were given and all I can say is that the narcotic sheets are missing. The DON was not able to answer how she knew the oxycodone was given if she did not have the narcotic sheets to show they were given. She responded because it says they were in the electronic medical record (EMR). On 03/03/25 at 4:15 PM, the Administrator reported that she was incorrect in her statement that there were missing narcotics. She stated just the narcotic sheets were missing. During an interview on 03/04/25 at 4:52 PM, Licensed Practical Nurse (LPN) 2 stated that when she arrived on 02/26/25 and completed the narcotic count with LPN1, she had asked where R8's oxycodone were. LPN2 stated LPN1 had told her the UM had brought three oxycodone tablets from her office and placed them in the medication cart in a pill crusher pouch for R8 to have for the evening dose on 02/25/25 and the two doses for 02/26/25. LPN2 stated LPN1 told her she had destroyed two of the pills (with a witness) because she was uncomfortable with the situation. LPN2 stated she went to the UM to obtain R8's morning dose of oxycodone, and the UM had told her she would bring it to her. LPN2 stated the UM came about 10 minutes later with a medication card in her hand and punched the medication. LPN2 stated the UM told her she had the narcotic count sheet in her office and she would bring the sheet to her to sign off for the medication. On 03/04/25 at 7:38 PM, the facility submitted an acceptable removal plan, which included the following: The resident's medications were replaced and the MAR show's no doses of the medication were missed. An audit of all narcotic medications and controlled substance count forms was conducted on 3/2/25. No other issues were identified. Policies and procedures were reviewed on 3/3/25 to identify any necessary revisions to aid in control of narcotic diversion. The facility reported the nurse to LLR on 3/2/25. F602 does not state the time frame for reporting to LLR. On 2/6/25 education for all staff was initiated on resident abuse, neglect, and misappropriation of property. This education includes the need for immediate reporting of suspicious behavior in relation to narcotic medications and is being provided to staff from all shifts and PRN and agency staff as well and will be conducted prior their next shift. This education will be completed on or before 3/5/25. All new hires will receive this education during their orientation, prior to resident contact. Policies and procedures were reviewed by the Admin, DON, RDO, and RNC, on 3/3/25 to identify any necessary revisions to aid in control of narcotic diversion. As a result of the review updates on the narcotic count sheet process and accounting were revised on the policy tilted Controlled Substance Administration and Accountability. These changes included updating of the how the total number of meds is noted on the sheets and it now requires two nurses' signatures to add or removed medications. The diverted medications were identified as actually missing at approx. 3pm on 2/26/25 and the 2-hour report was sent to the state agency at 4:57 pm which was within the 2-hour window. All reportable events will be reviewed monthly by the QAPI Committee to ensure timely reporting is accomplished. The facility reported the nurse to LLR on 3/2/25. F602 does not state the time frame for reporting to LLR. All allegations requiring reporting to LLR will be reported with the initial report to the state agency hence forth. The controlled substance card count sheet was updated to include a full count off on hand medications. With two nurse's signatures required to add or remove medications from the cart. The DON and/or Admin will audit narcotic counts and medications will be conducted three times weekly until no further instances of non-compliance are found to exist. Once compliance is achieved the audits will be conducted weekly going forward. All audit results will be provided the facility QAPI committee for review. The facility QAPI committee will review the narcotic count audits monthly times three months of audits showing no issues. All reportable events will be reviewed monthly by the QAPI Committee to ensure timely reporting is accomplished.

Based on interview, record review, and facility policy review, the facility failed to implement a Quality Assurance and Performance Improvement (QAPI) program when they did not adequately identify, analyze, and address issues impacting resident care through proper data collection, monitoring, and improvement initiatives related to pharmaceutical services. This had the potential to affect 85 of 85 residents who resided at the facility. The facility's failure to adequately identify, analyze, and address issues impacting resident care through proper data collection, monitoring, and improvement initiatives related to pharmaceutical services had the potential to cause serious harm to residents. Immediate Jeopardy was identified on 03/03/25 and was determined to exist on 02/26/25, in the area of S483.75 Quality Assurance and Performance Improvement at a scope and severity (S/S) of J. The Administrator was notified of the Immediate Jeopardy on 03/03/25 at 8:35 PM. The facility was notified that an acceptable plan of removal had been accepted on 03/04/25 at 7:38 PM. The survey team validated implementation of the removal plan through observations, staff interviews, and review of resident records and facility training records and the Immediate Jeopardy was removed on 03/05/25 at 1:50 PM. After removal of the Immediate Jeopardy, the deficiency remained at a D scope and severity for an isolated incident of potential harm. Findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Plan, revised 2019, revealed, . This facility shall develop, implement, and maintain and ongoing, facility-wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems . The objectives of the QAPI Plan are to: 1. Provide a means to identify and resolve present and potential negative outcomes related to resident care and services . Provide structure and processes to correct identified quality and/or safety deficiencies. 4. Establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcome . Establish systems and processes to maintain documentation relative to the QAPI Program, as a basis for demonstrating that there is an effective ongoing program . The committee shall approve any corrective actions, including changes in policies and / or procedures, employment practices, standards of care, etc., and shall also monitor all corrective activities for appropriateness and/or the need the alternative measures . 1. The facility failed to monitor, protect, and prevent misappropriation of narcotic medication for one of three residents (Resident (R)8) reviewed for misappropriation out of a total sample of 21 residents. This failure had the potential to place all residents receiving narcotic pain medication at risk of serious harm of uncontrolled pain due to drug diversion. The facility's failure to ensure prevention of misappropriation of property related to narcotic drug diversion had the potential to cause serious harm. Immediate Jeopardy was identified on 03/03/25 and was determined to exist on 02/26/25 in the area of S483.12 Misappropriation F602 at a scope and severity (S/S) of J. The Administrator was notified of the Immediate Jeopardy on 03/03/25 at 8:35 PM. The facility was notified that an acceptable plan of removal had been accepted on 03/04/25 at 7:38 PM. The survey team validated implementation of the removal plan through observations, staff interviews, and review of resident records and facility training records and the Immediate Jeopardy was removed on 03/05/25 at 1:50 PM. After removal of the Immediate Jeopardy, the deficiency remained at a D scope and severity for an isolated incident of potential harm. Cross Reference: F602 Misappropriation 2. The facility failed to provide and maintain pharmaceutical services for the receipt, disposition, reconciliation, and control of narcotic medication for one of three residents (Resident (R)8) reviewed for medications out of a total sample of 21 residents. This failure had the potential to place all residents receiving narcotic pain medication at risk of serious harm of uncontrolled pain due to drug diversion. The facility's failure to ensure pharmaceutical services were provided to meet the needs of each resident had the potential to cause serious harm. Immediate Jeopardy was identified on 03/03/25 and was determined to exist on 02/26/25, in the area of S483.45 Pharmacy Services F755 at a scope and severity (S/S) of J. The Administrator was notified of the Immediate Jeopardy on 03/03/25 at 8:35 PM. The facility was notified that an acceptable plan of removal had been accepted on 03/04/25 at 7:38 PM. The survey team validated implementation of the removal plan through observations, staff interviews, and review of resident records and facility training records and the Immediate Jeopardy was removed on 03/05/25 at 1:50 PM. After removal of the Immediate Jeopardy, the deficiency remained at a D scope and severity for an isolated incident of potential harm. Cross Reference: Pharmacy Services 3. Review of the facility's pharmacy Omnicare Quality Improvement: Consultant Pharmacist Summary, dated 10/01/24 to 10/31/24, revealed, . Quantities on back of MAR [Medication Administration Record] do not always match quantity on Narcotic sheet (one discrepancy noted on sample audit of four residents). Please ensure staff is documenting appropriately on MAR and on narcotic sheet when controlled substances are administered for 98 charts reviewed. Review of the facility's pharmacy Omnicare Quality Improvement: Consultant Pharmacist Summary, dated 11/01/24 to 11/30/24, revealed, Quantities on back of MAR do not always match quantity on Narcotic sheet (one discrepancy noted on sample audit of four residents, please ensure staff is documenting appropriately on MAR and narcotic sheet when controlled substances are administered for 97 charts reviewed. Review of the facility's pharmacy Omnicare Quality Improvement: Consultant Pharmacist Summary, dated 01/01/25 through 01/31/25, revealed, Quantities on back of MAR do not always match quantity on Narcotic sheet (three discrepancies noted on sample audit of four residents and one discrepancy was off by three pills) for 98 charts reviewed. During an interview on 03/02/25 at 4:15 PM, the DON stated, I used to keep all the excess narcotics in my office, but we won't be anymore. They're going straight to med cart. We don't have any accountability for them because no one touches them. We didn't need to have double verification for the Unit Manager (UM) to keep them in her office because she wasn't supposed to be doing it. During an interview on 03/02/25 at 5:25 PM, the Administer stated, Pharmacy will typically bring extra cards and [DON] keeps the narcotics with narcotic sheets in her office, but this process has changed now to storing them in the cart now since this incident. The DON and I have the keys. We don't do med reconciliation on them, but they're in there for storage and not accessible to anyone. During an interview on 03/03/25 at 2:50 PM, the Administer stated, We haven't addressed the pharmacy reports in QAPI yet. We do talk about them though. During an interview on 03/03/25 at 3:40 PM, the Director of Nursing (DON) stated, We go over all the pharmacy quality assurance reports. We discuss them only in QAPI, but we don't document anything on them. We haven't addressed January's pharmacy report yet. On 03/04/25 at 7:38 PM, the facility presented an acceptable plan of removal, which included: The resident's medications were replaced and the MAR show's no doses of the medication were missed. On 03/03/2025 the facility system for monitoring, identifying, reporting, tracking and investigating adverse events related to pharmacy services after noted discrepancies in narcotic medication reconciliation were reviewed and updated as necessary to ensure the safety and wellbeing of the facility residents receiving narcotic medications. On 2/26/25 education for all staff was initiated on resident abuse, neglect, and misappropriation of property. This education includes the need for immediate reporting of suspicious behavior in relation to narcotic medications and is being provided to staff from all shifts and PRN and agency staff as well and will be conducted prior their next shift. This education will be completed on or before 3/5/25. All new hires will receive this education during their orientation, prior to resident contact. Policies and procedures were reviewed by the Admin, DON, RDO, and RNC, on 3/3/25 to identify any necessary revisions to aid in control of narcotic diversion. As a result of the review updates on the narcotic count sheet process and accounting were revised on the policy tilted Controlled Substance Administration and Accountability. These changes included updating of the how the total number of meds is noted on the sheets and it now requires two nurses' signatures to add or remove medications and and for receiving medications from the pharmacy. The controlled substance card count sheet was updated to include a full count of on hand medications. With two nurse's signatures required to add or remove medications from the cart. The DON and/or Admin will audit narcotic counts and medications will be conducted three times weekly until no further instances of non-compliance are found to exist. Once compliance is achieved the audits will be conducted weekly going forward. All audit results will be provided the facility QAPI committee for review. The pharmacy report will also be reviewed monthly by the committee. The facility QAPI committee will review the narcotic count audits monthly times three months with no issues noted. Pharmacy reports will also be reviewed monthly by the QAPI Committee to ensure timely reporting is accomplished.

Based on observations, interviews, and record review, the facility failed to ensure food stored in the main kitchen was labeled and dated. The failures had the potential to increase the prevalence and spread of foodborne illness and infection for 79 residents who receive food from the kitchen. 6 residents receive tube feedings with no food/fluids provided by the kitchen. Findings include: Review of the facility's undated policy titled, Food Storage stated Sufficient storage facilities are provided to keep foods safe . and by methods designed to prevent contamination . Rewrap packages of frozen food which have been opened. This prevents freezer burns and spoilage . Review of the facility's policy dated 02/2023 titled, Food Safety Requirements stated, . Food will also be stored . in accordance with professional standards for food service safety . Food safety practices shall be followed throughout the facility's entire food handling process . Storage of food in a manner that helps prevent deterioration or contamination of food, including from growth of organisms . Labeling, dating, and monitoring refrigerated foods . Keeping foods covered or in tight containers . During an observation on 03/02/25 at 9:15 AM, of food storage in the meat freezer revealed an undated, opened bag of chicken tenders stored in a clear bag that was tied in a knot for closure. The use by date on the bag read 01/08/25. An undated clear bag containing fish fillets stored in a clear bag that was tied in a knot for closure was also observed. There was no use by date on the bag, no received date, and no date opened. Ice crystals were noted on the fillets. An opened brown bag of frozen French fries was observed with no opened date, no received date, and no use by date. The bag was rolled up and not securely closed. During an interview on 03/02/25 at 9:15 AM, the Dietary [NAME] (DC) stated that the chicken tenders were opened yesterday (03/01/25) but was not sure when they were received by the facility. DC stated that she was not sure when the fish fillets were opened or when they were last used. DC stated that she was not sure when the French fries were opened but when the staff have a question about if an item is okay to use they ask the Dietary Manager (DM) and she would let them know. The DC confirmed that it was the facility expectation for staff to write the received date and the date opened on all food items. The DC stated that if a use by date was not on the package, kitchen staff ask the DM to make sure it is okay to use. During an interview on 03/04/25 at 11:23 AM, the Dietary Manager (DM) stated that it was her expectation that all foods be labeled with the date received and the date opened.

Based on record review and interview, the facility failed to ensure Registered Nurse coverage was provided eight hours a day seven days a week for a total of seven days in July, August, and September 2024. The failure created the potential for the clinical needs of all residents not to be met. Findings include: Review of the facility's Job Description: Registered Nurse, provided by the Regional Director of Operations (RDO) noted, SUMMARY Assesses and evaluates the health status of resident/patient and provides care and treatment in accordance with physician orders and standards of practice. ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned Assesses patients by physical examination including pertinent diagnostic testing to determine health status. Administers medications and treatments. Participates in the care planning process and oversees implementation of the plan. Supervises LPNS [Licensed Practical Nurses] and Nursing Assistants. Oversees ADLS [activities of daily living] and documentation. Communicates with physicians regarding changes in conditions, diagnostic test results, etc. Documents assessments and care in compliance with standards of care and company policy. Educates patients and their families on health-related issues. The facility was licensed for a total of 112 beds. Review of the Payroll Based Journal (PBJ) from the fourth quarter of 2024 revealed the following dates had no Registered Nurse (RN) coverage: 07/06/24, 07/17/24, 07/20/24, 07/21/24, 08/18/24, 08/22/24, and 09/01/24. Review of the Daily Census Reports, provided by the Staffing/Medical Supplies (SMS) for the identified dates revealed the census was 99, 101, 100, 99, 97, 96, and 93, respectively. During an interview on 03/03/25 at 3:47 PM, both the SMS and the Human Resources Director (HRD), responsible for submitting the PBJ information, confirmed there was no RN coverage for the identified dates. In an interview on 03/04/25 at 12:47 PM, the Administrator and Director of Nurses confirmed there was no RN coverage for the seven identified dates in 2024. In an interview on 03/05/25 at 1:19 PM, the Regional Director of Operations (RDO) confirmed there was no RN coverage for the seven identified dates in 2024.

Based on review of the facility policy, record review and interviews, the facility failed to report an allegation of misappropriation of narcotic medication to the state survey agency within two hours for 1 of 3 residents (Resident (R)8) reviewed for abuse out of a total sample of 21 residents. This had the potential to allow continued misappropriation. Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised 2024, revealed, . It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Misappropriation of Resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent . Reporting / Response. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury . Review of R8's Face Sheet located in resident's electronic medical record (EMR) under the Profile tab, revealed, R8 was admitted to the facility on [DATE], with diagnoses including but not limited to: left breast cancer, chronic pain, major depressive disorder, affective mood disorder and anxiety disorder. Review of a Facility Reported Incident report, dated 02/26/25, revealed, . The Narcotic count for [R8] was not correct. The Director of Nursing (DON) contacted the pharmacy to verify the last date of delivery and count filled. Based on the information provided and number of pills on hand, it was determined that medications were likely missing. The Unit Manager (UM) was asked to come to the DON's office to discuss this issue and instead of coming to the office she left the facility grounds and quit. The Administrator contacted the UM and informed her that they were investigating the missing medications and that is when the UM informed them that she quit. She returned to the facility and gave her statement and produced a blister pack of [R8]'s oxycodone with two pills left in it that she had in her possession. Local County Sheriff department notified . During an interview on 03/02/25 at 3:56 PM, the Director of Nursing (DON) stated, I found out at 8:50 AM [on 02/26/25] from [Licensed Practical Nurse (LPN)2] about the drug diversion and missing oxycodone and told the Administrator right before the 9:00 AM morning meeting. We finished the morning meeting and started investigating. We had pharmacy come in and destroy drugs with us while they were here. The [Unit Manager (UM)] was doing care plan meetings in the MDS office. The Administrator called her down to come meet. The MDS told the Administrator the UM was not there. The Administrator asked Human Resources [HR] to try to track her down. The Administrator looked at the parking lot and saw that the [UM]'s car was no longer in the parking lot. So, the Administrator and I went into the [UM]'s office and found her nurse keys lying on top of the desk. We searched through her desk and office and the med cart. HR tried calling the [UM] on her cell phone and she didn't answer. [UM] called her back and asked, What do you want? HR asked her if she was at the facility. The [UM] responded, No I am not, and you people are full of 'bleep' and hung up. I called [UM] back and asked her where the missing narcotics were, and the missing narcotic sheets were and let her know we had already searched her office and didn't find anything. We asked her to come back to the facility. The Regional Corporate Director [RCD] arrived. Then the [UM] arrived and went straight to her office to try to get into it, but she left her keys earlier and was not able to. The [UM] handed me a blister card pack with two oxycodone pills from her purse and then left. The RCD called the local law enforcement to report it around 11:30 AM and possibly press charges. Law enforcement arrived. We kept the Administrator aware of everything via texts and calls. During an interview on 03/02/25 at 5:14 PM, the Administrator stated, It started Wednesday morning when [LPN2], the day shift nurse went to the DON and reported the missing narcotics to her right after meeting. The UM was in care plan meeting in the MDS office, and I called her around 11:00 AM to ask her to come to the office and talk with me. She never came. I called her again. The MDS nurse said she left. I had Human Resources try to contact her on her cell phone. I had a Dr. appointment and had to leave the building and couldn't follow up, but the staff kept in contact with me via phone calls and text to update me. During an interview on 03/04/25 at 4:52 PM, LPN2 stated, Between 8:00 AM and 8:30 AM, I let the [UM] know that I was out of [R8]'s oxycodone and needed more. The [UM] returned from her office with a blister pack of meds. She popped out one pill and I saw the blister pack had [R8]'s name on it and what the med was, but I didn't see how many meds were on the card. I didn't think this was the right way to handle narcotics and I reported it to the DON when she came in that morning before the morning meeting. During an interview on 03/05/25 at 12:25 PM, the Administrator stated, We didn't report it to the state until we validated that drugs were missing and that took until 3:00 PM when the RCD reported it. We don't report anything until we know for sure there is something to report, otherwise we would be reporting every little thing. During an interview on 03/05/25 at 5:25 AM, the DON stated, We didn't call into the state, because there was nothing to report until 3:00 PM. We didn't know she took anything or that anything was wrong until 3:00 PM.

Based on interviews, and facility policy review, the facility failed to use nursing rights of medication administration while administrating a medication for 1 of 21 residents (Resident (R)8), reviewed for professional standards. This failure had the potential for residents being subject to adverse effects leading to worsening symptoms, long-term effects, and death. Findings include: Review of the facility's policy titled, Medication Administration revised 2022, revealed, . Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. a. Refer to drug reference if unfamiliar with the medication, including its mechanism of action or common side effects . Review of R8's Face Sheet, located in resident's electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE], with diagnoses which included but was not limited to: left breast cancer, chronic pain, major depressive disorder, affective mood disorder, and anxiety disorder. Review of R8's Quarterly Minimum Data Set (MDS),'' with an Assessment Reference Date (ARD) of 12/23/24, and located in the Aspen MDS viewer, revealed R8 scored 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. Review of R8's Order Summary located in resident's EMR under the Orders tab, revealed that on 02/25/25, R8 had physician's orders for oxycodone five milligrams (mg) one tablet twice daily for pain. Review of a facility investigative file for R8 revealed the following: Statement from Registered Nurse (RN)1, dated 02/26/25 - . On Tuesday, February 25th, [Licensed Practical Nurse (LPN)1] brought to my attention a discrepancy in [R8]'s medication orders. A review revealed that the prescription had been altered on February 21st, changing [R8]'s oxycodone regimen to twice daily . for a five-day period (February 21st -27th. This change, while documented in the electronic medical record, was not accurately reflected in the hard-copy narcotics book . [LPN1] identified the discrepancy on Tuesday morning. Following this, my manager [Unit Manager (UM)] and I reconciled [R8]'s medication record. A corrected medication administration record (MAR) was created and placed in the narcotics book to prevent further errors. A total of six oxycodone 5gm [sic] tablets accounted for. Three of the six oxycodone 5mg tablets were secured. One tablet was dispensed for [LPN1]'s 9 PM shift, leaving two tablets for the morning and evening of February 26th. However, following shift change and after reconciliation with [LPN1], an additional decided to waste the other two tablets. [LPN1] and I signed a documented account of this discrepancy which was then placed in the designated management review folder. The discrepancy was rectified following review of this report . Statement from LPN1, dated 02/26/25 - . On 02/25/25 I relieved 7a-7p nurse when I opened the narcotic box I saw a pill pack with 3 small pills in it. The nurse informed me that the pills were for resident in [R8's room]. She showed me the narcotic sheet that it belong [sic] to. I informed the nurse that we had to waste those pills. I did use the 9p dose and she and I wasted the 9a and 1p dose. When my 7a-7p nurse came and we counted the narcotic box she asked where were [sic] [R8]'s oxycodone I informed her that we wasted the pills and that she could get the card from the unit manager . During an interview on 03/02/25 at 6:43 PM, Registered Nurse (RN)1 stated, The Unit Manager gave me three pills in a plastic crush pouch that I watched her pop out of the blister pack. She told me one was for 9:00 PM that night for [R8], and the other two were for 9:00 AM and 1:00 PM tomorrow. During an interview on 03/05/25 at 10:19 AM, LPN1 stated, The pill in the plastic crush pouch looked like an Oxycodone. [RN1] told me it was during shift change. If I didn't give it to R8, then she wouldn't have had any pain meds that night. We have a drug reference library on our electronic medical record (EMR) that we can use to look up a med is, but I did not use it for that pill. During an interview on 03/05/25 at 10:45 AM, the DON stated, I would expect that a nurse never give medication that they did not pop out of the blister pack themselves. They must know what they are giving. During an interview on 03/05/25 at 10:46 AM, the Administrator stated, I agree with the DON. No nurse should give medication that they didn't pull themselves. There is no way that nurse should have given that med.

Based on review of the facility policy, record reviews, and interviews, the facility failed to update Resident (R)1 and R2's care plan to reflect a person-centered change in status, related to potential desire/preference. 2 of 7 reviewed for Care Plans. Findings include: Review of the facility policy titled, Care Plan Revisions Upon Status Change, last revised 2021, revealed, The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Procedure for reviewing and revising the care plan when a resident experiences a status change: upon identification of a change in status, the nurse will notify the Minimum Data Set (MDS) Coordinator, the Physician, and the resident representative if applicable. The MDS Coordinator and the Interdisciplinary Team (IDT) team will discuss the resident condition and collaborate on intervention options. Staff involved in the care of the resident will report resident response to new or modified interventions. R1 was admitted to the facility on [DATE] with diagnoses including but not limited to; Human Immunodeficiency Virous (HIV), mild neurocognitive disorder due to known physiological condition without behaviors, and major depressive disorder. Review of the Quarterly MDS dated [DATE] revealed, R1 has a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicates she is cognitively intact. R2 was admitted to the facility on [DATE] with diagnoses including but not limited to; heart failure, hypertension, and psychoactive substance abuse. Review of the Quarterly MDS dated [DATE], revealed R2 has a BIMS score of 11 out of 15, which indicates he has a mild cognitive impairment. Record review of facility Five Day Reportable Incident dated 05/09/24 revealed R1 with a diagnosis of HIV approached R2 with a sexual advance in exchange for money. When questioned, R1 admits to receiving oral sex in exchange for money from R1. R1 denies any allegation when asked, R2 reports that he knows R1 has a disease because she told him. Since this incident he has not had any other contact with her. Record review of R1's and R2's Electronic Medical Record revealed no updates to the resident's Care Plan to reflect this incident. An interview on 05/23/24 at 12:51 PM with R1 revealed that she denies any sexual contact with R2 and did not receive any money from R2. R1 denied speaking with another resident about providing sexual advances on other male residents for money. An interview on 05/23/24 at 1:01 PM with R2 revealed that he denies any sexual contact with R1 because she has a serious disease. R2 also denied giving R1 money for a sexual favor, but was interested in R1 in a sexual way before R1 told him that she had a serious disease. R2 further stated that since being informed of R1's status (HIV diagnosis), he no longer wants contact with R1 and stays away from her and hasn't seen her much. A phone interview on 05/23/24 at 1:30 PM with R2's Resident Representative revealed that the facility notified them of the potential sexual interaction R2 had at the facility and they had no concerns with R2's change in status. The Resident Representative further stated that the facility contacted them to let them know that they completed appropriate Sexually Transmitted Disease (STD) testing on R2 for precautions. An interview on 05/23/24 at 1:41 PM with Certified Nursing Assistant (CNA)1 revealed that they overheard R1 discussing with another resident that she was running games on men here (at the facility) for money. R1 said that R2 wants me to perform a sexual act on him. CNA1 stated that she tried to speak to R1 and the other resident, but neither would discuss with her what she meant by that comment. CNA1 told the Social Worker about this incident. CNA1 further stated that she did not witness R1 and R2 having sexual contact, but had seen R1 in R2's room and sitting on his bed and chatting with him in the past. CNA1 further stated that they were unsure if R1's and R2's Care Plan was updated to reflect this incident, but they were instructed to re-direct R1 out of R2's room if observed, because he no longer wants contact with R1. An interview on 05/24/2024 at 9:15 AM with the Unit Manager (UM1) revealed that R2 had a lab draw for HIV testing that was completed on 05/10/24 with a non-reactive/ negative test result. UM1 further stated that both residents denied sexual activity when questioned and R2 stated that he is aware of R1's serious disease (HIV) because R1 told him and that he has not had any contact since being aware of her HIV status. UM1 stated that staff spoke with both residents and an re-educated them because they are cognitive enough to make their own sexual decisions. UM1 finally stated that R1 is Care Planned for an HIV diagnosis, but unsure if the resident's Care Plan was updated to reflect the potential for sexual contact with other resident. UM1 was also unsure if R2's Care Plan was updated to reflect R2 wishes of not wanting R1 near his environment. An interview on 05/24/24 at 9:41 AM with MDS Coordinator and Social Worker revealed that the facility did not update R1 and R2 Care Plan related to this incident. R1's Care Plan was not updated due to her denying the allegation of any sexual act occurring. The MDS Coordinator and Social Worker stated that R2's Care Plan was not updated due to the Resident Representative being okay with the potential of R2 having a sexual relationship with female residents. Both further stated that they were unaware that R2 no longer has the desire to be sexual with R1 due to him discovering her HIV status. A phone interview on 05/24/24 at 10:32 AM with the Administrator revealed that staff had spoken with R1 but she denied having sexual contact with R2 or any other male residents for money and failed to elaborate what she meant by running games on men for money when she was speaking with another resident at the facility. When staff spoke to R2, he admitted to receiving a sexual advance from R1 and also admitted to giving her money for the sexual act and told staff that it was consensual. Staff contacted R2's Resident Representative due to the resident having a mild cognitive impairment and notifying his representatives of the change of status. The Administrator further stated that R1's and R2's Care Plan should have been updated in a timely manner to reflect this change in condition.

Based on observations, interviews, and record review, the facility failed to maintain a clean and safe environment on 2 (Unit 100 and Unit 200) of 3 resident care units in 1 of 2 buildings. Findings include: 1. Observations during the initial tour on 06/27/23 at 8:30 AM revealed the following: room [ROOM NUMBER] - the baseboard underneath the window was away from the wall and laying on the floor. The window air conditioner unit did not fit securely in the window. There was a gap, approximately six inches long and two inches wide, between the air conditioner unit and the window frame; Rm 104A - the head of bed was crooked and loose; Rm 104B - the headboard was missing from the resident's bed, there was no privacy curtain to provide privacy for both residents, and the wall had heavy gouge marks; and Rm 112A - there were dried beige color splatter marks on feeding pump, pole, nightstand, and floor. During an interview on 06/28/23 at 2:20 PM, the Registered Nurse Unit Manager confirmed nursing staff were responsible for cleaning the feeding pumps and poles. 2. Observation on 06/28/23 at 3:45 PM revealed the walls behind both headboards in room [ROOM NUMBER] were severely damaged, with large and deep scrape marks in the wall in a two-foot-wide section behind each headboard. The bathroom door was completely covered in dried splashes of an unknown substance and dried drips of a clear substance. During an interview on 06/28/23 at 3:45 PM, Resident (R)4, who resided in room [ROOM NUMBER], stated she did not know what had caused the splashes and dried drips. R4 stated her bed made the marks on the wall. During an interview on 06/28/23 at 3:45 PM the Maintenance Director (MD) stated the marks on all the walls were scheduled for painting and the facility had hired a painter for all projects in the buildings. The MD stated he was not aware of any policy for maintenance reporting but that he accepted text messages or phone calls regarding reports about repairs in the facility. The MD stated he used Tells (a maintenance program software) for routine maintenance. The MD stated he did not make environmental rounds in the bedrooms. Observation of room [ROOM NUMBER] on 06/28/23 at 3:46 PM revealed bed two, which was by the window, and bed four, which was in the corner, had severe scuff marks two feet in diameter on the wall behind each headboard. Observation of room [ROOM NUMBER] on 06/28/23 at 3:48 PM revealed large scuffs, two feet in diameter, on the wall behind the headboard of bed two. One of the recessed cabinet doors was broken, with a large section of the door missing, and the handle was missing. Observation of room [ROOM NUMBER] on 06/28/23 at 3:50 PM revealed scuffs, measuring two feet in diameter, behind the headboards of both beds. 3. On 06/29/23 at 4:15 PM, an environmental tour of the 100 Unit was conducted with the Licensed Practical Nurse Unit Manager (LPNUM), Regional Nurse Consultant, Maintenance Director, and Regional Director of Operations. The following was noted: room [ROOM NUMBER] - the clothing closet door for Bed A was missing the doorknob. The clothing closet door for Bed B did not close completely. The baseboard underneath the window was partially attached to the wall. The window air conditioner unit did not fit securely in the window. There was a gap, approximately six inches long and two inches wide, between the air conditioner unit and the window frame. At the bottom of the air conditioner unit were sharp, loose screws that were not attached to the window frame; room [ROOM NUMBER]- the baseboard underneath the window was separating from the wall. The resident's sink had brown/black grime in it. Underneath the head of the resident's bed was dirt/dust debris; room [ROOM NUMBER]A - there were gnats in the resident's area. There were gouge marks in the wall from the resident's bed, and the wall paint was peeling. The clothing closet for Bed A was missing the bottom shelf; room [ROOM NUMBER]B - there was dust and debris under the resident's bed, and the bedframe was covered with dirt and grime. The bathroom doorframe had gouge marks; room [ROOM NUMBER]A - the clothing closet door had a hole, exposing splintered wood edges. The baseboard was missing next to the clothing closet for Bed B. Both nightstands had peeling veneer. The toilet had a yellow ring of grime inside. The call light outside the room was missing the covering; room [ROOM NUMBER]A - the resident's headboard was loose and crooked. The bottom frame of the clothing closet had splintered edges. There was no privacy curtain; Rm 104B - the clothing closet for Bed B had a missing wood panel at the bottom of the closet. A corner section of the overbed table was missing veneer. The window ledge by this bed had a missing section, leaving splintered edges; Rm 105 - the cabinet over the sink had rust residue on the bottom shelf and dust debris on the first and second shelves. The plastic covering over the cabinet light fixture was cracked with sharp edges; Rm 106 - the clothing closet door was missing a knob. The call light over the resident's door was missing the covering; Rm 107A - Bed A's footboard was missing a corner section and the black edging of the footboard was peeling, leaving splintered edges. Yellow colored stains were present in the bathroom toilet, and the side of the toilet had dried brown residue; Rm 108 - the clothing closet door for Bed A had a loose doorknob. The clothing closet door for Bed B had a hole in the middle of the door, exposing splintered wood edges. The door also had splintered edges at the bottom of the doorframe. The bathtub in the room has discolored standing water. The toilet had yellow/green color stains inside the toilet: Rm 110 - the bathtub had reddish brown stains on the bottom of the tub. There was a hard tan colored substance stuck in the drain. The toilet had a yellow/green color residue; and Rm 112A - there was a dried beige color splatter on the feeding pump, pole, nightstand, and pole. During an interview on 06/29/23 at 4:15 PM, the MD and the Regional Director of Operations revealed they were in the process of renovating as the rooms became available. The MD stated he had hired additional staff to assist with the repairs.

Based on observation, interview, and review of facility policy, the facility failed to follow the menu for 52 of 52 residents served mechanical soft or regular diets in the in 1 unit. Findings include: Review of the facility's undated policy titled Standardized Menus, revealed, . the facility will provide nourishing, palatable meals to meet the nutritional needs of the residents . Menus should have portions listed in ounces . Review of the facility's undated menu titled, Week 1 Revised Spring Summer revealed for 06/28/23, one cup of lasagna was to be served for the noon meal entree. During an observation on 06/28/23 from 11:55 AM to 1:05 PM, the Cook was observed using a #8 scoop (half-cup scoop) to plate lasagna for the residents. The Cook placed one scoop of lasagna on each plate for residents receiving either a mechanical soft or regular diet. During an interview on 06/28/23 at 12:10 PM, the Cook confirmed she was using a #8 scoop to plate the lasagna. During an interview with the Dietary Manager (DM) on 06/28/23 at 1:05 PM, the DM stated she did not notice the residents had only received one-half cup of lasagna. The DM observed the final cart leaving the kitchen and confirmed the lasagna serving was only one-half cup.

Based on review of facility files and interviews, the facility failed to notify the physician when there was a significant change in the resident's physical, mental, or psychosocial status. Review of facility files revealed Resident #2 was found outside the facility on three occasions. The physician was notified of only one occurrence. Resident #5 was noted with a change in behavior after returning from a geri psych hospitalization . The physician was not notified about the resident's behaviors. Two of nine residents reviewed for physician notification. The findings included: Review of Resident #2's Incident Report dated 9/10/17 revealed resident noted outside in parking lot of rear of facility. Resident assisted per staff in facility. Resident stated s/he was going to save (his/her) house. New order to place resident on 1:1 observation. Resident's condition was noted to be alert and confused. Equipment involved was noted as wheelchair. There was no documentation that there was an alarm sounding. There was no documentation related to the wander guard. Review of Resident #2's Incident Report dated 10/1/17 revealed resident outside without notifying staff. Resident noted to be alert and confused. Resident observed outside of building heading towards the street. CNA (certified nurse aide) and nurse assisted resident back into the building. Resident stated I'm going to get some clothes and I am trying to catch a ride. Equipment involved was noted as wheelchair. The Incident Report indicated the physician was not notified. There was no documentation that there was an alarm sounding. There was no documentation related to the wander guard. Review of Resident #2's Elopement Risk Assessments dated 7/21/17, 10/1/17, and 12/19/17 revealed the resident was coded as an elopement risk. Review of Resident #2's care plan revealed at risk for elopement as evidenced by multiple attempts to leave the building and making comments about leaving to go find his/her spouse was identified as a problem area. Interventions and approaches were listed on the care plan and included remove resident from unsafe situations and attempt to redirect. Review of Resident #2's Progress Notes revealed on 7/21/17 at 6:41 PM wanderguard placed to right wrist related to resident attempting to go outside without staff member despite much education to notify staff if resident would like to go outside during undesignated smoke times for leisure. On 7/23/17 at 6:10 PM resident with one attempt to go outside this shift but redirected and advised s/he could sit on front porch. Continues on every 15 minute checks. Review of Resident #2's Progress Notes dated 7/28/17 indicated resident was discussed in IDT (Interdisciplinary Team) related to behaviors. Resident had several exit seeking episodes this week where s/he attempted to go outside without a staff member. Review of the Progress Note dated 8/2/17 at 12:55 PM revealed resident continues to try to go to smoking area without assistance. Social Service brought him/her back in at 10:30 and re-educated him/her again about not going out without a staff member. On 8/3/17 at 10:45 AM the Progress Note indicated new order received to discharge every 15 minute checks. No further elopement attempts noted. On 8/6/17 at 2:34 PM resident continues to try to go to smoking area without assistance. On 9/10/17 at 1:02 PM resident alert and verbal with confusion noted at times. Resident was observed to be outside the building in the driveway. Staff assisted resident back into building. MD made aware. New order to place resident on 1:1. On 9/11/17 at 11:31 AM new order to discharge 1:1. [ENTITY]t every 15 minute checks related to exit seeking behaviors. Resident educated to not go outside without staff member present related to safety. Resident verbalized understanding. Non-compliant with request. Resident noted sitting outside of front porch without notifying staff. The Progress Note dated 9/15/17 at 8:27 AM by the Social Worker indicated resident continues to attempt to go outdoors without staff assistance or supervision. Social Worker contacted responsible party by phone to discuss exit seeking behaviors. Responsible party agreed that resident may need a secured building or a locked unit to ensure his/her safety. The Progress Note dated 10/1/17 at 11:33 AM indicated Resident #2 was observed propelling self-outside heading towards the street. Nurse and CNA assisted him/her back inside of building. Resident stated, I was going to get a ride to (town) to get me some clothes. Every 15 minute checks implemented to ensure resident safety. There was no documentation that the physician was notified. The Progress Note date 10/1/17 at 1:00 PM indicated the resident was noted with left sided facial drooping and was sent out to the hospital. The resident returned to the facility on [DATE]. Review of Resident #2's Physician order [REDACTED]. Review of Resident #2's Physician order [REDACTED]. The resident was placed on 1:1 related to elopement attempt 9/10/17-9/11/17. The resident was placed on every 15 minute checks related to exit seeking behaviors 9/11/17-9/12/17. The resident was placed on 1:1 related to exit seeking behaviors 10/3/17-10/16/17, the resident was found in front of the building heading for the road on 10/1/17. The resident was placed on every 15 minute checks related to behaviors 10/16/17-[DATE]. The resident was placed on every 15 minute checks x [AGE] hours 11/3/17-11/6/17. In an interview with the surveyor on 12/19/17 at approximately 11:10 AM, LPN (Licensed Practical Nurse) #1 stated s/he works with Resident #2 on a regular basis. When the resident first came s/he was very anxious. Resident #2 would try to exit seek to go out to smoke. The resident would try to go out all doors, but mostly it was out the back door where they go outside to smoke. The resident was educated on having a staff member go outside with him/her multiple times. LPN #1 stated the resident had been on 1:1, every 15 minutes checks, and enhanced monitoring for his/her exit seeking behaviors. Resident #2 had a wander guard and now they have the mag locks in place. The resident's wander guard was discharged when the locks where put in place on the doors. In an interview with the surveyor on 12/19/17 at approximately 11:35 PM, the DON (Director of Nursing) stated Resident #2 was out in the front driveway on 10/1/17. The DON stated on 9/10/17 another staff member saw the resident and they brought him/her back in. The DON stated Resident #2 is alert with periods of confusion. The resident was told to let someone know if s/he wanted to go outside. The DON stated the resident was not supposed to be outside unsupervised, s/he should have a staff member outside with him/her. The DON stated as long as there is no injury, then they do not have to notify the physician about a resident getting outside. The DON stated Resident #2 got outside twice, 9/10/17 and 10/1/17 and s/he does not recall the resident getting outside any other time. The mag locks were placed on [DATE], they stopped the enhanced monitoring of the resident on 10/27/17. The DON stated all doors have a key pad that requires a code to get in and out of the facility. They do not give the code out to family or visitors, only staff have the code. The receptionist has a button in his/her office to let people in or out. A staff member can also use the code on a box beside the door to let someone in or out. Review of Resident #5's medical record revealed the resident was sent out to a geri-psych hospital unit on 11/10/17-12/6/17 because s/he was paranoid and having active auditory hallucinations. Review of the resident's Progress Notes 8/1/17-11/10/17 revealed no documentation of behaviors related to the resident attempting to exit the facility. The Progress Note on 12/7/17 at 12:36 AM revealed Resident #5 was observed going out the back door by a staff member and was escorted back into the building. On 12/11/17 at 3:25 AM the resident was noted to know the front door code, and going outside numerous times through the night. The Progress Note dated 12/14/17 at 12:05 AM indicated observed resident going in and out of lobby door 10 (+) times on 3-11 shift. Cautioned resident against going outside alone and without proper winter apparel. Observed resident pushing another wheelchair bound resident outside. On 12/14/17 at 6:35 AM the resident was noted to repeatedly exit the building (20+ times) through the front door, setting off alarm. On 12/14/17 at 5:26 PM the Progress Note indicated Resident #5 had learned the new door code already that was changed yesterday because s/he had watched others coming and going and learned the new code. On 12/14/17 at 11:39 PM the resident was observed attempting to push the exit release button, located behind the nurses' station, so that s/he may go outside. The resident was redirected multiple times to no avail. The Progress Note on 12/17/17 at 4:04 AM indicated Resident #5 continued to go outside despite having automatic door locks with alarm. The resident can manipulate the door in such a way that s/he can get outside without the alarm sounding. S/he does need someone to let him/her back inside however. On 12/18/17 at 2:13 AM the resident was observed exiting facility unassisted, through the front door (10+ times). On 12/18/17 at 11:52 PM the resident was noted to exit the facility unassisted through the front door (20+ times). Review of Resident #5's Elopement Risk Assessments dated 7/15/17, 10/1/17, and 12/19/17 revealed the resident was assessed as an elopement risk. Review of Resident #5's care plan revealed resident will leave building and walk around yard on his/her own if not stopped was identified as a problem area. Interventions and approaches were listed on the care plan and included to alert staff to residents wandering behavior. In a telephone interview with the surveyor on 12/20/17 at approximately 3:10 PM, the physician stated that s/he had not been made aware by the facility that Resident #5 was attempting to exit the facility constantly since returning from his/her psych hospitalization . Review of the facility's Policy Statement on Elopements revealed staff shall promptly reorient any resident who tries to leave the premises to the Charge Nurse or DON. If an employee observes a resident leaving the premises, he/she should attempt to prevent the departure in a courteous manner. When a resident returns to the facility, the DON or Charge Nurse shall contact the attending physician and report findings and condition of the resident, notify the resident's legal representative, complete and file an incident report, and document relevant information in the resident's medical record. On December 19, 2017 at 1:15 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at a scope and severity of K. The Immediate Jeopardy and Substandard Quality of Care existed in the facility on August 2, 2017.

Based on review of facility files and interview, the facility failed to ensure that each resident received adequate supervision to prevent accidents. Resident #2 and Resident #5 were both noted to be found outside of the building. Resident #2 was found outside the building on three occasions. Resident #5 was noted to have multiple occurrences of leaving the building. Both residents were coded as elopement risks per the facility's assessment. Two of nine residents reviewed for incidents. The findings included: Review of the facility's Incident Log from September-December 2017 revealed Resident #2 was noted outside on 10/1/17. Resident #2 had no other documented elopements on the Incident Log. Resident #5 had no documentation of his/her elopements. In an interview with the surveyor on 12/20/17 at 1:00 PM the unit manager stated Resident #5 had not had any Incident Reports since August 2017. Review of Resident #2's Incident Report dated 9/10/17 revealed resident noted outside in parking lot of rear of facility. Resident assisted per staff in facility. Resident stated s/he was going to save (his/her) house. New order to place resident on 1:1 observation. Resident's condition was noted to be alert and confused. Equipment involved was noted as wheelchair. There was no documentation that there was an alarm sounding. There was no documentation related to the wander guard. Review of Resident #2's Incident Report dated 10/1/17 revealed resident outside without notifying staff. Resident noted to be alert and confused. Resident observed outside of building heading towards the street. CNA (certified nurse aide) and nurse assisted resident back into the building. Resident stated I'm going to get some clothes and I am trying to catch a ride. Equipment involved was noted as wheelchair. The Incident Report indicated the physician was not notified. There was no documentation that there was an alarm sounding. There was no documentation related to the wander guard. Review of Resident #2's Elopement Risk Assessments dated 7/21/17, 10/1/17, and 12/19/17 revealed the resident was coded as an elopement risk. Review of Resident #2's care plan revealed at risk for elopement as evidenced by multiple attempts to leave the building and making comments about leaving to go find his/her spouse was identified as a problem area. Interventions and approaches were listed on the care plan and included remove resident from unsafe situations and attempt to redirect. Review of Resident #2's Progress Notes revealed on 7/21/17 at 6:41 PM wander guard placed to right wrist related to resident attempting to go outside without staff member despite much education to notify staff if resident would like to go outside during undesignated smoke times for leisure. On 7/23/17 at 6:10 PM resident with one attempt to go outside this shift but redirected and advised s/he could sit on front porch. Continues on every 15 minute checks. Review of Resident #2's Progress Notes dated 7/28/17 indicated resident was discussed in IDT (Interdisciplinary Team) related to behaviors. Resident had several exit seeking episodes this week where s/he attempted to go outside without a staff member. Review of the Progress Note dated 8/2/17 at 12:55 PM revealed resident continues to try to go to smoking area without assistance. Social Service brought him/her back in at 10:30 and re-educated him/her again about not going out without a staff member. On 8/3/17 at 10:45 AM the Progress Note indicated new order received to discharge every 15 minute checks. No further elopement attempts noted. On 8/6/17 at 2:34 PM resident continues to try to go to smoking area without assistance. On 9/10/17 at 1:02 PM resident alert and verbal with confusion noted at times. Resident was observed to be outside the building in the driveway. Staff assisted resident back into building. MD made aware. New order to place resident on 1:1. On 9/11/17 at 11:31 AM new order to discharge 1:1. [ENTITY]t every 15 minute checks related to exit seeking behaviors. Resident educated to not go outside without staff member present related to safety. Resident verbalized understanding. Non-compliant with request. Resident noted sitting outside of front porch without notifying staff. The Progress Note dated 9/15/17 at 8:27 AM by the Social Worker indicated resident continues to attempt to go outdoors without staff assistance or supervision. Social Worker contacted responsible party by phone to discuss exit seeking behaviors. Responsible party agreed that resident may need a secured building or a locked unit to ensure his/her safety. The Progress Note dated 10/1/17 at 11:33 AM indicated Resident #2 was observed propelling self-outside heading towards the street. Nurse and CNA assisted him/her back inside of building. Resident stated, I was going to get a ride to (town) to get me some clothes. Every 15 minute checks implemented to ensure resident safety. There was no documentation that the physician was notified. The Progress Note date 10/1/17 at 1:00 PM indicated the resident was noted with left sided facial drooping and was sent out to the hospital. The resident returned to the facility on [DATE]. Review of Resident #2's Physician order [REDACTED]. Review of Resident #2's Physician order [REDACTED]. The resident was placed on 1:1 related to elopement attempt 9/10/17-9/11/17. The resident was placed on every 15 minute checks related to exit seeking behaviors 9/11/17-9/12/17. The resident was placed on 1:1 related to exit seeking behaviors 10/3/17-10/16/17, the resident was noted outside the building heading for the road on 10/1/17. The resident was placed on every 15 minute checks related to behaviors 10/16/17-[DATE]. The resident was placed on every 15 minute checks x [AGE] hours 11/3/17-11/6/17. In an interview with the surveyor on 12/19/17 at approximately 11:10 AM, LPN (Licensed Practical Nurse) #1 stated s/he works with Resident #2 on a regular basis. When the resident first came s/he was very anxious. Resident #2 would try to exit seek to go out to smoke. T/he resident would try to go out all doors, but mostly it was out the back door where they go outside to smoke. The resident was educated on having a staff member go outside with him/her multiple times. LPN #1 stated the resident had been on 1:1, every 15 minutes checks, and enhanced monitoring for his/her exit seeking behaviors. Resident #2 had a wander guard and now they have the mag locks in place. The resident's wander guard was discharged when the locks where put in place on the doors. In an interview with the surveyor on 12/19/17 at approximately 11:20 AM, the Unit Manager stated they placed a wander guard on Resident #2 on 7/21/17 because s/he kept talking about needing to leave to go to an appointment. If they approached the door, it would alarm to let the staff member know. The wander guard system would cause the door to alarm, it would not lock the door. It would alarm all over the building. The facility placed a mag lock system that requires a code on doors on [DATE]. They discharged all wander guards at that time. In an interview with the surveyor on 12/19/17 at approximately 11:35 PM, the DON (Director of Nursing) stated Resident #2 was out in the front driveway on 10/1/17. The DON stated on 9/10/17 another staff member saw the resident and they brought him/her back in. The DON stated Resident #2 is alert with periods of confusion. The resident was told to let someone know if s/he wanted to go outside. The DON stated the resident was not supposed to be outside unsupervised, s/he should have a staff member outside with him/her. The DON stated as long as there is no injury, then they do not have to notify the physician about a resident getting outside. The DON stated Resident #2 got outside twice, 9/10/17 and 10/1/17 and s/he does not recall the resident getting outside any other time. The mag locks were placed on [DATE], they stopped the enhanced monitoring of the resident on 10/27/17. The DON stated all doors have a key pad that requires a code to get in and out of the facility. They do not give the code out to family or visitors, only staff have the code. The receptionist has a button in his/her office to let people in or out. A staff member can also use the code on a box beside the door to let someone in or out. In an interview with the surveyor on 12/19/17 at approximately 11:55 AM, the social services staff stated the resident gets obsessed with going home, s/he won't accept their spouse can't take care of them. The social services staff stated s/he does not remember what happened with the note from 8/2/17 related to bringing the resident back inside. The social services staff stated s/he could not remember if Resident #2 was outside or not. In an interview with the surveyor on 12/20/17 at 1:00 PM, the unit manager stated Resident #2 is not followed by psych. Review of facility paperwork revealed they had a mag lock system installed on doors on [DATE]. In an interview with the surveyor on 12/20/17 at 12:05 PM, the DON confirmed that the wander guard boxes were removed when the mag lock system was installed in October 2017. Review of Resident #5's medical record revealed the resident was sent out to a geri-psych hospital unit on 11/10/17-12/6/17 because s/he was paranoid and having active auditory hallucinations. Review of the resident's Progress Notes 8/1/17-11/10/17 revealed no documentation of behaviors related to the resident attempting to exit the facility. The Progress Note on 12/7/17 at 12:36 AM revealed Resident #5 was observed going out the back door by a staff member and was escorted back into the building. On 12/11/17 at 3:25 AM the resident was noted to know the front door code, and going outside numerous times through the night. The Progress Note dated 12/14/17 at 12:05 AM indicated observed resident going in and out of lobby door 10 (+) times on 3-11 shift. Cautioned resident against going outside alone and without proper winter apparel. Observed resident pushing another wheelchair bound resident outside. On 12/14/17 at 6:35 AM the resident was noted to repeatedly exit the building (20+ times) through the front door, setting off alarm. On 12/14/17 at 5:26 PM the Progress Note indicated Resident #5 had learned the new door code already that was changed yesterday because s/he had watched others coming and going and learned the new code. On 12/14/17 at 11:39 PM the resident was observed attempting to push the exit release button, located behind the nurses' station, so that s/he may go outside. The resident was redirected multiple times to no avail. The Progress Note on 12/17/17 at 4:04 AM indicated Resident #5 continued to go outside despite having automatic door locks with alarm. The resident can manipulate the door in such a way that s/he can get outside without the alarm sounding. S/he does need someone to let him/her back inside however. On 12/18/17 at 2:13 AM the resident was observed exiting facility unassisted, through the front door (10+ times). On 12/18/17 at 11:52 PM the resident was noted to exit the facility unassisted through the front door (20+ times). Review of Resident #5's Physician order [REDACTED]. Review of Resident #5's Elopement Risk Assessments dated 7/15/17, 10/1/17, and 12/19/17 revealed the resident was assessed as an elopement risk. Review of Resident #5's care plan revealed resident will leave building and walk around yard on his/her own if not stopped was identified as a problem area. Interventions and approaches were listed on the care plan and included to alert staff to residents wandering behavior. Review of the Discharge Instructions from Resident #5's Geri-Psych hospitalization [DATE]-[DATE] revealed the resident's primary discharge [DIAGNOSES REDACTED]. The instructions for medications indicated to take all the dosage at the time and for the reasons indicated on the medication list. Review of the Discharge Plan for Resident #5 indicated a new medication of [MED]e [MEDICATION NAME] 100 mg tablet take 300 milligrams at bedtime. The resident was to continue [MEDICATION NAME] [MED] 324 milligrams 1 tablet daily, [MEDICATION NAME] 20 milligrams 1 tablet daily, and 4000 units Vitamin D daily. The Discharge Plan indicated to stop taking [MEDICATION NAME] 10 milligrams daily, [MEDICATION NAME] 25 milligrams at bedtime, [MEDICATION NAME] 5 milligrams daily, [MEDICATION NAME] 0.5 milligram as needed, [MEDICATION NAME] 10 milligrams at bedtime, [MEDICATION NAME] 0.25 milligrams at bedtime, and [MEDICATION NAME] 7.5 milligrams at bedtime. Review of Resident #5's hospital course revealed the resident was paranoid and depressed. [MEDICATION NAME] was maximized up to a dose of 30 milligrams at bedtime. It lifted the resident out of his/her depression but s/he also became manic. The resident was very intrusive and was trying to inappropriately touch female patients and female staff members. S/he was also not sleeping and there were nights that s/he also slept less than an hour. [MEDICATION NAME] was eventually changed to [MEDICATION NAME] ([MED]e [MEDICATION NAME]). S/he did respond to the medication better. S/he was sleeping 6-7 hours at night and was less manic. Review of Resident #5's facility Medication Administration Record [REDACTED]. The resident's order for [MEDICATION NAME] 0.5 milligrams as needed was also continued when the resident returned from the hospital. Review of Resident #5's Physician's Clinical Summary for encounter date 12/11/17 indicated the resident presented with continued manic type behavior. Resident #5 had not slept much at all for the past 3 nights, walking around facility. The physician indicated the resident had [MEDICAL CONDITION] disorder, [MEDICAL CONDITION] type - will start by scheduling [MEDICATION NAME]. If that does not help, will increase [MEDICATION NAME]. [MEDICATION NAME] was scheduled 0.5 milligrams one tablet daily. The Clinical Summary indicated changed medications were [MEDICATION NAME] 0.5 milligrams. Discontinued medications by other physician were noted as [MEDICATION NAME], [MED] and [MED]. There was no documentation related to the orders for [MEDICATION NAME] and [MEDICATION NAME]. There were no additional physician notes between 12/6/17-12/11/17. In an interview with the surveyor on 12/20/17 at approximately 1:05 PM, the unit manager and DON were interviewed about Resident #5's exit seeking behaviors. Resident #5 is [MEDICAL CONDITION] and went out to the geri-psych hospital where he was treated and returned. The resident went out for visual hallucinations and paranoia. Since Resident #5 came back from the psych unit, s/he wants to go outside constantly. They stated Resident #5 will go outside constantly. The resident goes out and wants to come right back in. They stated Resident #5 was put on 1:1 yesterday because the threshold for elopement had changed. They previously thought if the resident did not leave the facility grounds then it was not an elopement. They did not report any of the incidents because the resident did not leave the facility grounds. With the mag lock system, if you hold the door for 12 seconds it will automatically release because of fire code. After 12 seconds, the lock releases and the alarm will sound. There is an alarm panel at the nurses' station that alarms as well as at the door. The alarm panel alerts staff to what door is sounding as well. They stated it was not feasible to keep Resident #5 on 1:1. In an interview with the surveyor on 12/20/17 at approximately 2:50 PM, the DON stated the physician will come in and evaluate the medication list from the hospital and decide what medications the resident will be on. The physician has to sign off on all the medications when they are readmitted . In an interview with the surveyor on 12/20/17 at approximately 3:00 PM, the nurse practitioner stated they look at the discharge medications from the hospital and decide what is appropriate for the resident. They then decide what medications the resident will be on. They will document any changes from the hospital discharge medication list on their visit note. The discharge summary they saw said to continue the [MEDICATION NAME], and [MEDICATION NAME]. The nurse practitioner stated the physician was the one who saw Resident #5 when s/he returned to the facility from the psych hospital. In a telephone interview with the surveyor on 12/20/17 at approximately 3:10 PM, the physician stated s/he usually gets the transfer summary and will generally compare with the previous medications to see if there are any changes. The physician stated s/he usually documents the medication changes in the physician visit note. The physician stated s/he would generally try to go down the medication lists from the hospital and facility and compare the two and make sure the resident is on the medications s/he should be on. The stated s/he was not sure about Resident #5's medication list and what s/he looked at. The physician stated that s/he had not been made aware by the facility that Resident #5 was attempting to exit the facility constantly since returning from his/her psych hospitalization . In an interview with the surveyor on 12/20/17 at approximately 2:25 PM, RN (Registered Nurse) #1 stated they go through the home medications from the hospital and input them each. If a resident is being readmitted , they check the medication orders against what they were getting before. If it is not ordered per the hospital, they will discharge from the facility medication list. If they have a question, they will put in the doctor's book for the doctor to check. The doctor will look through the book and they will write the orders or mark through and leave discharged . Review of the facility's policy on Accident and Incidents - Investigating and Reporting revealed all accidents and incidents involving residents occurring on our premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. Review of the facility's Policy Statement on Elopements revealed staff shall promptly reorient any resident who tries to leave the premises to the Charge Nurse or DON. If an employee observes a resident leaving the premises, he/she should attempt to prevent the departure in a courteous manner. When a resident returns to the facility, the DON or Charge Nurse shall contact the attending physician and report findings and condition of the resident, notify the resident's legal representative, complete and file an incident report, and document relevant information in the resident's medical record. Review of the facility's Safety and Supervision of Resident Policy Statement revealed the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. On December 19, 2017 at 1:15 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at a scope and severity of K. The Immediate Jeopardy and Substandard Quality of Care existed in the facility on August 2, 2017.

Based on review of facility files and interviews, the facility failed to ensure staff had competencies and skills sets for caring for residents with mental and psychosocial disorders. Resident #2 was noted to display adjustment difficulties when s/he was admitted to the facility. The resident was not referred to the psychiatrist to address the adjustment difficulties. Resident #2 was found by staff outside the building three times in which twice s/he stated s/he was leaving to go home. Resident #5 was noted with increased behaviors when s/he returned from a geri psych hospitalization . There was no documentation the facility staff notified the physician about the resident's change in behavior. Two of nine residents reviewed for behaviors. The findings included: Review of the facility's Incident Log from September-December 2017 revealed Resident #2 was noted outside on 10/1/17. Resident #2 had no other documented elopements on the Incident Log. Resident #5 had no documentation of his/her elopements. In an interview with the surveyor on 12/20/17 at 1:00 PM the unit manager stated Resident #5 had not had any Incident Reports since August 2017. Review of Resident #2's Incident Report dated 9/10/17 revealed resident noted outside in parking lot of rear of facility. Resident assisted per staff in facility. Resident stated s/he was going to save (his/her) house. New order to place resident on 1:1 observation. Resident's condition was noted to be alert and confused. Equipment involved was noted as wheelchair. There was no documentation that there was an alarm sounding. There was no documentation related to the wander guard. Review of Resident #2's Incident Report dated 10/1/17 revealed resident outside without notifying staff. Resident noted to be alert and confused. Resident observed outside of building heading towards the street. CNA (certified nurse aide) and nurse assisted resident back into the building. Resident stated I'm going to get some clothes and I am trying to catch a ride. Equipment involved was noted as wheelchair. The Incident Report indicated the physician was not notified. There was no documentation that there was an alarm sounding. There was no documentation related to the wander guard. Review of Resident #2's Elopement Risk Assessments dated 7/21/17, 10/1/17, and 12/19/17 revealed the resident was coded as an elopement risk. Review of Resident #2's care plan revealed at risk for elopement as evidenced by multiple attempts to leave the building and making comments about leaving to go find his/her spouse was identified as a problem area. Interventions and approaches were listed on the care plan and included remove resident from unsafe situations and attempt to redirect. Review of Resident #2's Progress Notes revealed on 7/21/17 at 6:41 PM wander guard placed to right wrist related to resident attempting to go outside without staff member despite much education to notify staff if resident would like to go outside during undesignated smoke times for leisure. On 7/23/17 at 6:10 PM resident with one attempt to go outside this shift but redirected and advised s/he could sit on front porch. Continues on every 15 minute checks. Review of Resident #2's Progress Notes dated 7/28/17 indicated resident was discussed in IDT (Interdisciplinary Team) related to behaviors. Resident had several exit seeking episodes this week where s/he attempted to go outside without a staff member. Review of the Progress Note dated 8/2/17 at 12:55 PM revealed resident continues to try to go to smoking area without assistance. Social Service brought him/her back in at 10:30 and re-educated him/her again about not going out without a staff member. On 8/3/17 at 10:45 AM the Progress Note indicated new order received to discharge every 15 minute checks. No further elopement attempts noted. On 8/6/17 at 2:34 PM resident continues to try to go to smoking area without assistance. On 9/10/17 at 1:02 PM resident alert and verbal with confusion noted at times. Resident was observed to be outside the building in the driveway. Staff assisted resident back into building. MD made aware. New order to place resident on 1:1. On 9/11/17 at 11:31 AM new order to discharge 1:1. [ENTITY]t every 15 minute checks related to exit seeking behaviors. Resident educated to not go outside without staff member present related to safety. Resident verbalized understanding. Non-compliant with request. Resident noted sitting outside of front porch without notifying staff. The Progress Note dated 9/15/17 at 8:27 AM by the Social Worker indicated resident continues to attempt to go outdoors without staff assistance or supervision. Social Worker contacted responsible party by phone to discuss exit seeking behaviors. Responsible party agreed that resident may need a secured building or a locked unit to ensure his/her safety. The Progress Note dated 10/1/17 at 11:33 AM indicated Resident #2 was observed propelling self-outside heading towards the street. Nurse and CNA assisted him/her back inside of building. Resident stated, I was going to get a ride to (town) to get me some clothes. Every 15 minute checks implemented to ensure resident safety. There was no documentation that the physician was notified. The Progress Note date 10/1/17 at 1:00 PM indicated the resident was noted with left sided facial drooping and was sent out to the hospital. The resident returned to the facility on [DATE]. Review of Resident #2's Physician order [REDACTED]. Review of Resident #2's Physician order [REDACTED]. The resident was placed on 1:1 related to elopement attempt 9/10/17-9/11/17. The resident was placed on every 15 minute checks related to exit seeking behaviors 9/11/17-9/12/17. The resident was placed on 1:1 related to exit seeking behaviors 10/3/17-10/16/17. The resident was placed on every 15 minute checks related to behaviors 10/16/17-[DATE]. The resident was placed on every 15 minute checks x [AGE] hours 11/3/17-11/6/17. In an interview with the surveyor on 12/19/17 at approximately 11:10 AM, LPN (Licensed Practical Nurse) #1 stated s/he works with Resident #2 on a regular basis. When the resident first came s/he was very anxious. Resident #2 would try to exit seek to go out to smoke. T/he resident would try to go out all doors, but mostly it was out the back door where they go outside to smoke. The resident was educated on having a staff member go outside with him/her multiple times. LPN #1 stated the resident had been on 1:1, every 15 minutes checks, and enhanced monitoring for his/her exit seeking behaviors. Resident #2 had a wander guard and now they have the mag locks in place. The resident's wander guard was discharged when the locks where put in place on the doors. In an interview with the surveyor on 12/19/17 at approximately 11:20 AM, the Unit Manager stated they placed a wander guard on Resident #2 on 7/21/17 because s/he kept talking about needing to leave to go to an appointment. If they approached the door, it would alarm to let the staff member know. The wander guard system would cause the door to alarm, it would not lock the door. It would alarm all over the building. The facility placed a mag lock system that requires a code on doors on [DATE]. They discharged all wander guards at that time. In an interview with the surveyor on 12/19/17 at approximately 11:35 PM, the DON (Director of Nursing) stated Resident #2 was out in the front driveway on 10/1/17. The DON stated on 9/10/17 another staff member saw the resident and they brought him/her back in. The DON stated Resident #2 is alert with periods of confusion. The resident was told to let someone know if s/he wanted to go outside. The DON stated the resident was not supposed to be outside unsupervised, s/he should have a staff member outside with him/her. The DON stated as long as there is no injury, then they do not have to notify the physician about a resident getting outside. The DON stated Resident #2 got outside twice, 9/10/17 and 10/1/17 and s/he does not recall the resident getting outside any other time. The mag locks were placed on [DATE], they stopped the enhanced monitoring of the resident on 10/27/17. The DON stated all doors have a key pad that requires a code to get in and out of the facility. They do not give the code out to family or visitors, only staff have the code. The receptionist has a button in his/her office to let people in or out. A staff member can also use the code on a box beside the door to let someone in or out. In an interview with the surveyor on 12/19/17 at approximately 11:55 AM, the social services staff stated the resident gets obsessed with going home, s/he won't accept their spouse can't take care of them. The social services staff stated s/he does not remember what happened with the note from 8/2/17 related to bringing the resident back inside. The social services staff stated s/he could not remember if Resident #2 was outside or not. In an interview with the surveyor on 12/20/17 at 1:00 PM, the unit manager stated Resident #2 is not followed by psych. Review of facility paperwork revealed they had a mag lock system installed on doors on [DATE]. In an interview with the surveyor on 12/20/17 at 12:05 PM, the DON confirmed that the wander guard boxes were removed when the mag lock system was installed in October 2017. Review of Resident #5's medical record revealed the resident was sent out to a geri-psych hospital unit on 11/10/17-12/6/17 because s/he was paranoid and having active auditory hallucinations. Review of the resident's Progress Notes 8/1/17-11/10/17 revealed no documentation of behaviors related to the resident attempting to exit the facility. The Progress Note on 12/7/17 at 12:36 AM revealed Resident #5 was observed going out the back door by a staff member and was escorted back into the building. On 12/11/17 at 3:25 AM the resident was noted to know the front door code, and going outside numerous times through the night. The Progress Note dated 12/14/17 at 12:05 AM indicated observed resident going in and out of lobby door 10 (+) times on 3-11 shift. Cautioned resident against going outside alone and without proper winter apparel. Observed resident pushing another wheelchair bound resident outside. On 12/14/17 at 6:35 AM the resident was noted to repeatedly exit the building (20+ times) through the front door, setting off alarm. On 12/14/17 at 5:26 PM the Progress Note indicated Resident #5 had learned the new door code already that was changed yesterday because s/he had watched others coming and going and learned the new code. On 12/14/17 at 11:39 PM the resident was observed attempting to push the exit release button, located behind the nurses' station, so that s/he may go outside. The resident was redirected multiple times to no avail. The Progress Note on 12/17/17 at 4:04 AM indicated Resident #5 continued to go outside despite having automatic door locks with alarm. The resident can manipulate the door in such a way that s/he can get outside without the alarm sounding. S/he does need someone to let him/her back inside however. On 12/18/17 at 2:13 AM the resident was observed exiting facility unassisted, through the front door (10+ times). On 12/18/17 at 11:52 PM the resident was noted to exit the facility unassisted through the front door (20+ times). Review of Resident #5's Physician order [REDACTED]. Review of Resident #5's Elopement Risk Assessments dated 7/15/17, 10/1/17, and 12/19/17 revealed the resident was assessed as an elopement risk. Review of Resident #5's care plan revealed resident will leave building and walk around yard on his/her own if not stopped was identified as a problem area. Interventions and approaches were listed on the care plan and included to alert staff to residents wandering behavior. Review of the Discharge Instructions from Resident #5's Geri-Psych hospitalization [DATE]-[DATE] revealed the resident's primary discharge [DIAGNOSES REDACTED]. The instructions for medications indicated to take all the dosage at the time and for the reasons indicated on the medication list. Review of the Discharge Plan for Resident #5 indicated a new medication of [MED]e [MEDICATION NAME] 100 mg tablet take 300 milligrams at bedtime. The resident was to continue [MEDICATION NAME] [MED] 324 milligrams 1 tablet daily, [MEDICATION NAME] 20 milligrams 1 tablet daily, and 4000 units Vitamin D daily. The Discharge Plan indicated to stop taking [MEDICATION NAME] 10 milligrams daily, [MEDICATION NAME] 25 milligrams at bedtime, [MEDICATION NAME] 5 milligrams daily, [MEDICATION NAME] 0.5 milligram as needed, [MEDICATION NAME] 10 milligrams at bedtime, [MEDICATION NAME] 0.25 milligrams at bedtime, and [MEDICATION NAME] 7.5 milligrams at bedtime. Review of Resident #5's hospital course revealed the resident was paranoid and depressed. [MEDICATION NAME] was maximized up to a dose of 30 milligrams at bedtime. It lifted the resident out of his/her depression but s/he also became manic. The resident was very intrusive and was trying to inappropriately touch female patients and female staff members. S/he was also not sleeping and there were nights that s/he also slept less than an hour. [MEDICATION NAME] was eventually changed to [MEDICATION NAME] ([MED]e [MEDICATION NAME]). S/he did respond to the medication better. S/he was sleeping 6-7 hours at night and was less manic. Review of Resident #5's facility Medication Administration Record [REDACTED]. The resident's order for [MEDICATION NAME] 0.5 milligrams as needed was also continued when the resident returned from the hospital. Review of Resident #5's Physician's Clinical Summary for encounter date 12/11/17 indicated the resident presented with continued manic type behavior. Resident #5 had not slept much at all for the past 3 nights, walking around facility. The physician indicated the resident had [MEDICAL CONDITION] disorder, [MEDICAL CONDITION] type - will start by scheduling [MEDICATION NAME]. If that does not help, will increase [MEDICATION NAME]. [MEDICATION NAME] was scheduled 0.5 milligrams one tablet daily. The Clinical Summary indicated changed medications were [MEDICATION NAME] 0.5 milligrams. Discontinued medications by other physician were noted as [MEDICATION NAME], [MED] and [MED]. There was no documentation related to the orders for [MEDICATION NAME] and [MEDICATION NAME]. There were no additional physician notes between 12/6/17-12/11/17. In an interview with the surveyor on 12/20/17 at approximately 1:05 PM, the unit manager and DON were interviewed about Resident #5's exit seeking behaviors. Resident #5 is [MEDICAL CONDITION] and went out to the geri-psych hospital where he was treated and returned. The resident went out for visual hallucinations and paranoia. Since Resident #5 came back from the psych unit, s/he wants to go outside constantly. They stated Resident #5 will go outside constantly. The resident goes out and wants to come right back in. The stated Resident #5 was put on 1:1 yesterday because the threshold for elopement had changed. They previously thought if the resident did not leave the facility grounds then it was not an elopement. They did not report any of the incidents because the resident did not leave the facility grounds. With the mag lock system, if you hold the door for 12 seconds it will automatically release because of fire code. After 12 seconds, the lock releases and the alarm will sound. There is an alarm panel at the nurses' station that alarms as well as at the door. The alarm panel alerts staff to what door is sounding as well. They stated it was not feasible to keep Resident #5 on 1:1. In an interview with the surveyor on 12/20/17 at approximately 2:50 PM, the DON stated the physician will come in and evaluate the medication list from the hospital and decide what medications the resident will be on. The physician has to sign off on all the medications when they are readmitted . In an interview with the surveyor on 12/20/17 at approximately 3:00 PM, the nurse practitioner stated they look at the discharge medications from the hospital and decide what is appropriate for the resident. They then decide what medications the resident will be on. They will document any changes from the hospital discharge medication list on their visit note. The discharge summary they saw said to continue the [MEDICATION NAME], and [MEDICATION NAME]. The nurse practitioner stated the physician was the one who saw Resident #5 when s/he returned to the facility from the psych hospital. In a telephone interview with the surveyor on 12/20/17 at approximately 3:10 PM, the physician stated s/he usually gets the transfer summary and will generally compare with the previous medications to see if there are any changes. The physician stated s/he usually documents the medication changes in the physician visit note. The physician stated s/he would generally try to go down the medication lists from the hospital and facility and compare the two and make sure the resident is on the medications s/he should be on. The stated s/he was not sure about Resident #5's medication list and what s/he looked at. The physician stated that s/he had not been made aware by the facility that Resident #5 was attempting to exit the facility constantly since returning from his/her psych hospitalization . In an interview with the surveyor on 12/20/17 at approximately 2:25 PM, RN (Registered Nurse) #1 stated they go through the home medications from the hospital and input them each. If a resident is being readmitted , they check the medication orders against what they were getting before. If it is not ordered per the hospital, they will discharge from the facility medication list. If they have a question, they will put in the doctor's book for the doctor to check. The doctor will look through the book and they will write the orders or mark through and leave discharged . Review of the facility's policy on Accident and Incidents - Investigating and Reporting revealed all accidents and incidents involving residents occurring on our premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. Review of the facility's Policy Statement on Elopements revealed staff shall promptly reorient any resident who tries to leave the premises to the Charge Nurse or DON. If an employee observes a resident leaving the premises, he/she should attempt to prevent the departure in a courteous manner. When a resident returns to the facility, the DON or Charge Nurse shall contact the attending physician and report findings and condition of the resident, notify the resident's legal representative, complete and file an incident report, and document relevant information in the resident's medical record. Review of the facility's Safety and Supervision of Resident Policy Statement revealed the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. On December 19, 2017 at 1:15 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at a scope and severity of K. The Immediate Jeopardy and Substandard Quality of Care existed in the facility on August 2, 2017.

Based on review of facility files and interviews, the facility failed to ensure residents who displayed or were diagnosed with [REDACTED]. Resident #2 was noted to display adjustment difficulties when s/he was admitted to the facility. The resident was not referred to the psychiatrist to address the adjustment difficulties. Resident #2 was found by staff outside the building three times in which twice s/he stated s/he was leaving to go home. Resident #5 was noted with increased behaviors when they returned from a geri psych hospitalization . There was no documentation the facility staff notified the physician about the resident's change in behavior. Two of nine residents reviewed for behaviors. The findings included: Review of the facility's Incident Log from September-December 2017 revealed Resident #2 was noted outside on 10/1/17. Resident #2 had no other documented elopements on the Incident Log. Resident #5 had no documentation of his/her elopements. In an interview with the surveyor on 12/20/17 at 1:00 PM the unit manager stated Resident #5 had not had any Incident Reports since August 2017. Review of Resident #2's Incident Report dated 9/10/17 revealed resident noted outside in parking lot of rear of facility. Resident assisted per staff in facility. Resident stated s/he was going to save (his/her) house. New order to place resident on 1:1 observation. Resident's condition was noted to be alert and confused. Equipment involved was noted as wheelchair. There was no documentation that there was an alarm sounding. There was no documentation related to the wander guard. Review of Resident #2's Incident Report dated 10/1/17 revealed resident outside without notifying staff. Resident noted to be alert and confused. Resident observed outside of building heading towards the street. CNA (certified nurse aide) and nurse assisted resident back into the building. Resident stated I'm going to get some clothes and I am trying to catch a ride. Equipment involved was noted as wheelchair. The Incident Report indicated the physician was not notified. There was no documentation that there was an alarm sounding. There was no documentation related to the wander guard. Review of Resident #2's Elopement Risk Assessments dated 7/21/17, 10/1/17, and 12/19/17 revealed the resident was coded as an elopement risk. Review of Resident #2's care plan revealed at risk for elopement as evidenced by multiple attempts to leave the building and making comments about leaving to go find his/her spouse was identified as a problem area. Interventions and approaches were listed on the care plan and included remove resident from unsafe situations and attempt to redirect. Review of Resident #2's Progress Notes revealed on 7/21/17 at 6:41 PM wander guard placed to right wrist related to resident attempting to go outside without staff member despite much education to notify staff if resident would like to go outside during undesignated smoke times for leisure. On 7/23/17 at 6:10 PM resident with one attempt to go outside this shift but redirected and advised s/he could sit on front porch. Continues on every 15 minute checks. Review of Resident #2's Progress Notes dated 7/28/17 indicated resident was discussed in IDT (Interdisciplinary Team) related to behaviors. Resident had several exit seeking episodes this week where s/he attempted to go outside without a staff member. Review of the Progress Note dated 8/2/17 at 12:55 PM revealed resident continues to try to go to smoking area without assistance. Social Service brought him/her back in at 10:30 and re-educated him/her again about not going out without a staff member. On 8/3/17 at 10:45 AM the Progress Note indicated new order received to discharge every 15 minute checks. No further elopement attempts noted. On 8/6/17 at 2:34 PM resident continues to try to go to smoking area without assistance. On 9/10/17 at 1:02 PM resident alert and verbal with confusion noted at times. Resident was observed to be outside the building in the driveway. Staff assisted resident back into building. MD made aware. New order to place resident on 1:1. On 9/11/17 at 11:31 AM new order to discharge 1:1. [ENTITY]t every 15 minute checks related to exit seeking behaviors. Resident educated to not go outside without staff member present related to safety. Resident verbalized understanding. Non-compliant with request. Resident noted sitting outside of front porch without notifying staff. The Progress Note dated 9/15/17 at 8:27 AM by the Social Worker indicated resident continues to attempt to go outdoors without staff assistance or supervision. Social Worker contacted responsible party by phone to discuss exit seeking behaviors. Responsible party agreed that resident may need a secured building or a locked unit to ensure his/her safety. The Progress Note dated 10/1/17 at 11:33 AM indicated Resident #2 was observed propelling self-outside heading towards the street. Nurse and CNA assisted him/her back inside of building. Resident stated, I was going to get a ride to (town) to get me some clothes. Every 15 minute checks implemented to ensure resident safety. There was no documentation that the physician was notified. The Progress Note date 10/1/17 at 1:00 PM indicated the resident was noted with left sided facial drooping and was sent out to the hospital. The resident returned to the facility on [DATE]. Review of Resident #2's Physician order [REDACTED]. Review of Resident #2's Physician order [REDACTED]. The resident was placed on 1:1 related to elopement attempt 9/10/17-9/11/17. The resident was placed on every 15 minute checks related to exit seeking behaviors 9/11/17-9/12/17. The resident was placed on 1:1 related to exit seeking behaviors 10/3/17-10/16/17. The resident was placed on every 15 minute checks related to behaviors 10/16/17-[DATE]. The resident was placed on every 15 minute checks x [AGE] hours 11/3/17-11/6/17. In an interview with the surveyor on 12/19/17 at approximately 11:10 AM, LPN (Licensed Practical Nurse) #1 stated s/he works with Resident #2 on a regular basis. When the resident first came s/he was very anxious. Resident #2 would try to exit seek to go out to smoke. T/he resident would try to go out all doors, but mostly it was out the back door where they go outside to smoke. The resident was educated on having a staff member go outside with him/her multiple times. LPN #1 stated the resident had been on 1:1, every 15 minutes checks, and enhanced monitoring for his/her exit seeking behaviors. Resident #2 had a wander guard and now they have the mag locks in place. The resident's wander guard was discharged when the locks where put in place on the doors. In an interview with the surveyor on 12/19/17 at approximately 11:20 AM, the Unit Manager stated they placed a wander guard on Resident #2 on 7/21/17 because s/he kept talking about needing to leave to go to an appointment. If they approached the door, it would alarm to let the staff member know. The wander guard system would cause the door to alarm, it would not lock the door. It would alarm all over the building. The facility placed a mag lock system that requires a code on doors on [DATE]. They discharged all wander guards at that time. In an interview with the surveyor on 12/19/17 at approximately 11:35 PM, the DON (Director of Nursing) stated Resident #2 was out in the front driveway on 10/1/17. The DON stated on 9/10/17 another staff member saw the resident and they brought him/her back in. The DON stated Resident #2 is alert with periods of confusion. The resident was told to let someone know if s/he wanted to go outside. The DON stated the resident was not supposed to be outside unsupervised, s/he should have a staff member outside with him/her. The DON stated as long as there is no injury, then they do not have to notify the physician about a resident getting outside. The DON stated Resident #2 got outside twice, 9/10/17 and 10/1/17 and s/he does not recall the resident getting outside any other time. The mag locks were placed on [DATE], they stopped the enhanced monitoring of the resident on 10/27/17. The DON stated all doors have a key pad that requires a code to get in and out of the facility. They do not give the code out to family or visitors, only staff have the code. The receptionist has a button in his/her office to let people in or out. A staff member can also use the code on a box beside the door to let someone in or out. In an interview with the surveyor on 12/19/17 at approximately 11:55 AM, the social services staff stated the resident gets obsessed with going home, s/he won't accept their spouse can't take care of them. The social services staff stated s/he does not remember what happened with the note from 8/2/17 related to bringing the resident back inside. The social services staff stated s/he could not remember if Resident #2 was outside or not. In an interview with the surveyor on 12/20/17 at 1:00 PM, the unit manager stated Resident #2 is not followed by psych. Review of facility paperwork revealed they had a mag lock system installed on doors on [DATE]. In an interview with the surveyor on 12/20/17 at 12:05 PM, the DON confirmed that the wander guard boxes were removed when the mag lock system was installed in October 2017. Review of Resident #5's medical record revealed the resident was sent out to a geri-psych hospital unit on 11/10/17-12/6/17 because s/he was paranoid and having active auditory hallucinations. Review of the resident's Progress Notes 8/1/17-11/10/17 revealed no documentation of behaviors related to the resident attempting to exit the facility. The Progress Note on 12/7/17 at 12:36 AM revealed Resident #5 was observed going out the back door by a staff member and was escorted back into the building. On 12/11/17 at 3:25 AM the resident was noted to know the front door code, and going outside numerous times through the night. The Progress Note dated 12/14/17 at 12:05 AM indicated observed resident going in and out of lobby door 10 (+) times on 3-11 shift. Cautioned resident against going outside alone and without proper winter apparel. Observed resident pushing another wheelchair bound resident outside. On 12/14/17 at 6:35 AM the resident was noted to repeatedly exit the building (20+ times) through the front door, setting off alarm. On 12/14/17 at 5:26 PM the Progress Note indicated Resident #5 had learned the new door code already that was changed yesterday because s/he had watched others coming and going and learned the new code. On 12/14/17 at 11:39 PM the resident was observed attempting to push the exit release button, located behind the nurses' station, so that s/he may go outside. The resident was redirected multiple times to no avail. The Progress Note on 12/17/17 at 4:04 AM indicated Resident #5 continued to go outside despite having automatic door locks with alarm. The resident can manipulate the door in such a way that s/he can get outside without the alarm sounding. S/he does need someone to let him/her back inside however. On 12/18/17 at 2:13 AM the resident was observed exiting facility unassisted, through the front door (10+ times). On 12/18/17 at 11:52 PM the resident was noted to exit the facility unassisted through the front door (20+ times). Review of Resident #5's Physician order [REDACTED]. Review of Resident #5's Elopement Risk Assessments dated 7/15/17, 10/1/17, and 12/19/17 revealed the resident was assessed as an elopement risk. Review of Resident #5's care plan revealed resident will leave building and walk around yard on his/her own if not stopped was identified as a problem area. Interventions and approaches were listed on the care plan and included to alert staff to residents wandering behavior. Review of the Discharge Instructions from Resident #5's Geri-Psych hospitalization [DATE]-[DATE] revealed the resident's primary discharge [DIAGNOSES REDACTED]. The instructions for medications indicated to take all the dosage at the time and for the reasons indicated on the medication list. Review of the Discharge Plan for Resident #5 indicated a new medication of [MED]e [MEDICATION NAME] 100 mg tablet take 300 milligrams at bedtime. The resident was to continue [MEDICATION NAME] [MED] 324 milligrams 1 tablet daily, [MEDICATION NAME] 20 milligrams 1 tablet daily, and 4000 units Vitamin D daily. The Discharge Plan indicated to stop taking [MEDICATION NAME] 10 milligrams daily, [MEDICATION NAME] 25 milligrams at bedtime, [MEDICATION NAME] 5 milligrams daily, [MEDICATION NAME] 0.5 milligram as needed, [MEDICATION NAME] 10 milligrams at bedtime, [MEDICATION NAME] 0.25 milligrams at bedtime, and [MEDICATION NAME] 7.5 milligrams at bedtime. Review of Resident #5's hospital course revealed the resident was paranoid and depressed. [MEDICATION NAME] was maximized up to a dose of 30 milligrams at bedtime. It lifted the resident out of his/her depression but s/he also became manic. The resident was very intrusive and was trying to inappropriately touch female patients and female staff members. S/he was also not sleeping and there were nights that s/he also slept less than an hour. [MEDICATION NAME] was eventually changed to [MEDICATION NAME] ([MED]e [MEDICATION NAME]). S/he did respond to the medication better. S/he was sleeping 6-7 hours at night and was less manic. Review of Resident #5's facility Medication Administration Record [REDACTED]. The resident's order for [MEDICATION NAME] 0.5 milligrams as needed was also continued when the resident returned from the hospital. Review of Resident #5's Physician's Clinical Summary for encounter date 12/11/17 indicated the resident presented with continued manic type behavior. Resident #5 had not slept much at all for the past 3 nights, walking around facility. The physician indicated the resident had [MEDICAL CONDITION] disorder, [MEDICAL CONDITION] type - will start by scheduling [MEDICATION NAME]. If that does not help, will increase [MEDICATION NAME]. [MEDICATION NAME] was scheduled 0.5 milligrams one tablet daily. The Clinical Summary indicated changed medications were [MEDICATION NAME] 0.5 milligrams. Discontinued medications by other physician were noted as [MEDICATION NAME], [MED] and [MED]. There was no documentation related to the orders for [MEDICATION NAME] and [MEDICATION NAME]. There were no additional physician notes between 12/6/17-12/11/17. There were no additional physician notes between 12/11/17-12/20/17. In an interview with the surveyor on 12/20/17 at approximately 1:05 PM, the unit manager and DON were interviewed about Resident #5's exit seeking behaviors. Resident #5 is [MEDICAL CONDITION] and went out to the geri-psych hospital where he was treated and returned. The resident went out for visual hallucinations and paranoia. Since Resident #5 came back from the psych unit, s/he wants to go outside constantly. They stated Resident #5 will go outside constantly. The resident goes out and wants to come right back in. The stated Resident #5 was put on 1:1 yesterday because the threshold for elopement had changed. They previously thought if the resident did not leave the facility grounds then it was not an elopement. They did not report any of the incidents because the resident did not leave the facility grounds. With the mag lock system, if you hold the door for 12 seconds it will automatically release because of fire code. After 12 seconds, the lock releases and the alarm will sound. There is an alarm panel at the nurses' station that alarms as well as at the door. The alarm panel alerts staff to what door is sounding as well. They stated it was not feasible to keep Resident #5 on 1:1. In an interview with the surveyor on 12/20/17 at approximately 2:50 PM, the DON stated the physician will come in and evaluate the medication list from the hospital and decide what medications the resident will be on. The physician has to sign off on all the medications when they are readmitted . In an interview with the surveyor on 12/20/17 at approximately 3:00 PM, the nurse practitioner stated they look at the discharge medications from the hospital and decide what is appropriate for the resident. They then decide what medications the resident will be on. They will document any changes from the hospital discharge medication list on their visit note. The discharge summary they saw said to continue the [MEDICATION NAME], and [MEDICATION NAME]. The nurse practitioner stated the physician was the one who saw Resident #5 when s/he returned to the facility from the psych hospital. In a telephone interview with the surveyor on 12/20/17 at approximately 3:10 PM, the physician stated s/he usually gets the transfer summary and will generally compare with the previous medications to see if there are any changes. The physician stated s/he usually documents the medication changes in the physician visit note. The physician stated s/he would generally try to go down the medication lists from the hospital and facility and compare the two and make sure the resident is on the medications s/he should be on. The stated s/he was not sure about Resident #5's medication list and what s/he looked at. The physician stated that s/he had not been made aware by the facility that Resident #5 was attempting to exit the facility constantly since returning from his/her psych hospitalization . In an interview with the surveyor on 12/20/17 at approximately 2:25 PM, RN (Registered Nurse) #1 stated they go through the home medications from the hospital and input them each. If a resident is being readmitted , they check the medication orders against what they were getting before. If it is not ordered per the hospital, they will discharge from the facility medication list. If they have a question, they will put in the doctor's book for the doctor to check. The doctor will look through the book and they will write the orders or mark through and leave discharged . Review of the facility's policy on Accident and Incidents - Investigating and Reporting revealed all accidents and incidents involving residents occurring on our premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. Review of the facility's Policy Statement on Elopements revealed staff shall promptly reorient any resident who tries to leave the premises to the Charge Nurse or DON. If an employee observes a resident leaving the premises, he/she should attempt to prevent the departure in a courteous manner. When a resident returns to the facility, the DON or Charge Nurse shall contact the attending physician and report findings and condition of the resident, notify the resident's legal representative, complete and file an incident report, and document relevant information in the resident's medical record. Review of the facility's Safety and Supervision of Resident Policy Statement revealed the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. On December 19, 2017 at 1:15 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at a scope and severity of K. The Immediate Jeopardy and Substandard Quality of Care existed in the facility on August 2, 2017.

Based on record review and interview, the facility failed to ensure residents are not given drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Resident #5 was noted to be hospitalized at a geri psych unit 11/10/17-12/6/17. The Discharge List indicated to stop [MEDICATION NAME], and [MEDICATION NAME]. There was no documentation of the rationale to continue these medications. Review of Resident #5's Medication Administration Record [REDACTED]. There was one physician progress notes [REDACTED]. There was no documentation by the physician that indicated the medications were stopped by the hospital physician or why they were restarted. One of nine residents reviewed for medications. The findings included: Review of Resident #5's medical record revealed the resident was sent out to a geri-psych hospital unit on 11/10/17-12/6/17 because s/he was paranoid and having active auditory hallucinations. Review of the resident's Progress Notes 8/1/17-11/10/17 revealed no documentation of behaviors related to the resident attempting to exit the facility. The Progress Note on 12/7/17 at 12:36 AM revealed Resident #5 was observed going out the back door by a staff member and was escorted back into the building. On 12/11/17 at 3:25 AM the resident was noted to know the front door code, and going outside numerous times through the night. The Progress Note dated 12/14/17 at 12:05 AM indicated observed resident going in and out of lobby door 10 (+) times on 3-11 shift. Cautioned resident against going outside alone and without proper winter apparel. Observed resident pushing another wheelchair bound resident outside. On 12/14/17 at 6:35 AM the resident was noted to repeatedly exit the building (20+ times) through the front door, setting off alarm. On 12/14/17 at 5:26 PM the Progress Note indicated Resident #5 had learned the new door code already that was changed yesterday because s/he had watched others coming and going and learned the new code. On 12/14/17 at 11:39 PM the resident was observed attempting to push the exit release button, located behind the nurses' station, so that s/he may go outside. The resident was redirected multiple times to no avail. The Progress Note on 12/17/17 at 4:04 AM indicated Resident #5 continued to go outside despite having automatic door locks with alarm. The resident can manipulate the door in such a way that s/he can get outside without the alarm sounding. S/he does need someone to let him/her back inside however. On 12/18/17 at 2:13 AM the resident was observed exiting facility unassisted, through the front door (10+ times). On 12/18/17 at 11:52 PM the resident was noted to exit the facility unassisted through the front door (20+ times). Review of Resident #5's care plan revealed resident will leave building and walk around yard on his/her own if not stopped was identified as a problem area. Interventions and approaches were listed on the care plan and included to alert staff to residents wandering behavior. Review of the Discharge Instructions from Resident #5's Geri-Psych hospitalization [DATE]-[DATE] revealed the resident's primary discharge [DIAGNOSES REDACTED]. The instructions for medications indicated to take all the dosage at the time and for the reasons indicated on the medication list. Review of the Discharge Plan for Resident #5 indicated a new medication of [MED]e [MEDICATION NAME] 100 mg tablet take 300 milligrams at bedtime. The resident was to continue [MEDICATION NAME] [MED] 324 milligrams 1 tablet daily, [MEDICATION NAME] 20 milligrams 1 tablet daily, and 4000 units Vitamin D daily. The Discharge Plan indicated to stop taking [MEDICATION NAME] 10 milligrams daily, [MEDICATION NAME] 25 milligrams at bedtime, [MEDICATION NAME] 5 milligrams daily, [MEDICATION NAME] 0.5 milligram as needed, [MEDICATION NAME] 10 milligrams at bedtime, [MEDICATION NAME] 0.25 milligrams at bedtime, and [MEDICATION NAME] 7.5 milligrams at bedtime. Review of Resident #5's hospital course revealed the resident was paranoid and depressed. [MEDICATION NAME] was maximized up to a dose of 30 milligrams at bedtime. It lifted the resident out of his/her depression but s/he also became manic. The resident was very intrusive and was trying to inappropriately touch female patients and female staff members. S/he was also not sleeping and there were nights that s/he also slept less than an hour. [MEDICATION NAME] was eventually changed to [MEDICATION NAME] ([MED]e [MEDICATION NAME]). S/he did respond to the medication better. S/he was sleeping 6-7 hours at night and was less manic. Review of Resident #5's facility Medication Administration Record [REDACTED]. The resident's order for [MEDICATION NAME] 0.5 milligrams as needed was also continued when the resident returned from the hospital. Review of Resident #5's Physician's Clinical Summary for encounter date 12/11/17 indicated the resident presented with continued manic type behavior. Resident #5 had not slept much at all for the past 3 nights, walking around facility. The physician indicated the resident had [MEDICAL CONDITION] disorder, [MEDICAL CONDITION] type - will start by scheduling [MEDICATION NAME]. If that does not help, will increase [MEDICATION NAME]. [MEDICATION NAME] was scheduled 0.5 milligrams one tablet daily. The Clinical Summary indicated changed medications were [MEDICATION NAME] 0.5 milligrams. Discontinued medications by other physician were noted as [MEDICATION NAME], [MED] and [MED]. There was no documentation related to the orders for [MEDICATION NAME] and [MEDICATION NAME]. There were no additional physician notes between 12/6/17-12/11/17. In an interview with the surveyor on 12/20/17 at approximately 1:05 PM, the unit manager and Director of Nursing (DON) were interviewed about Resident #5's exit seeking behaviors. Resident #5 is [MEDICAL CONDITION] and went out to the geri-psych hospital where he was treated and returned. The resident went out for visual hallucinations and paranoia. Since Resident #5 came back from the psych unit, s/he wants to go outside constantly. They stated Resident #5 will go outside constantly. The resident goes out and wants to come right back in. The stated Resident #5 was put on 1:1 yesterday because the threshold for elopement had changed. They previously thought if the resident did not leave the facility grounds then it was not an elopement. They did not report any of the incidents because the resident did not leave the facility grounds. With the mag lock system, if you hold the door for 12 seconds it will automatically release because of fire code. After 12 seconds, the lock releases and the alarm will sound. There is an alarm panel at the nurses' station that alarms as well as at the door. The alarm panel alerts staff to what door is sounding as well. They stated it was not feasible to keep Resident #5 on 1:1. In an interview with the surveyor on 12/20/17 at approximately 2:50 PM, the DON stated the physician will come in and evaluate the medication list from the hospital and decide what medications the resident will be on. The physician has to sign off on all the medications when they are readmitted . In an interview with the surveyor on 12/20/17 at approximately 3:00 PM, the nurse practitioner stated they look at the discharge medications from the hospital and decide what is appropriate for the resident. They then decide what medications the resident will be on. They will document any changes from the hospital discharge medication list on their visit note. The discharge summary they saw said to continue the [MEDICATION NAME], and [MEDICATION NAME]. The nurse practitioner stated the physician was the one who saw Resident #5 when s/he returned to the facility from the psych hospital. In a telephone interview with the surveyor on 12/20/17 at approximately 3:10 PM, the physician stated s/he usually gets the transfer summary and will generally compare with the previous medications to see if there are any changes. The physician stated s/he usually documents the medication changes in the physician visit note. The physician stated s/he would generally try to go down the medication lists from the hospital and facility and compare the two and make sure the resident is on the medications s/he should be on. The stated s/he was not sure about Resident #5's medication list and what s/he looked at. The physician stated that s/he had not been made aware by the facility that Resident #5 was attempting to exit the facility constantly since returning from his/her psych hospitalization . In an interview with the surveyor on 12/20/17 at approximately 2:25 PM, RN (Registered Nurse) #1 stated they go through the home medications from the hospital and input them each. If a resident is being readmitted , they check the medication orders against what they were getting before. If it is not ordered per the hospital, they will discharge from the facility medication list. If they have a question, they will put in the doctor's book for the doctor to check. The doctor will look through the book and they will write the orders or mark through and leave discharged . On December 19, 2017 at 1:15 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at a scope and severity of K. The Immediate Jeopardy and Substandard Quality of Care existed in the facility on August 2, 2017.

Based on review of facility files and interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Resident #2 and Resident #5 were both noted to exit the building unsupervised. The facility failed to address the incidents for both residents. Two of nine residents reviewed for elopement. The findings included: Review of the facility's Incident Log from September-December 2017 revealed Resident #2 was noted outside on 10/1/17. Resident #2 had no other documented elopements on the Incident Log. Resident #5 had no documentation of his/her elopements. In an interview with the surveyor on 12/20/17 at 1:00 PM the unit manager stated Resident #5 had not had any Incident Reports since August 2017. Review of Resident #2's Incident Report dated 9/10/17 revealed resident noted outside in parking lot of rear of facility. Resident assisted per staff in facility. Resident stated s/he was going to save (his/her) house. New order to place resident on 1:1 observation. Resident's condition was noted to be alert and confused. Equipment involved was noted as wheelchair. There was no documentation that there was an alarm sounding. There was no documentation related to the wander guard. Review of Resident #2's Incident Report dated 10/1/17 revealed resident outside without notifying staff. Resident noted to be alert and confused. Resident observed outside of building heading towards the street. CNA (certified nurse aide) and nurse assisted resident back into the building. Resident stated I'm going to get some clothes and I am trying to catch a ride. Equipment involved was noted as wheelchair. The Incident Report indicated the physician was not notified. There was no documentation that there was an alarm sounding. There was no documentation related to the wander guard. Review of Resident #2's Elopement Risk Assessments dated 7/21/17, 10/1/17, and 12/19/17 revealed the resident was coded as an elopement risk. Review of Resident #2's care plan revealed at risk for elopement as evidenced by multiple attempts to leave the building and making comments about leaving to go find his/her spouse was identified as a problem area. Interventions and approaches were listed on the care plan and included remove resident from unsafe situations and attempt to redirect. Review of Resident #2's Progress Notes revealed on 7/21/17 at 6:41 PM wander guard placed to right wrist related to resident attempting to go outside without staff member despite much education to notify staff if resident would like to go outside during undesignated smoke times for leisure. On 7/23/17 at 6:10 PM resident with one attempt to go outside this shift but redirected and advised s/he could sit on front porch. Continues on every 15 minute checks. Review of Resident #2's Progress Notes dated 7/28/17 indicated resident was discussed in IDT (Interdisciplinary Team) related to behaviors. Resident had several exit seeking episodes this week where s/he attempted to go outside without a staff member. Review of the Progress Note dated 8/2/17 at 12:55 PM revealed resident continues to try to go to smoking area without assistance. Social Service brought him/her back in at 10:30 and re-educated him/her again about not going out without a staff member. On 8/3/17 at 10:45 AM the Progress Note indicated new order received to discharge every 15 minute checks. No further elopement attempts noted. On 8/6/17 at 2:34 PM resident continues to try to go to smoking area without assistance. On 9/10/17 at 1:02 PM resident alert and verbal with confusion noted at times. Resident was observed to be outside the building in the driveway. Staff assisted resident back into building. MD made aware. New order to place resident on 1:1. On 9/11/17 at 11:31 AM new order to discharge 1:1. [ENTITY]t every 15 minute checks related to exit seeking behaviors. Resident educated to not go outside without staff member present related to safety. Resident verbalized understanding. Non-compliant with request. Resident noted sitting outside of front porch without notifying staff. The Progress Note dated 9/15/17 at 8:27 AM by the Social Worker indicated resident continues to attempt to go outdoors without staff assistance or supervision. Social Worker contacted responsible party by phone to discuss exit seeking behaviors. Responsible party agreed that resident may need a secured building or a locked unit to ensure his/her safety. The Progress Note dated 10/1/17 at 11:33 AM indicated Resident #2 was observed propelling self-outside heading towards the street. Nurse and CNA assisted him/her back inside of building. Resident stated, I was going to get a ride to (town) to get me some clothes. Every 15 minute checks implemented to ensure resident safety. There was no documentation that the physician was notified. The Progress Note date 10/1/17 at 1:00 PM indicated the resident was noted with left sided facial drooping and was sent out to the hospital. The resident returned to the facility on [DATE]. Review of Resident #2's Physician order [REDACTED]. Review of Resident #2's Physician order [REDACTED]. The resident was placed on 1:1 related to elopement attempt 9/10/17-9/11/17. The resident was placed on every 15 minute checks related to exit seeking behaviors 9/11/17-9/12/17. The resident was placed on 1:1 related to exit seeking behaviors 10/3/17-10/16/17. The resident was placed on every 15 minute checks related to behaviors 10/16/17-[DATE]. The resident was placed on every 15 minute checks x [AGE] hours 11/3/17-11/6/17. In an interview with the surveyor on 12/19/17 at approximately 11:10 AM, LPN (Licensed Practical Nurse) #1 stated s/he works with Resident #2 on a regular basis. When the resident first came s/he was very anxious. Resident #2 would try to exit seek to go out to smoke. T/he resident would try to go out all doors, but mostly it was out the back door where they go outside to smoke. The resident was educated on having a staff member go outside with him/her multiple times. LPN #1 stated the resident had been on 1:1, every 15 minutes checks, and enhanced monitoring for his/her exit seeking behaviors. Resident #2 had a wander guard and now they have the mag locks in place. The resident's wander guard was discharged when the locks where put in place on the doors. In an interview with the surveyor on 12/19/17 at approximately 11:20 AM, the Unit Manager stated they placed a wander guard on Resident #2 on 7/21/17 because s/he kept talking about needing to leave to go to an appointment. If they approached the door, it would alarm to let the staff member know. The wander guard system would cause the door to alarm, it would not lock the door. It would alarm all over the building. The facility placed a mag lock system that requires a code on doors on [DATE]. They discharged all wander guards at that time. In an interview with the surveyor on 12/19/17 at approximately 11:35 PM, the DON (Director of Nursing) stated Resident #2 was out in the front driveway on 10/1/17. The DON stated on 9/10/17 another staff member saw the resident and they brought him/her back in. The DON stated Resident #2 is alert with periods of confusion. The resident was told to let someone know if s/he wanted to go outside. The DON stated the resident was not supposed to be outside unsupervised, s/he should have a staff member outside with him/her. The DON stated as long as there is no injury, then they do not have to notify the physician about a resident getting outside. The DON stated Resident #2 got outside twice, 9/10/17 and 10/1/17 and s/he does not recall the resident getting outside any other time. The mag locks were placed on [DATE], they stopped the enhanced monitoring of the resident on 10/27/17. The DON stated all doors have a key pad that requires a code to get in and out of the facility. They do not give the code out to family or visitors, only staff have the code. The receptionist has a button in his/her office to let people in or out. A staff member can also use the code on a box beside the door to let someone in or out. In an interview with the surveyor on 12/19/17 at approximately 11:55 AM, the social services staff stated the resident gets obsessed with going home, s/he won't accept their spouse can't take care of them. The social services staff stated s/he does not remember what happened with the note from 8/2/17 related to bringing the resident back inside. The social services staff stated s/he could not remember if Resident #2 was outside or not. In an interview with the surveyor on 12/20/17 at 1:00 PM, the unit manager stated Resident #2 is not followed by psych. Review of facility paperwork revealed they had a mag lock system installed on doors on [DATE]. In an interview with the surveyor on 12/20/17 at 12:05 PM, the DON confirmed that the wander guard boxes were removed when the mag lock system was installed in October 2017. Review of Resident #5's medical record revealed the resident was sent out to a geri-psych hospital unit on 11/10/17-12/6/17 because s/he was paranoid and having active auditory hallucinations. Review of the resident's Progress Notes 8/1/17-11/10/17 revealed no documentation of behaviors related to the resident attempting to exit the facility. The Progress Note on 12/7/17 at 12:36 AM revealed Resident #5 was observed going out the back door by a staff member and was escorted back into the building. On 12/11/17 at 3:25 AM the resident was noted to know the front door code, and going outside numerous times through the night. The Progress Note dated 12/14/17 at 12:05 AM indicated observed resident going in and out of lobby door 10 (+) times on 3-11 shift. Cautioned resident against going outside alone and without proper winter apparel. Observed resident pushing another wheelchair bound resident outside. On 12/14/17 at 6:35 AM the resident was noted to repeatedly exit the building (20+ times) through the front door, setting off alarm. On 12/14/17 at 5:26 PM the Progress Note indicated Resident #5 had learned the new door code already that was changed yesterday because s/he had watched others coming and going and learned the new code. On 12/14/17 at 11:39 PM the resident was observed attempting to push the exit release button, located behind the nurses' station, so that s/he may go outside. The resident was redirected multiple times to no avail. The Progress Note on 12/17/17 at 4:04 AM indicated Resident #5 continued to go outside despite having automatic door locks with alarm. The resident can manipulate the door in such a way that s/he can get outside without the alarm sounding. S/he does need someone to let him/her back inside however. On 12/18/17 at 2:13 AM the resident was observed exiting facility unassisted, through the front door (10+ times). On 12/18/17 at 11:52 PM the resident was noted to exit the facility unassisted through the front door (20+ times). Review of Resident #5's Physician order [REDACTED]. Review of Resident #5's Elopement Risk Assessments dated 7/15/17, 10/1/17, and 12/19/17 revealed the resident was assessed as an elopement risk. Review of Resident #5's care plan revealed resident will leave building and walk around yard on his/her own if not stopped was identified as a problem area. Interventions and approaches were listed on the care plan and included to alert staff to residents wandering behavior. Review of the Discharge Instructions from Resident #5's Geri-Psych hospitalization [DATE]-[DATE] revealed the resident's primary discharge [DIAGNOSES REDACTED]. The instructions for medications indicated to take all the dosage at the time and for the reasons indicated on the medication list. Review of the Discharge Plan for Resident #5 indicated a new medication of [MED]e [MEDICATION NAME] 100 mg tablet take 300 milligrams at bedtime. The resident was to continue [MEDICATION NAME] [MED] 324 milligrams 1 tablet daily, [MEDICATION NAME] 20 milligrams 1 tablet daily, and 4000 units Vitamin D daily. The Discharge Plan indicated to stop taking [MEDICATION NAME] 10 milligrams daily, [MEDICATION NAME] 25 milligrams at bedtime, [MEDICATION NAME] 5 milligrams daily, [MEDICATION NAME] 0.5 milligram as needed, [MEDICATION NAME] 10 milligrams at bedtime, [MEDICATION NAME] 0.25 milligrams at bedtime, and [MEDICATION NAME] 7.5 milligrams at bedtime. Review of Resident #5's hospital course revealed the resident was paranoid and depressed. [MEDICATION NAME] was maximized up to a dose of 30 milligrams at bedtime. It lifted the resident out of his/her depression but s/he also became manic. The resident was very intrusive and was trying to inappropriately touch female patients and female staff members. S/he was also not sleeping and there were nights that s/he also slept less than an hour. [MEDICATION NAME] was eventually changed to [MEDICATION NAME] ([MED]e [MEDICATION NAME]). S/he did respond to the medication better. S/he was sleeping 6-7 hours at night and was less manic. Review of Resident #5's facility Medication Administration Record [REDACTED]. The resident's order for [MEDICATION NAME] 0.5 milligrams as needed was also continued when the resident returned from the hospital. Review of Resident #5's Physician's Clinical Summary for encounter date 12/11/17 indicated the resident presented with continued manic type behavior. Resident #5 had not slept much at all for the past 3 nights, walking around facility. The physician indicated the resident had [MEDICAL CONDITION] disorder, [MEDICAL CONDITION] type - will start by scheduling [MEDICATION NAME]. If that does not help, will increase [MEDICATION NAME]. [MEDICATION NAME] was scheduled 0.5 milligrams one tablet daily. The Clinical Summary indicated changed medications were [MEDICATION NAME] 0.5 milligrams. Discontinued medications by other physician were noted as [MEDICATION NAME], [MED] and [MED]. There was no documentation related to the orders for [MEDICATION NAME] and [MEDICATION NAME]. There were no additional physician notes between 12/6/17-12/11/17. In an interview with the surveyor on 12/20/17 at approximately 1:05 PM, the unit manager and DON were interviewed about Resident #5's exit seeking behaviors. Resident #5 is [MEDICAL CONDITION] and went out to the geri-psych hospital where he was treated and returned. The resident went out for visual hallucinations and paranoia. Since Resident #5 came back from the psych unit, s/he wants to go outside constantly. They stated Resident #5 will go outside constantly. The resident goes out and wants to come right back in. The stated Resident #5 was put on 1:1 yesterday because the threshold for elopement had changed. They previously thought if the resident did not leave the facility grounds then it was not an elopement. They did not report any of the incidents because the resident did not leave the facility grounds. With the mag lock system, if you hold the door for 12 seconds it will automatically release because of fire code. After 12 seconds, the lock releases and the alarm will sound. There is an alarm panel at the nurses' station that alarms as well as at the door. The alarm panel alerts staff to what door is sounding as well. They stated it was not feasible to keep Resident #5 on 1:1. In an interview with the surveyor on 12/20/17 at approximately 2:50 PM, the DON stated the physician will come in and evaluate the medication list from the hospital and decide what medications the resident will be on. The physician has to sign off on all the medications when they are readmitted . In an interview with the surveyor on 12/20/17 at approximately 3:00 PM, the nurse practitioner stated they look at the discharge medications from the hospital and decide what is appropriate for the resident. They then decide what medications the resident will be on. They will document any changes from the hospital discharge medication list on their visit note. The discharge summary they saw said to continue the [MEDICATION NAME], and [MEDICATION NAME]. The nurse practitioner stated the physician was the one who saw Resident #5 when s/he returned to the facility from the psych hospital. In a telephone interview with the surveyor on 12/20/17 at approximately 3:10 PM, the physician stated s/he usually gets the transfer summary and will generally compare with the previous medications to see if there are any changes. The physician stated s/he usually documents the medication changes in the physician visit note. The physician stated s/he would generally try to go down the medication lists from the hospital and facility and compare the two and make sure the resident is on the medications s/he should be on. The stated s/he was not sure about Resident #5's medication list and what s/he looked at. The physician stated that s/he had not been made aware by the facility that Resident #5 was attempting to exit the facility constantly since returning from his/her psych hospitalization . In an interview with the surveyor on 12/20/17 at approximately 2:25 PM, RN (Registered Nurse) #1 stated they go through the home medications from the hospital and input them each. If a resident is being readmitted , they check the medication orders against what they were getting before. If it is not ordered per the hospital, they will discharge from the facility medication list. If they have a question, they will put in the doctor's book for the doctor to check. The doctor will look through the book and they will write the orders or mark through and leave discharged . Review of the facility's policy on Accident and Incidents - Investigating and Reporting revealed all accidents and incidents involving residents occurring on our premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. Review of the facility's Policy Statement on Elopements revealed staff shall promptly reorient any resident who tries to leave the premises to the Charge Nurse or DON. If an employee observes a resident leaving the premises, he/she should attempt to prevent the departure in a courteous manner. When a resident returns to the facility, the DON or Charge Nurse shall contact the attending physician and report findings and condition of the resident, notify the resident's legal representative, complete and file an incident report, and document relevant information in the resident's medical record. Review of the facility's Safety and Supervision of Resident Policy Statement revealed the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. On December 19, 2017 at 1:15 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at a scope and severity of K. The Immediate Jeopardy and Substandard Quality of Care existed in the facility on August 2, 2017.

Based on review of facility files and interview, the medical director failed to be responsible for the coordination of medical care in the facility. Resident #2 and Resident #5 were both noted to exit the building unsupervised. The facility failed to address the incidents for both residents. Resident #5 was not assessed for medication changes upon return to the facility from a geri psych hospitalization . Two of nine residents reviewed for elopement and behaviors. The findings included: Review of the facility's Incident Log from September-December 2017 revealed Resident #2 was noted outside on 10/1/17. Resident #2 had no other documented elopements on the Incident Log. Resident #5 had no documentation of his/her elopements. In an interview with the surveyor on 12/20/17 at 1:00 PM the unit manager stated Resident #5 had not had any Incident Reports since August 2017. Review of Resident #2's Incident Report dated 9/10/17 revealed resident noted outside in parking lot of rear of facility. Resident assisted per staff in facility. Resident stated s/he was going to save (his/her) house. New order to place resident on 1:1 observation. Resident's condition was noted to be alert and confused. Equipment involved was noted as wheelchair. There was no documentation that there was an alarm sounding. There was no documentation related to the wander guard. Review of Resident #2's Incident Report dated 10/1/17 revealed resident outside without notifying staff. Resident noted to be alert and confused. Resident observed outside of building heading towards the street. CNA (certified nurse aide) and nurse assisted resident back into the building. Resident stated I'm going to get some clothes and I am trying to catch a ride. Equipment involved was noted as wheelchair. The Incident Report indicated the physician was not notified. There was no documentation that there was an alarm sounding. There was no documentation related to the wander guard. Review of Resident #2's Elopement Risk Assessments dated 7/21/17, 10/1/17, and 12/19/17 revealed the resident was coded as an elopement risk. Review of Resident #2's care plan revealed at risk for elopement as evidenced by multiple attempts to leave the building and making comments about leaving to go find his/her spouse was identified as a problem area. Interventions and approaches were listed on the care plan and included remove resident from unsafe situations and attempt to redirect. Review of Resident #2's Progress Notes revealed on 7/21/17 at 6:41 PM wander guard placed to right wrist related to resident attempting to go outside without staff member despite much education to notify staff if resident would like to go outside during undesignated smoke times for leisure. On 7/23/17 at 6:10 PM resident with one attempt to go outside this shift but redirected and advised s/he could sit on front porch. Continues on every 15 minute checks. Review of Resident #2's Progress Notes dated 7/28/17 indicated resident was discussed in IDT (Interdisciplinary Team) related to behaviors. Resident had several exit seeking episodes this week where s/he attempted to go outside without a staff member. Review of the Progress Note dated 8/2/17 at 12:55 PM revealed resident continues to try to go to smoking area without assistance. Social Service brought him/her back in at 10:30 and re-educated him/her again about not going out without a staff member. On 8/3/17 at 10:45 AM the Progress Note indicated new order received to discharge every 15 minute checks. No further elopement attempts noted. On 8/6/17 at 2:34 PM resident continues to try to go to smoking area without assistance. On 9/10/17 at 1:02 PM resident alert and verbal with confusion noted at times. Resident was observed to be outside the building in the driveway. Staff assisted resident back into building. MD made aware. New order to place resident on 1:1. On 9/11/17 at 11:31 AM new order to discharge 1:1. [ENTITY]t every 15 minute checks related to exit seeking behaviors. Resident educated to not go outside without staff member present related to safety. Resident verbalized understanding. Non-compliant with request. Resident noted sitting outside of front porch without notifying staff. The Progress Note dated 9/15/17 at 8:27 AM by the Social Worker indicated resident continues to attempt to go outdoors without staff assistance or supervision. Social Worker contacted responsible party by phone to discuss exit seeking behaviors. Responsible party agreed that resident may need a secured building or a locked unit to ensure his/her safety. The Progress Note dated 10/1/17 at 11:33 AM indicated Resident #2 was observed propelling self-outside heading towards the street. Nurse and CNA assisted him/her back inside of building. Resident stated, I was going to get a ride to (town) to get me some clothes. Every 15 minute checks implemented to ensure resident safety. There was no documentation that the physician was notified. The Progress Note date 10/1/17 at 1:00 PM indicated the resident was noted with left sided facial drooping and was sent out to the hospital. The resident returned to the facility on [DATE]. Review of Resident #2's Physician order [REDACTED]. Review of Resident #2's Physician order [REDACTED]. The resident was placed on 1:1 related to elopement attempt 9/10/17-9/11/17. The resident was placed on every 15 minute checks related to exit seeking behaviors 9/11/17-9/12/17. The resident was placed on 1:1 related to exit seeking behaviors 10/3/17-10/16/17. The resident was placed on every 15 minute checks related to behaviors 10/16/17-[DATE]. The resident was placed on every 15 minute checks x [AGE] hours 11/3/17-11/6/17. In an interview with the surveyor on 12/19/17 at approximately 11:10 AM, LPN (Licensed Practical Nurse) #1 stated s/he works with Resident #2 on a regular basis. When the resident first came s/he was very anxious. Resident #2 would try to exit seek to go out to smoke. T/he resident would try to go out all doors, but mostly it was out the back door where they go outside to smoke. The resident was educated on having a staff member go outside with him/her multiple times. LPN #1 stated the resident had been on 1:1, every 15 minutes checks, and enhanced monitoring for his/her exit seeking behaviors. Resident #2 had a wander guard and now they have the mag locks in place. The resident's wander guard was discharged when the locks where put in place on the doors. In an interview with the surveyor on 12/19/17 at approximately 11:20 AM, the Unit Manager stated they placed a wander guard on Resident #2 on 7/21/17 because s/he kept talking about needing to leave to go to an appointment. If they approached the door, it would alarm to let the staff member know. The wander guard system would cause the door to alarm, it would not lock the door. It would alarm all over the building. The facility placed a mag lock system that requires a code on doors on [DATE]. They discharged all wander guards at that time. In an interview with the surveyor on 12/19/17 at approximately 11:35 PM, the DON (Director of Nursing) stated Resident #2 was out in the front driveway on 10/1/17. The DON stated on 9/10/17 another staff member saw the resident and they brought him/her back in. The DON stated Resident #2 is alert with periods of confusion. The resident was told to let someone know if s/he wanted to go outside. The DON stated the resident was not supposed to be outside unsupervised, s/he should have a staff member outside with him/her. The DON stated as long as there is no injury, then they do not have to notify the physician about a resident getting outside. The DON stated Resident #2 got outside twice, 9/10/17 and 10/1/17 and s/he does not recall the resident getting outside any other time. The mag locks were placed on [DATE], they stopped the enhanced monitoring of the resident on 10/27/17. The DON stated all doors have a key pad that requires a code to get in and out of the facility. They do not give the code out to family or visitors, only staff have the code. The receptionist has a button in his/her office to let people in or out. A staff member can also use the code on a box beside the door to let someone in or out. In an interview with the surveyor on 12/19/17 at approximately 11:55 AM, the social services staff stated the resident gets obsessed with going home, s/he won't accept their spouse can't take care of them. The social services staff stated s/he does not remember what happened with the note from 8/2/17 related to bringing the resident back inside. The social services staff stated s/he could not remember if Resident #2 was outside or not. In an interview with the surveyor on 12/20/17 at 1:00 PM, the unit manager stated Resident #2 is not followed by psych. Review of facility paperwork revealed they had a m aglock system installed on doors on [DATE]. In an interview with the surveyor on 12/20/17 at 12:05 PM, the DON confirmed that the wander guard boxes were removed when the mag lock system was installed in October 2017. Review of Resident #5's medical record revealed the resident was sent out to a geri-psych hospital unit on 11/10/17-12/6/17 because s/he was paranoid and having active auditory hallucinations. Review of the resident's Progress Notes 8/1/17-11/10/17 revealed no documentation of behaviors related to the resident attempting to exit the facility. The Progress Note on 12/7/17 at 12:36 AM revealed Resident #5 was observed going out the back door by a staff member and was escorted back into the building. On 12/11/17 at 3:25 AM the resident was noted to know the front door code, and going outside numerous times through the night. The Progress Note dated 12/14/17 at 12:05 AM indicated observed resident going in and out of lobby door 10 (+) times on 3-11 shift. Cautioned resident against going outside alone and without proper winter apparel. Observed resident pushing another wheelchair bound resident outside. On 12/14/17 at 6:35 AM the resident was noted to repeatedly exit the building (20+ times) through the front door, setting off alarm. On 12/14/17 at 5:26 PM the Progress Note indicated Resident #5 had learned the new door code already that was changed yesterday because s/he had watched others coming and going and learned the new code. On 12/14/17 at 11:39 PM the resident was observed attempting to push the exit release button, located behind the nurses' station, so that s/he may go outside. The resident was redirected multiple times to no avail. The Progress Note on 12/17/17 at 4:04 AM indicated Resident #5 continued to go outside despite having automatic door locks with alarm. The resident can manipulate the door in such a way that s/he can get outside without the alarm sounding. S/he does need someone to let him/her back inside however. On 12/18/17 at 2:13 AM the resident was observed exiting facility unassisted, through the front door (10+ times). On 12/18/17 at 11:52 PM the resident was noted to exit the facility unassisted through the front door (20+ times). Review of Resident #5's Physician order [REDACTED]. Review of Resident #5's Elopement Risk Assessments dated 7/15/17, 10/1/17, and 12/19/17 revealed the resident was assessed as an elopement risk. Review of Resident #5's care plan revealed resident will leave building and walk around yard on his/her own if not stopped was identified as a problem area. Interventions and approaches were listed on the care plan and included to alert staff to residents wandering behavior. Review of the Discharge Instructions from Resident #5's Geri-Psych hospitalization [DATE]-[DATE] revealed the resident's primary discharge [DIAGNOSES REDACTED]. The instructions for medications indicated to take all the dosage at the time and for the reasons indicated on the medication list. Review of the Discharge Plan for Resident #5 indicated a new medication of [MED]e [MEDICATION NAME] 100 mg tablet take 300 milligrams at bedtime. The resident was to continue [MEDICATION NAME] [MED] 324 milligrams 1 tablet daily, [MEDICATION NAME] 20 milligrams 1 tablet daily, and 4000 units Vitamin D daily. The Discharge Plan indicated to stop taking [MEDICATION NAME] 10 milligrams daily, [MEDICATION NAME] 25 milligrams at bedtime, [MEDICATION NAME] 5 milligrams daily, [MEDICATION NAME] 0.5 milligram as needed, [MEDICATION NAME] 10 milligrams at bedtime, [MEDICATION NAME] 0.25 milligrams at bedtime, and [MEDICATION NAME] 7.5 milligrams at bedtime. Review of Resident #5's hospital course revealed the resident was paranoid and depressed. [MEDICATION NAME] was maximized up to a dose of 30 milligrams at bedtime. It lifted the resident out of his/her depression but s/he also became manic. The resident was very intrusive and was trying to inappropriately touch female patients and female staff members. S/he was also not sleeping and there were nights that s/he also slept less than an hour. [MEDICATION NAME] was eventually changed to [MEDICATION NAME] ([MED]e [MEDICATION NAME]). S/he did respond to the medication better. S/he was sleeping 6-7 hours at night and was less manic. Review of Resident #5's facility Medication Administration Record [REDACTED]. The resident's order for [MEDICATION NAME] 0.5 milligrams as needed was also continued when the resident returned from the hospital. Review of Resident #5's Physician's Clinical Summary for encounter date 12/11/17 indicated the resident presented with continued manic type behavior. Resident #5 had not slept much at all for the past 3 nights, walking around facility. The physician indicated the resident had [MEDICAL CONDITION] disorder, [MEDICAL CONDITION] type - will start by scheduling [MEDICATION NAME]. If that does not help, will increase [MEDICATION NAME]. [MEDICATION NAME] was scheduled 0.5 milligrams one tablet daily. The Clinical Summary indicated changed medications were [MEDICATION NAME] 0.5 milligrams. Discontinued medications by other physician were noted as [MEDICATION NAME], [MED] and [MED]. There was no documentation related to the orders for [MEDICATION NAME] and [MEDICATION NAME]. There were no additional physician notes between 12/6/17-12/11/17. In an interview with the surveyor on 12/20/17 at approximately 1:05 PM, the unit manager and DON were interviewed about Resident #5's exit seeking behaviors. Resident #5 is [MEDICAL CONDITION] and went out to the geri-psych hospital where he was treated and returned. The resident went out for visual hallucinations and paranoia. Since Resident #5 came back from the psych unit, s/he wants to go outside constantly. They stated Resident #5 will go outside constantly. The resident goes out and wants to come right back in. The stated Resident #5 was put on 1:1 yesterday because the threshold for elopement had changed. They previously thought if the resident did not leave the facility grounds then it was not an elopement. They did not report any of the incidents because the resident did not leave the facility grounds. With the mag lock system, if you hold the door for 12 seconds it will automatically release because of fire code. After 12 seconds, the lock releases and the alarm will sound. There is an alarm panel at the nurses' station that alarms as well as at the door. The alarm panel alerts staff to what door is sounding as well. They stated it was not feasible to keep Resident #5 on 1:1. In an interview with the surveyor on 12/20/17 at approximately 2:50 PM, the DON stated the physician will come in and evaluate the medication list from the hospital and decide what medications the resident will be on. The physician has to sign off on all the medications when they are readmitted . In an interview with the surveyor on 12/20/17 at approximately 3:00 PM, the nurse practitioner stated they look at the discharge medications from the hospital and decide what is appropriate for the resident. They then decide what medications the resident will be on. They will document any changes from the hospital discharge medication list on their visit note. The discharge summary they saw said to continue the [MEDICATION NAME], and [MEDICATION NAME]. The nurse practitioner stated the physician was the one who saw Resident #5 when s/he returned to the facility from the psych hospital. In a telephone interview with the surveyor on 12/20/17 at approximately 3:10 PM, the physician stated s/he usually gets the transfer summary and will generally compare with the previous medications to see if there are any changes. The physician stated s/he usually documents the medication changes in the physician visit note. The physician stated s/he would generally try to go down the medication lists from the hospital and facility and compare the two and make sure the resident is on the medications s/he should be on. The stated s/he was not sure about Resident #5's medication list and what s/he looked at. The physician stated that s/he had not been made aware by the facility that Resident #5 was attempting to exit the facility constantly since returning from his/her psych hospitalization . In an interview with the surveyor on 12/20/17 at approximately 2:25 PM, RN (Registered Nurse) #1 stated they go through the home medications from the hospital and input them each. If a resident is being readmitted , they check the medication orders against what they were getting before. If it is not ordered per the hospital, they will discharge from the facility medication list. If they have a question, they will put in the doctor's book for the doctor to check. The doctor will look through the book and they will write the orders or mark through and leave discharged . Review of the facility's policy on Accident and Incidents - Investigating and Reporting revealed all accidents and incidents involving residents occurring on our premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. Review of the facility's Policy Statement on Elopements revealed staff shall promptly reorient any resident who tries to leave the premises to the Charge Nurse or DON. If an employee observes a resident leaving the premises, he/she should attempt to prevent the departure in a courteous manner. When a resident returns to the facility, the DON or Charge Nurse shall contact the attending physician and report findings and condition of the resident, notify the resident's legal representative, complete and file an incident report, and document relevant information in the resident's medical record. Review of the facility's Safety and Supervision of Resident Policy Statement revealed the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. On December 19, 2017 at 1:15 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at a scope and severity of K. The Immediate Jeopardy and Substandard Quality of Care existed in the facility on August 2, 2017.

Based on review of facility files and interview, the quality assessment and assurance committee failed to develop and implement appropriate plans of action to correct identified quality deficiencies. Resident #2 and Resident #5 were both noted to exit the building unsupervised. The facility installed mag locks and removed the wander guard system. There was no follow-up for the residents who were previously wearing wander guards. The system was not reassessed when Resident #5 continuously exited the facility after the mag locks were installed. Two of nine residents reviewed for elopement. The findings included: Review of the facility's Incident Log from September-December 2017 revealed Resident #2 was noted outside on 10/1/17. Resident #2 had no other documented elopements on the Incident Log. Resident #5 had no documentation of his/her elopements. In an interview with the surveyor on 12/20/17 at 1:00 PM the unit manager stated Resident #5 had not had any Incident Reports since August 2017. Review of Resident #2's Incident Report dated 9/10/17 revealed resident noted outside in parking lot of rear of facility. Resident assisted per staff in facility. Resident stated s/he was going to save (his/her) house. New order to place resident on 1:1 observation. Resident's condition was noted to be alert and confused. Equipment involved was noted as wheelchair. There was no documentation that there was an alarm sounding. There was no documentation related to the wander guard. Review of Resident #2's Incident Report dated 10/1/17 revealed resident outside without notifying staff. Resident noted to be alert and confused. Resident observed outside of building heading towards the street. CNA (certified nurse aide) and nurse assisted resident back into the building. Resident stated I'm going to get some clothes and I am trying to catch a ride. Equipment involved was noted as wheelchair. The Incident Report indicated the physician was not notified. There was no documentation that there was an alarm sounding. There was no documentation related to the wander guard. Review of Resident #2's Elopement Risk Assessments dated 7/21/17, 10/1/17, and 12/19/17 revealed the resident was coded as an elopement risk. Review of Resident #2's care plan revealed at risk for elopement as evidenced by multiple attempts to leave the building and making comments about leaving to go find his/her spouse was identified as a problem area. Interventions and approaches were listed on the care plan and included remove resident from unsafe situations and attempt to redirect. Review of Resident #2's Progress Notes revealed on 7/21/17 at 6:41 PM wander guard placed to right wrist related to resident attempting to go outside without staff member despite much education to notify staff if resident would like to go outside during undesignated smoke times for leisure. On 7/23/17 at 6:10 PM resident with one attempt to go outside this shift but redirected and advised s/he could sit on front porch. Continues on every 15 minute checks. Review of Resident #2's Progress Notes dated 7/28/17 indicated resident was discussed in IDT (Interdisciplinary Team) related to behaviors. Resident had several exit seeking episodes this week where s/he attempted to go outside without a staff member. Review of the Progress Note dated 8/2/17 at 12:55 PM revealed resident continues to try to go to smoking area without assistance. Social Service brought him/her back in at 10:30 and re-educated him/her again about not going out without a staff member. On 8/3/17 at 10:45 AM the Progress Note indicated new order received to discharge every 15 minute checks. No further elopement attempts noted. On 8/6/17 at 2:34 PM resident continues to try to go to smoking area without assistance. On 9/10/17 at 1:02 PM resident alert and verbal with confusion noted at times. Resident was observed to be outside the building in the driveway. Staff assisted resident back into building. MD made aware. New order to place resident on 1:1. On 9/11/17 at 11:31 AM new order to discharge 1:1. [ENTITY]t every 15 minute checks related to exit seeking behaviors. Resident educated to not go outside without staff member present related to safety. Resident verbalized understanding. Non-compliant with request. Resident noted sitting outside of front porch without notifying staff. The Progress Note dated 9/15/17 at 8:27 AM by the Social Worker indicated resident continues to attempt to go outdoors without staff assistance or supervision. Social Worker contacted responsible party by phone to discuss exit seeking behaviors. Responsible party agreed that resident may need a secured building or a locked unit to ensure his/her safety. The Progress Note dated 10/1/17 at 11:33 AM indicated Resident #2 was observed propelling self-outside heading towards the street. Nurse and CNA assisted him/her back inside of building. Resident stated, I was going to get a ride to (town) to get me some clothes. Every 15 minute checks implemented to ensure resident safety. There was no documentation that the physician was notified. The Progress Note date 10/1/17 at 1:00 PM indicated the resident was noted with left sided facial drooping and was sent out to the hospital. The resident returned to the facility on [DATE]. Review of Resident #2's Physician order [REDACTED]. Review of Resident #2's Physician order [REDACTED]. The resident was placed on 1:1 related to elopement attempt 9/10/17-9/11/17. The resident was placed on every 15 minute checks related to exit seeking behaviors 9/11/17-9/12/17. The resident was placed on 1:1 related to exit seeking behaviors 10/3/17-10/16/17. The resident was placed on every 15 minute checks related to behaviors 10/16/17-[DATE]. The resident was placed on every 15 minute checks x [AGE] hours 11/3/17-11/6/17. In an interview with the surveyor on 12/19/17 at approximately 11:10 AM, LPN (Licensed Practical Nurse) #1 stated s/he works with Resident #2 on a regular basis. When the resident first came s/he was very anxious. Resident #2 would try to exit seek to go out to smoke. T/he resident would try to go out all doors, but mostly it was out the back door where they go outside to smoke. The resident was educated on having a staff member go outside with him/her multiple times. LPN #1 stated the resident had been on 1:1, every 15 minutes checks, and enhanced monitoring for his/her exit seeking behaviors. Resident #2 had a wander guard and now they have the mag locks in place. The resident's wander guard was discharged when the locks where put in place on the doors. In an interview with the surveyor on 12/19/17 at approximately 11:20 AM, the Unit Manager stated they placed a wander guard on Resident #2 on 7/21/17 because s/he kept talking about needing to leave to go to an appointment. If they approached the door, it would alarm to let the staff member know. The wander guard system would cause the door to alarm, it would not lock the door. It would alarm all over the building. The facility placed a mag lock system that requires a code on doors on [DATE]. They discharged all wander guards at that time. In an interview with the surveyor on 12/19/17 at approximately 11:35 PM, the DON (Director of Nursing) stated Resident #2 was out in the front driveway on 10/1/17. The DON stated on 9/10/17 another staff member saw the resident and they brought him/her back in. The DON stated Resident #2 is alert with periods of confusion. The resident was told to let someone know if s/he wanted to go outside. The DON stated the resident was not supposed to be outside unsupervised, s/he should have a staff member outside with him/her. The DON stated as long as there is no injury, then they do not have to notify the physician about a resident getting outside. The DON stated Resident #2 got outside twice, 9/10/17 and 10/1/17 and s/he does not recall the resident getting outside any other time. The mag locks were placed on [DATE], they stopped the enhanced monitoring of the resident on 10/27/17. The DON stated all doors have a key pad that requires a code to get in and out of the facility. They do not give the code out to family or visitors, only staff have the code. The receptionist has a button in his/her office to let people in or out. A staff member can also use the code on a box beside the door to let someone in or out. In an interview with the surveyor on 12/19/17 at approximately 11:55 AM, the social services staff stated the resident gets obsessed with going home, s/he won't accept their spouse can't take care of them. The social services staff stated s/he does not remember what happened with the note from 8/2/17 related to bringing the resident back inside. The social services staff stated s/he could not remember if Resident #2 was outside or not. In an interview with the surveyor on 12/20/17 at 1:00 PM, the unit manager stated Resident #2 is not followed by psych. Review of facility paperwork revealed they had a mag lock system installed on doors on [DATE]. In an interview with the surveyor on 12/20/17 at 12:05 PM, the DON confirmed that the wander guard boxes were removed when the mag lock system was installed in October 2017. Review of Resident #5's medical record revealed the resident was sent out to a geri-psych hospital unit on 11/10/17-12/6/17 because s/he was paranoid and having active auditory hallucinations. Review of the resident's Progress Notes 8/1/17-11/10/17 revealed no documentation of behaviors related to the resident attempting to exit the facility. The Progress Note on 12/7/17 at 12:36 AM revealed Resident #5 was observed going out the back door by a staff member and was escorted back into the building. On 12/11/17 at 3:25 AM the resident was noted to know the front door code, and going outside numerous times through the night. The Progress Note dated 12/14/17 at 12:05 AM indicated observed resident going in and out of lobby door 10 (+) times on 3-11 shift. Cautioned resident against going outside alone and without proper winter apparel. Observed resident pushing another wheelchair bound resident outside. On 12/14/17 at 6:35 AM the resident was noted to repeatedly exit the building (20+ times) through the front door, setting off alarm. On 12/14/17 at 5:26 PM the Progress Note indicated Resident #5 had learned the new door code already that was changed yesterday because s/he had watched others coming and going and learned the new code. On 12/14/17 at 11:39 PM the resident was observed attempting to push the exit release button, located behind the nurses' station, so that s/he may go outside. The resident was redirected multiple times to no avail. The Progress Note on 12/17/17 at 4:04 AM indicated Resident #5 continued to go outside despite having automatic door locks with alarm. The resident can manipulate the door in such a way that s/he can get outside without the alarm sounding. S/he does need someone to let him/her back inside however. On 12/18/17 at 2:13 AM the resident was observed exiting facility unassisted, through the front door (10+ times). On 12/18/17 at 11:52 PM the resident was noted to exit the facility unassisted through the front door (20+ times). Review of Resident #5's Physician order [REDACTED]. Review of Resident #5's Elopement Risk Assessments dated 7/15/17, 10/1/17, and 12/19/17 revealed the resident was assessed as an elopement risk. Review of Resident #5's care plan revealed resident will leave building and walk around yard on his/her own if not stopped was identified as a problem area. Interventions and approaches were listed on the care plan and included to alert staff to residents wandering behavior. Review of the Discharge Instructions from Resident #5's Geri-Psych hospitalization [DATE]-[DATE] revealed the resident's primary discharge [DIAGNOSES REDACTED]. The instructions for medications indicated to take all the dosage at the time and for the reasons indicated on the medication list. Review of the Discharge Plan for Resident #5 indicated a new medication of [MED]e [MEDICATION NAME] 100 mg tablet take 300 milligrams at bedtime. The resident was to continue [MEDICATION NAME] [MED] 324 milligrams 1 tablet daily, [MEDICATION NAME] 20 milligrams 1 tablet daily, and 4000 units Vitamin D daily. The Discharge Plan indicated to stop taking [MEDICATION NAME] 10 milligrams daily, [MEDICATION NAME] 25 milligrams at bedtime, [MEDICATION NAME] 5 milligrams daily, [MEDICATION NAME] 0.5 milligram as needed, [MEDICATION NAME] 10 milligrams at bedtime, [MEDICATION NAME] 0.25 milligrams at bedtime, and [MEDICATION NAME] 7.5 milligrams at bedtime. Review of Resident #5's hospital course revealed the resident was paranoid and depressed. [MEDICATION NAME] was maximized up to a dose of 30 milligrams at bedtime. It lifted the resident out of his/her depression but s/he also became manic. The resident was very intrusive and was trying to inappropriately touch female patients and female staff members. S/he was also not sleeping and there were nights that s/he also slept less than an hour. [MEDICATION NAME] was eventually changed to [MEDICATION NAME] ([MED]e [MEDICATION NAME]). S/he did respond to the medication better. S/he was sleeping 6-7 hours at night and was less manic. Review of Resident #5's facility Medication Administration Record [REDACTED]. The resident's order for [MEDICATION NAME] 0.5 milligrams as needed was also continued when the resident returned from the hospital. Review of Resident #5's Physician's Clinical Summary for encounter date 12/11/17 indicated the resident presented with continued manic type behavior. Resident #5 had not slept much at all for the past 3 nights, walking around facility. The physician indicated the resident had [MEDICAL CONDITION] disorder, [MEDICAL CONDITION] type - will start by scheduling [MEDICATION NAME]. If that does not help, will increase [MEDICATION NAME]. [MEDICATION NAME] was scheduled 0.5 milligrams one tablet daily. The Clinical Summary indicated changed medications were [MEDICATION NAME] 0.5 milligrams. Discontinued medications by other physician were noted as [MEDICATION NAME], [MED] and [MED]. There was no documentation related to the orders for [MEDICATION NAME] and [MEDICATION NAME]. There were no additional physician notes between 12/6/17-12/11/17. In an interview with the surveyor on 12/20/17 at approximately 1:05 PM, the unit manager and DON were interviewed about Resident #5's exit seeking behaviors. Resident #5 is [MEDICAL CONDITION] and went out to the geri-psych hospital where he was treated and returned. The resident went out for visual hallucinations and paranoia. Since Resident #5 came back from the psych unit, s/he wants to go outside constantly. They stated Resident #5 will go outside constantly. The resident goes out and wants to come right back in. The stated Resident #5 was put on 1:1 yesterday because the threshold for elopement had changed. They previously thought if the resident did not leave the facility grounds then it was not an elopement. They did not report any of the incidents because the resident did not leave the facility grounds. With the mag lock system, if you hold the door for 12 seconds it will automatically release because of fire code. After 12 seconds, the lock releases and the alarm will sound. There is an alarm panel at the nurses' station that alarms as well as at the door. The alarm panel alerts staff to what door is sounding as well. They stated it was not feasible to keep Resident #5 on 1:1. In an interview with the surveyor on 12/20/17 at approximately 2:50 PM, the DON stated the physician will come in and evaluate the medication list from the hospital and decide what medications the resident will be on. The physician has to sign off on all the medications when they are readmitted . In an interview with the surveyor on 12/20/17 at approximately 3:00 PM, the nurse practitioner stated they look at the discharge medications from the hospital and decide what is appropriate for the resident. They then decide what medications the resident will be on. They will document any changes from the hospital discharge medication list on their visit note. The discharge summary they saw said to continue the [MEDICATION NAME], and [MEDICATION NAME]. The nurse practitioner stated the physician was the one who saw Resident #5 when s/he returned to the facility from the psych hospital. In a telephone interview with the surveyor on 12/20/17 at approximately 3:10 PM, the physician stated s/he usually gets the transfer summary and will generally compare with the previous medications to see if there are any changes. The physician stated s/he usually documents the medication changes in the physician visit note. The physician stated s/he would generally try to go down the medication lists from the hospital and facility and compare the two and make sure the resident is on the medications s/he should be on. The stated s/he was not sure about Resident #5's medication list and what s/he looked at. The physician stated that s/he had not been made aware by the facility that Resident #5 was attempting to exit the facility constantly since returning from his/her psych hospitalization . In an interview with the surveyor on 12/20/17 at approximately 2:25 PM, RN (Registered Nurse) #1 stated they go through the home medications from the hospital and input them each. If a resident is being readmitted , they check the medication orders against what they were getting before. If it is not ordered per the hospital, they will discharge from the facility medication list. If they have a question, they will put in the doctor's book for the doctor to check. The doctor will look through the book and they will write the orders or mark through and leave discharged . Review of the facility's policy on Accident and Incidents - Investigating and Reporting revealed all accidents and incidents involving residents occurring on our premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. Review of the facility's Policy Statement on Elopements revealed staff shall promptly reorient any resident who tries to leave the premises to the Charge Nurse or DON. If an employee observes a resident leaving the premises, he/she should attempt to prevent the departure in a courteous manner. When a resident returns to the facility, the DON or Charge Nurse shall contact the attending physician and report findings and condition of the resident, notify the resident's legal representative, complete and file an incident report, and document relevant information in the resident's medical record. Review of the facility's Safety and Supervision of Resident Policy Statement revealed the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. On December 19, 2017 at 1:15 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at a scope and severity of K. The Immediate Jeopardy and Substandard Quality of Care existed in the facility on August 2, 2017.

Based on review of facility files and interview, the facility failed to review the resident's total program of care, including medications and treatments, at each visit required. Resident #5 was noted to go out to the geri psych hospital 11/10/17-12/6/17 for increased behaviors. The geri psych hospital indicated new medications, continued medications, and stop medications on the resident's Discharge Plan. The physician at the hospital indicated the resident was manic and sleeping less than an hour some nights on [MEDICATION NAME]. The medication was discharged and [MED]e [MEDICATION NAME] was started. The resident was noted to sleep 6-7 hours a night and be less manic when the medication was changed. When Resident #5 returned to the facility s/he continue to receive [MEDICATION NAME] and two additional medications stopped by the geri psych hospital physician. There was no documentation in Resident #5's medical record that indicated why the medications were to continue. One of nine residents reviewed for physician visits. The findings included: Review of Resident #5's medical record revealed the resident was sent out to a geri-psych hospital unit on 11/10/17-12/6/17 because s/he was paranoid and having active auditory hallucinations. Review of the resident's Progress Notes 8/1/17-11/10/17 revealed no documentation of behaviors related to the resident attempting to exit the facility. The Progress Note on 12/7/17 at 12:36 AM revealed Resident #5 was observed going out the back door by a staff member and was escorted back into the building. On 12/11/17 at 3:25 AM the resident was noted to know the front door code, and going outside numerous times through the night. The Progress Note dated 12/14/17 at 12:05 AM indicated observed resident going in and out of lobby door 10 (+) times on 3-11 shift. Cautioned resident against going outside alone and without proper winter apparel. Observed resident pushing another wheelchair bound resident outside. On 12/14/17 at 6:35 AM the resident was noted to repeatedly exit the building (20+ times) through the front door, setting off alarm. On 12/14/17 at 5:26 PM the Progress Note indicated Resident #5 had learned the new door code already that was changed yesterday because s/he had watched others coming and going and learned the new code. On 12/14/17 at 11:39 PM the resident was observed attempting to push the exit release button, located behind the nurses' station, so that s/he may go outside. The resident was redirected multiple times to no avail. The Progress Note on 12/17/17 at 4:04 AM indicated Resident #5 continued to go outside despite having automatic door locks with alarm. The resident can manipulate the door in such a way that s/he can get outside without the alarm sounding. S/he does need someone to let him/her back inside however. On 12/18/17 at 2:13 AM the resident was observed exiting facility unassisted, through the front door (10+ times). On 12/18/17 at 11:52 PM the resident was noted to exit the facility unassisted through the front door (20+ times). Review of Resident #5's Physician order [REDACTED]. Review of Resident #5's Elopement Risk Assessments dated 7/15/17, 10/1/17, and 12/19/17 revealed the resident was assessed as an elopement risk. Review of Resident #5's care plan revealed resident will leave building and walk around yard on his/her own if not stopped was identified as a problem area. Interventions and approaches were listed on the care plan and included to alert staff to residents wandering behavior. Review of the Discharge Instructions from Resident #5's Geri-Psych hospitalization [DATE]-[DATE] revealed the resident's primary discharge [DIAGNOSES REDACTED]. The instructions for medications indicated to take all the dosage at the time and for the reasons indicated on the medication list. Review of the Discharge Plan for Resident #5 indicated a new medication of [MED]e [MEDICATION NAME] 100 mg tablet take 300 milligrams at bedtime. The resident was to continue [MEDICATION NAME] [MED] 324 milligrams 1 tablet daily, [MEDICATION NAME] 20 milligrams 1 tablet daily, and 4000 units Vitamin D daily. The Discharge Plan indicated to stop taking [MEDICATION NAME] 10 milligrams daily, [MEDICATION NAME] 25 milligrams at bedtime, [MEDICATION NAME] 5 milligrams daily, [MEDICATION NAME] 0.5 milligram as needed, [MEDICATION NAME] 10 milligrams at bedtime, [MEDICATION NAME] 0.25 milligrams at bedtime, and [MEDICATION NAME] 7.5 milligrams at bedtime. Review of Resident #5's hospital course revealed the resident was paranoid and depressed. [MEDICATION NAME] was maximized up to a dose of 30 milligrams at bedtime. It lifted the resident out of his/her depression but s/he also became manic. The resident was very intrusive and was trying to inappropriately touch female patients and female staff members. S/he was also not sleeping and there were nights that s/he also slept less than an hour. [MEDICATION NAME] was eventually changed to [MEDICATION NAME] ([MED]e [MEDICATION NAME]). S/he did respond to the medication better. S/he was sleeping 6-7 hours at night and was less manic. Review of Resident #5's facility Medication Administration Record [REDACTED]. The resident's order for [MEDICATION NAME] 0.5 milligrams as needed was also continued when the resident returned from the hospital. Review of Resident #5's Physician's Clinical Summary for encounter date 12/11/17 indicated the resident presented with continued manic type behavior. Resident #5 had not slept much at all for the past 3 nights, walking around facility. The physician indicated the resident had [MEDICAL CONDITION] disorder, [MEDICAL CONDITION] type - will start by scheduling [MEDICATION NAME]. If that does not help, will increase [MEDICATION NAME]. [MEDICATION NAME] was scheduled 0.5 milligrams one tablet daily. The Clinical Summary indicated changed medications were [MEDICATION NAME] 0.5 milligrams. Discontinued medications by other physician were noted as [MEDICATION NAME], [MED] and [MED]. There was no documentation related to the orders for [MEDICATION NAME] and [MEDICATION NAME]. There were no additional physician notes between 12/6/17-12/11/17. In an interview with the surveyor on 12/20/17 at approximately 1:05 PM, the unit manager and Director of Nursing (DON) were interviewed about Resident #5's exit seeking behaviors. Resident #5 is [MEDICAL CONDITION] and went out to the geri-psych hospital where he was treated and returned. The resident went out for visual hallucinations and paranoia. Since Resident #5 came back from the psych unit, s/he wants to go outside constantly. They stated Resident #5 will go outside constantly. The resident goes out and wants to come right back in. The stated Resident #5 was put on 1:1 yesterday because the threshold for elopement had changed. They previously thought if the resident did not leave the facility grounds then it was not an elopement. They did not report any of the incidents because the resident did not leave the facility grounds. With the mag lock system, if you hold the door for 12 seconds it will automatically release because of fire code. After 12 seconds, the lock releases and the alarm will sound. There is an alarm panel at the nurses' station that alarms as well as at the door. The alarm panel alerts staff to what door is sounding as well. They stated it was not feasible to keep Resident #5 on 1:1. In an interview with the surveyor on 12/20/17 at approximately 2:50 PM, the DON stated the physician will come in and evaluate the medication list from the hospital and decide what medications the resident will be on. The physician has to sign off on all the medications when they are readmitted . In an interview with the surveyor on 12/20/17 at approximately 3:00 PM, the nurse practitioner stated they look at the discharge medications from the hospital and decide what is appropriate for the resident. They then decide what medications the resident will be on. They will document any changes from the hospital discharge medication list on their visit note. The discharge summary they saw said to continue the [MEDICATION NAME], and [MEDICATION NAME]. The nurse practitioner stated the physician was the one who saw Resident #5 when s/he returned to the facility from the psych hospital. In a telephone interview with the surveyor on 12/20/17 at approximately 3:10 PM, the physician stated s/he usually gets the transfer summary and will generally compare with the previous medications to see if there are any changes. The physician stated s/he usually documents the medication changes in the physician visit note. The physician stated s/he would generally try to go down the medication lists from the hospital and facility and compare the two and make sure the resident is on the medications s/he should be on. The stated s/he was not sure about Resident #5's medication list and what s/he looked at. The physician stated that s/he had not been made aware by the facility that Resident #5 was attempting to exit the facility constantly since returning from his/her psych hospitalization . In an interview with the surveyor on 12/20/17 at approximately 2:25 PM, RN (Registered Nurse) #1 stated they go through the home medications from the hospital and input them each. If a resident is being readmitted , they check the medication orders against what they were getting before. If it is not ordered per the hospital, they will discharge from the facility medication list. If they have a question, they will put in the doctor's book for the doctor to check. The doctor will look through the book and they will write the orders or mark through and leave discharged . On December 19, 2017 at 1:15 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at a scope and severity of J. The Immediate Jeopardy and Substandard Quality of Care existed in the facility on August 2, 2017.

Based on review of facility files and interviews, the facility failed to ensure each resident remained free from abuse. Certified Nursing Assistant (CNA) #1 was observed hitting Resident #1 in the facility dining room while arguing with the resident. One of one residents reviewed for physical abuse. The findings included: The facility reported an allegation of physical abuse for Resident #1 by CNA #1 to the State Agency on 4/20/17. Review of the facility's Five-Day Follow-Up Report dated 4/26/17 indicated abuse was substantiated and CNA #1 was terminated. The facility summary indicated on 4/20/17, the floor nurse was called to the dining room by staff. Upon entering, the resident had a busted plate and tray beside his/her wheelchair and was swinging and cursing at CNA #1. The floor nurse asked CNA #1 to leave the situation and s/he resisted. The floor nurse got in between Resident #1 and CNA #1 and witnessed the CNA reach around and strike the resident three times on the arm. Review of Resident #1's medical record revealed a Nurses' Note dated 4/20/17 at 7:47 PM that indicated resident was noted yelling/cursing loudly in dining room at 5 PM today. Nurse to dining room, the resident noted yelling and cursing at staff member. Tray of food noted on floor beside resident. Resident in wheelchair. Nurse attempting to redirect resident. Resident swinging arms, attempting to get wheelchair to staff member while yelling and cursing loudly. Physical contact made. After several minutes, resident calm and agreed to go to room. Physical assessment completed. No injury noted. 911 called. Medical Doctor (MD) notified. Review of the physician progress notes [REDACTED]. Per staff the resident really does not have frequent issues. Further review of the medical record revealed the Annual Minimum Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 15. The Quarterly MDS coded Resident #1 as independent for transfers, dressing, hygiene and bed mobility with no behaviors coded as occurring during the assessment period. Review of the care plan revealed displays combative behaviors towards staff and other residents was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to approach resident warmly, calmly and positively. In an interview with the surveyor on 5/31/17, Licensed Practical Nurse (LPN) #1 stated that it was dinner time between 4:30 and 5:00 when the incident occurred. A CNA came up to him/her on the 300 hall and said they were down there arguing, s/he was on the way down to the dining room because s/he had heard some yelling. There was a plate of food on the floor by Resident #1. CNA #1 and Resident #1 were yelling, something about coffee. Resident #1 later said s/he had asked for a cup of coffee and CNA #1 wouldn't give it to him/her. Another resident came and asked for a cup and s/he gave it to them, and that is what started the argument. Resident #1 was sitting on the edge of his/her wheelchair and CNA #1 was a few feet away from him/her. LPN #1 got in between them. LPN #1 told CNA #1 s/he needed to leave and s/he wouldn't. CNA #1 walked off and came back, reached around LPN #1 and hit Resident #1 on his/her left arm twice. CNA #1 walked to another table in the dining room and came back. CNA #1 said something about the resident being disrespectful and s/he didn't have to take it. By that time, other staff had arrived and got CNA #1 to leave. LPN #1 took Resident #1 to his/her room to talk to him/her about what happened. The police came and Resident #1 told them what happened. Resident #1 decided not to press charges. CNA #1 did not usually work with Resident #1, s/he was working in the dining room that night. In an interview with the surveyor on 5/31/17 at approximately 10:05 AM, LPN #2 stated s/he heard a commotion when s/he was getting ready to leave. LPN #2 went to the dining room, LPN #1 was already there standing between CNA #1 and Resident #1. LPN #1 was telling CNA #1 to leave, LPN #2 told CNA #1 to leave also. CNA #1 reached around LPN #1 and popped Resident #1 on the arm, s/he was still arguing with the resident. Resident #1 had behaviors before, but they had improved before the incident with CNA #1. The resident had come off the behavior monitoring list.

Based on observations, interviews, and record reviews, the facility failed to provide medically related social services with interventions and treatment to promote the psychosocial well-being for 12 of 12 residents reviewed for psychiatric services. The facility failed to adequately assess, monitor and evaluate Resident #32's psychosocial needs related to a physician's orders [REDACTED].#38; Resident #74 exhibiting inappropriate behaviors failed to have consistent coordination of care with facility staff, mental health staff, physician and the responsible party to ensure appropriate treatment was administered; Resident #79, with a physician's orders [REDACTED].#25, #35, #57, #58, #62, #77, #82, & #116 noted with [DIAGNOSES REDACTED]. The findings included: Cross Refer to F-406 as it relates to the facility failure to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility admitted Resident #32 with [DIAGNOSES REDACTED]. During record review of the progress notes on 7/28/15 at approximately 3:15 PM, it was revealed that Resident #32 had long and short term memory loss, was unhappy, sad, with confusion at times but was able to make needs known to the staff. Multiple observations were made 7/28/15 and 7/29/15 at different times revealing Resident #32 was participating in activities with bingo and church services. An interview was conducted on 7/29/15 at approximately 9:35 AM with the resident's daughter present. Resident #32 revealed he/she had a panic attack. He/she stated, I turned on the light and no one came. When they finally came the CNA (Certified Nursing Assistant) turned off the call light and told me he/she would be back in a few minutes. S/he never came back. Resident #32 went on to say, I was soiled and had to call my daughter to get some help months ago around February/March 2015. I called my son about the CNA not putting cream on my buttocks and I had pain, a red area on my buttocks. After calling the CNA several times, I called my son one time and he told me to call my daughter. Then I called one time about cleaning me up to my daughter. I just started having panic attacks since I have been here. I feel someone is walking on my chest like having a heart attack. I have the heartburn bad. The doctor told me he is going to get mental health to come see me here. Sometimes when I ask for help and call and I have to call for a long time, I cry and have a panic attack. The staff comes in and answers the call light. Sometimes takes care of me and sometimes the CNA tells me he/she is coming back and the CNA comes back. I push the button and it takes less than 5 minutes. It was the only 2 episodes that it took a long time, approximately one hour, we were having supper. I rang the bell over 3-4 times and CNA never came back after supper to help me. During the interview, the resident's daughter stated, .called me at home approximately Feb/March and told me s/he needed cleaning up. I knew s/he was talking about a bowel movement. I told her/him to hang up the phone and I called up here. I do not know the name of the person I talked with. I told the female please go in the room. S/he was messed up and s/he had asked for someone to clean her/him up. The female told me I will go in and check on the resident .I can't remember but (parent) called me late at night approx 2:00 AM feeling like s/he was having anxiety and a panic attack. (Parent) had a nervous breakdown in 1972. S/he tells me s/he has to make her/himself satisfied. S/he would rather be at home. S/he lived with me [AGE] years until s/he had a fall 2 years ago. S/he fell off the front porch and broke her/his leg. Review of the nursing notes on 7/28/15 at approximately 3:20 PM revealed no mention of panic attacks or the incident described by the resident. Review of the care plan dated 8/20/14 revealed no mention of anxiety or panic attacks as a problem area. There was a [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. The staff did provide evidence of a psychiatric evaluation completed by mental health services. The evaluation was dated four months later on 1/12/15. In addition, there was an order written [REDACTED]. During an interview on 7/30/15 at approximately 3:11 PM, the Social Services Director revealed Resident #32 did not report to her about having any panic attacks or behaviors. There was no documentation in the nursing notes about behaviors, anxiety or panic attacks. The staff have not told me of any concerns, problems or changes in (Resident #32). The Social Services Director confirmed that the family was supportive, visited regularly, and the resident talked on the telephone daily with the daughter or son. During a telephone interview on 8/03/15 at approximately 2:40 PM with the Psychiatric Nurse Practitioner (PNP) it was confirmed that Resident #32 was not evaluated until January 2015. The PNP further stated he/she did not recall the reason for the 9/10/14 mental health services physician's orders [REDACTED]. The PNP indicated he/she relied on a blue book used by the nurses to document resident concerns, but the blue book was a hit or miss book. There was no evidence provided by the facility to indicate a referral was made to social services or that social services intervened to ensure mental health services/any recommendations were followed through. Record review of the facility Behavioral Monitoring chart on July 31, 2015 at approximately 5:15 PM revealed no documentation of behaviors for May, June or July for the resident. During record review on 7/29/15 at approximately 5:00 PM, review of the progress notes from 5/4/15 through 6/19/15 revealed the Nurse Practitioner documented Resident #32's cognitive status as has known dementia, pleasantly confused at times, some anxiety, followed by Mental Health. The facility admitted resident #38 with [DIAGNOSES REDACTED]. Record review of the Social Progress Notes on 7/28/2015 at approximately 2:35 PM revealed that on 5/6/2015 the Social Services Director (SSD) met with Resident #38 for the resident's quarterly assessment. The resident's PHQ-9 (depression scale) score was noted to be 18, indicating moderately severe depression. This was an increase from a PHQ-9 score of 6 (mild depression) per the Social Progress Notes on 2/23/105. The SSD documented she/he would get a psychiatric (psych) evaluation (eval) for the resident due to the increased PHQ-9 score. There was no indication in the clinical record that the resident's physician was notified of the increased PHQ-9 score. Record review of a Progress Note by the Medical Director, dated 5/21/2015, on 07/29/2015 at 8:48 AM revealed that the resident was seen by the Medical Director, but the resident's depression was not addressed. There were no progress notes to indicate that the resident had received a psych eval. Record review of the Physicians' Orders and Telephone Orders on 07/28/2015 at 2:55 PM revealed no orders for a psych eval. Record review of the Nurse's Notes on 7/28/2015 at 1:56 PM revealed that on 5/23/2015 at 12:30 AM the resident had increased anxiety and was crying due to an ill family member. The resident was medicated with Ativan (anti-anxiety medication). At 11:00 AM the resident was noted to have increased anxiety and did not want to get out of bed. The resident stated her mother was sick and in the hospital. The resident was medicated with Ativan. A Nurse's Note from 7/10/2015 at 6:20 PM revealed that the resident was noted crying when the nurse entered her/his room. The Resident stated she was crying because she wants to go home but there was no one at home that could take care of her. She also stated her kidney doctor had given her bad news. The resident was comforted by staff and given Ativan. On 7/25/2015 at 1:30 AM the resident was noted to be crying and stated she was upset. The resident did not give a reason why she/he was upset. The nurse documented that Ativan was given for the crying episode. On 7/25/2015 at 9:30 AM the resident was noted to be crying and upset and stated I just want to go home. The resident was medicated with Ativan. Record review of the Care Plan on 07/28/2015 at 3:31 PM revealed that the resident's Depression, Insomnia, and Anxiety were care planned for, but the Care Plan was not reviewed and revised after the resident was assessed with [REDACTED]. During an interview with the SSD on 07/28/2015 at 3:43 PM, the SSD was informed there was no documentation to indicate that the resident received a psych eval related to increased depression per her/his quarterly assessment on 5/6/2015. The SSD states she/he would have to look at the psych consults to see if the appointment had been made for the resident. During an interview with the SSD on 07/29/2015 at 8:54 AM, the SSD confirmed that the resident did not get the psych eval. The SSD stated that psych appointments were made by the MDS (Minimum Data Set) nurse and that an appointment was not made for the resident. The SSD stated that several psych appointments were made on 5/7/2015, but not for Resident #38. The SSD director also confirmed that the Care Plan had not been reviewed and revised related to the increased depression and need for a psych consult. The facility admitted Resident #57 with [DIAGNOSES REDACTED]. Record review of the Progress Notes on 7/31/2015 at 9:29 AM revealed that the resident had been followed by Mental Health. The resident was seen by Mental Health on 3/16/2015 and 5/21/2015 for depression. The resident's Trazodone was increased after the 5/21/2015 visit for depression. Record review of the Care Plan on 7/31/2015 at 10:56 AM revealed that the Care Plan had not been reviewed and revised to reflect that the resident was receiving Mental Health Services. During an interview with the SSD on 07/31/2015 at approximately 10:56 AM, the SSD confirmed the Care Plan had not been updated to show the resident was receiving Mental Health services. The facility admitted Resident #116 with [DIAGNOSES REDACTED]. Record review of the Social Progress Notes on 7/31/2015 at 9:58 AM revealed that the resident was being followed by Mental Health for depression and anxiety. No Mental Health Progress Notes were in the clinical record. Record review of the Nurse's Notes on 7/31/2015 at 10:48 AM revealed that the resident was seen by Mental Health on 6/3/2015 and his/her Paxil was increased related to depression. Record review of the Care Plan on 7/31/2015 at approximately 10:48 AM revealed that the Care Plan had not been reviewed and revised to reflect that the resident was receiving Mental Health Services. During an interview with the SSD on 07/31/2015 at approximately 10:56 AM, the SSD confirmed the Care Plan had not been updated to show the resident was receiving Mental Health services. In addition the SSD confirmed that the Mental Health Progress Notes were not on the chart. The facility admitted Resident #74 with [DIAGNOSES REDACTED]. Review of the social service notes on 7/28/2015 at approximately 3:24 PM revealed,Resident has a history of disrobing and throwing himself in the floor, kicking, yelling, screaming and becomes combative at times. An interview on 7/29/2015 at approximately 9:28 AM revealed that he/she did not know that Resident #74 was not being followed by Mental Health per his/her family. The medical record contained only one evaluation dated 2/17/2015. The social worker continued to list Resident #74 on the list to be seen by mental health. The list of residents to be seen by mental health had a note beside Resident #74, and states not seen per PCP requests. During an interview on 7/30/2015 at approximately 9:16 AM with the Nurse Manager of the Home, he/she stated, this resident does not see the psychiatrist because his/her family does not think he/she needs to. During an interview on 7/30/2015 at approximately 10:25 AM with the Licensed Social Worker Consultant, he/she stated, the facility has finally gotten this resident to the place he/she is doing better. He/she also stated the resident's family will not agree to a lot of interventions that the resident could possibly benefit from. An interview on 7/30/2015 at approximately 12:25 PM with the Nurse Practitioner verified that the family had called the Psychiatrist and stated he/she did not want this resident seen by them anymore. He/she thinks this resident does not have any behaviors. The Nurse Practitioner stated, We are trying to give a combination of medications that will keep him/her from hurting himself/herself and others. No documentation could be found in Resident #74's medical record to ensure this issue was discussed with the family and Psych services were denied by the family. During an interview on 7/30/2015 at approximately 2:29 PM with the Medical Director and physician for Resident #74, he/she stated, This resident's behavior has been better with less episodes of impulsive behaviors. He/she also stated that he/she is not sure that this resident would benefit from psych services. He/she went on to say that if anything changes with the resident he/she would be open to getting a psych consult or sending him/her out for a psych evaluation. He/she stated as for now this resident is doing well with the present medication regime. Review on 7/30/2015 at approximately 3:00 PM of the Clinical Summaries dated 1/7/2015 states, .continues to have behavior issues and outbursts. Medication tweaked, increased and changed. Can be combative. Anxious and verbally abusive. Family will not let Mental Health evaluate. The clinical summary dated 2/11/2015 states, .continues to have behavior issues and outbursts. Can yell and cuss at staff. Needs constant redirection and monitoring. The clinical summary dated 5/20/2015 states, .has been combative and abusive with staff. Crawling out of bed. Tore off some of his/her right big toe nail. Family has refused mental health evaluation in the past. The clinical summary dated 5/21/2015 states, seeing patient to follow up on behaviors. Had been well managed but had difficulties this weekend. The clinical summary dated 6/15/2015 states, Has had increasing agitation and behavior issues. Also had a couple of falls where he/she throws themselves out of the geri chair. Recommended mental health for evaluation but family is against reports. Review on 7/30/2015 at approximately 3:28 PM of the facility policy titled, Behavior Management Program, under Purpose states, Residents who display mental and psychosocial adjustment difficulty should receive appropriate services in an attempt to correct the problem. The facility admitted Resident #79 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Resident #79 was not seen by the psychiatrist until 3/16/2015. Review of the psych consult scheduling book on 7/31/2015 at approximately 9:35 AM revealed a visit from the Psychiatrist on 3/16/2015, 5/11/2015, and 5/21/2015. An interview on 7/31/2015 at approximately 10:30 AM with the Social Services Worker, he/she verified that Resident #7 had a physician's orders [REDACTED]. He/she also verified that Resident #79 had not been seen by the psychiatrist until 3/16/2015. The facility admitted Resident #58 with [DIAGNOSES REDACTED]. The facility admitted Resident #82 with [DIAGNOSES REDACTED]. The facility admitted Resident #35 with [DIAGNOSES REDACTED]. A record review on 7/31/15 at approximately 10:05 AM revealed medically related social services were not coordinated and included in the care plan. The facility admitted Resident #25 with [DIAGNOSES REDACTED]. A record review on 7/31/15 at approximately 10:31 AM revealed medically related social services were not coordinated and included in the care plan. The facility admitted Resident #62 with [DIAGNOSES REDACTED]. A record review on 7/31/15 at approximately 10:35 AM revealed medically related social services were not coordinated and included in the care plan. The facility admitted Resident #77 with [DIAGNOSES REDACTED]. A record review on 7/31/15 at approximately 10:42 AM revealed medically related social services were not coordinated and included in the care plan. An interview with the Social Services Director (SSD) on 7/31/15 at approximately 10:19 AM revealed he/she will check with the agency that provides mental health services to see the timeline for therapy to begin. On 7/30/15 at approximately 5:20 PM, the Administrator and Director of Nursing were notified that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility. 483.15 (g) Social Services, F-250 was identified at Immediate Jeopardy and Substandard Quality of Care at a scope and severity of L. The Immediate Jeopardy was not removed at the completion date of the survey on 8/3/15.

Based on interview and record review, the facility failed to review and revise the care plans for multiple residents with changes in behavior, Activities of Daily Living (ADLs), psychiatric services, and increased depression. Eleven of 38 residents sampled had care plans not reviewed and revised for these issues, including Resident #32 with changes in anxiety/depression that required a psych eval and follow-up, Resident #38 with behavior change with increased depression, Residents #57, #116, #25, #35, #58, #62 & #77 receiving mental health services with no care plan related to current treatment or possible interventions, Resident #27 with improvement in ADLs, and Resident #108 with decline in ADLs. The findings included: Cross Refer to F406/F250 as it relates to residents seen by mental health services with no coordination of care and facility failure to revise care plans to allow for staff to adequately address identified concerns. The facility admitted Resident #32 with [DIAGNOSES REDACTED]. A record review on 7/28/15 at approximately 3:15 PM revealed a physician's orders [REDACTED]. The order was to have Resident #32 evaluated by psychiatric services. Even though the order was written on 9/10/14 there was no documentation in the chart to indicate that the resident was seen or evaluated for mental health services before 1/12/15, four months after the initial order. Progress notes documenting mental health visits were not found in the resident's clinical record or available to staff for use in treating Resident #32. The visits and notes had to be requested from mental health services and faxed to the facility. During an interview on 7/29/15 at approximately 8:00 AM, Resident #32 stated s/he was having panic attacks 2 times a week when she would get upset with staff for not answering her call light and meeting her needs timely. The panic attacks started happening in February or March 2015 with an incident of not getting cleaned up timely from an incontinent episode. In an interview on 7/30/15, the Social Services Director stated s/he was not aware Resident #32 was having increased anxiety and panic attacks. S/he stated there were no reports from the resident, staff, or family about any mental status changes. During an interview on 7/30/15 the Unit Manager stated (Resident #32) did not report to her/him s/he was having panic attacks 2x a week, feeling sharp pain in his/her chest or becoming short of breath for a couple of hours. Record review of Resident #32's care plan during July 27 through July 31, 2015 revealed the care plan had the following documentation : Problem Onset: 08-20-2014 Dx of [MEDICAL CONDITION]. Has antipsychotic meds in use. Goal and Target Date: Resident will not experience any side effects from medications thru next review date (8/1/15). The care plan for Resident #32 did not have documentation of behaviors/complaints of increased anxiety, and panic attacks. The care plan was not evaluated and revised as the resident's status changed from approximately February 2015 through July 2015. No interventions or recommendations were included on the care plan as a result of mental health services involvement. The facility admitted resident #38 with [DIAGNOSES REDACTED]. Record review of the Social Progress Notes on 7/28/2015 at approximately 2:35 PM revealed that on 5/6/2015 the Social Services Director (SSD) met with Resident #38 for the resident's quarterly assessment. The resident's PHQ-9 (depression scale) score was noted to be 18, indicating moderately severe depression, This was an increase from a PHQ-9 score of 6 (mild depression) per the Social Progress Notes on 2/23/105. The SSD documented she/he would get a psychiatric (psych) evaluation (eval) for the resident due to the increased PHQ-9 score. There were no progress notes to indicate that the resident had received a psych eval. Record review of the Physicians Orders and Telephone Orders on 07/28/2015 at 2:55 PM revealed no orders for a psych eval. Record review of the Care Plan on 07/28/2015 at 3:31 PM revealed that the resident's Depression, [MEDICAL CONDITION] and Anxiety were care planned for, but the Care Plan was not reviewed and revised after the resident was assessed with [REDACTED]. During an interview with the SSD on 07/29/2015 at 8:54 AM, the SSD confirmed that the resident did not get the psych eval. The SSD stated that psych appointments were made by the MDS (Minimum Data Set) nurse and that an appointment was not made for the resident. The SSD director also confirmed that the Care Plan had not been reviewed and revised related to the increased depression and need for a psych consult. The facility admitted Resident #57 with [DIAGNOSES REDACTED]. Record review of the Progress Notes on 7/31/2015 at 9:29 AM revealed that the resident had been followed by Mental Health. The resident was seen by Mental Health on 3/16/2015 and 5/21/2015 for depression, The resident's [MEDICATION NAME] was increased after the 5/21/2015 visit for depression. Record review of the Care Plan on 7/31/2015 at 10:56 AM revealed that the Care Plan had not been reviewed and revised to reflect that the resident was receiving Mental Health Services nor were the Mental Health recommendations care planned for. During an interview with the SSD on 07/31/2015 at approximately 10:56 AM, the SSD confirmed the Care Plan had not been revised to show the resident was receiving Mental Health services. The facility admitted Resident #116 with [DIAGNOSES REDACTED]. Record review of the Social Progress Notes on 7/31/2015 at 9:58 AM revealed that the resident was being followed by Mental Health for depression and anxiety. Record review of the Nurse's Notes on 7/31/2015 at 10:48 AM revealed that the resident was seen by Mental Health on 6/3/2015 and his/her [MEDICATION NAME] was increased related to depression. Record review of the Care Plan on 7/31/2015 at approximately 10:48 AM revealed that the Care Plan had not been reviewed and revised to reflect that the resident was receiving Mental Health Services nor were the Mental Health recommendations care planned for. During an interview with the SSD on 07/31/2015 at approximately 10:56 AM, the SSD confirmed the Care Plan had not been revised to show the resident was receiving Mental Health services. The facility admitted Resident #108 with [DIAGNOSES REDACTED]. Review on 7/29/2015 at approximately 12:30 PM of Resident #108's Comprehensive Plan of Care revealed no interventions in place to prevent further decline in ADLs related to a significant change in functional status. Resident # 108 had a decline in ADLs for walking, dressing, and personal hygiene. The facility admitted Resident #27 with [DIAGNOSES REDACTED]. Review on 7/29/2015 at approximately 12:20 PM of Resident #27's Comprehensive Plan of Care revealed no interventions in place to reflect the improvement in ADLs related to a significant improvement in Resident #27's functional status. No interventions were in place to assist with continuing improvement or assuring the maximum potential for Resident #27 was met. Resident #27 had an improvement in bed mobility and transfers. An interview on 7/29/2015 at approximately 1:00 PM with the MDS/Care Plan Coordinator/Consultant confirmed that the Comprehensive Plan of Care was not updated to reflect interventions to prevent further decline in ADL's for Resident #108 . He/she also confirmed that the Comprehensive Plan of Care was not updated to reflect the improvement in ADL's for Resident #108. The facility admitted Resident #58 with [DIAGNOSES REDACTED]. The facility admitted Resident #82 with [DIAGNOSES REDACTED]. The facility admitted Resident #35 with [DIAGNOSES REDACTED]. A record review on 7/31/15 at approximately 10:05 AM revealed medically related social services were not coordinated and included in the care plan. The facility admitted Resident #25 with [DIAGNOSES REDACTED]. A record review on 7/31/15 at approximately 10:31 AM revealed medically related social services were not coordinated and included in the care plan. The facility admitted Resident #62 with [DIAGNOSES REDACTED]. A record review on 7/31/15 at approximately 10:35 AM revealed medically related social services were not coordinated and included in the care plan. The facility admitted Resident #77 with [DIAGNOSES REDACTED]. A record review on 7/31/15 at approximately 10:42 AM revealed medically related social services were not coordinated and included in the care plan. An interview on 7/31/15 at approximately 10:19 AM with the SSD confirmed the residents were not care planned for mental health services and further stated he/she was in the process of care planning residents for mental health services. The SSD stated he/she would include initial psychological evaluation on the care plan and not additional follow up related to mental health services. On 7/30/15 at approximately 5:20 PM, the Administrator and Director of Nursing was notified that Immediate Jeopardy and/or Substandard Quality of Care existed. 483.20 (k)(2) Care Plan, F-280 was identified at Immediate Jeopardy at a scope and severity of L. The facility failed to update, review and revise Resident #32, #25, #35, #38, #57, #58, #62, #77, & #116's Plan of Care related to physician ordered mental health services to include goals and coordination of care interventions. The Immediate Jeopardy and/or Substandard Quality of Care was not removed at the time the surveyors completed the Recertification and Extended Survey.

Based on record reviews, interviews and review of facility policies, it was determined on 7/30/15 at approximately 5:20 PM Immediate Jeopardy was identified at a scope and severity level of (L). The facility failed to provide mental health services timely for 4 of 12 sampled residents with physician ordered mental health evaluations/treatments. Residents #32, #38, #74 and #79 were not provided mental health services timely. The findings included: The facility admitted Resident #32 with [DIAGNOSES REDACTED]. A review of the medications revealed that Resident #32 was on [MEDICATION NAME] 0.25 mg one po (by mouth) every 6 hours prn (as needed) anxiety (ordered July 2015), [MEDICATION NAME] 50 mg. one tab tid (three times a day). A physician's progress note indicated that Resident #32 had long and short term memory loss. The progress note further indicated the resident was unhappy, sad, and confused at times. A record review on 7/28/15 at approximately 3:15 PM revealed a physician's orders [REDACTED]. The order was to have Resident #32 evaluated by psychiatric services. Even though the order was written on 9/10/14 there was no documentation in the chart to indicate that the resident was seen or evaluated for mental health services before 1/12/15, four months after the initial order. Progress notes documenting mental health visits were not found in the resident's clinical record or available to staff for use in treating Resident #32. The visits and notes had to be requested from mental health services and faxed to the facility. A psychiatric note dated 1/12/15 indicated Resident #32 had a [DIAGNOSES REDACTED]. A second psychiatric note dated 1/21/15 indicated the resident had [DIAGNOSES REDACTED]. A physician's progress note dated 1/26/15 indicated the resident was not acting right. There was no documentation to indicate a referral was made to social services or that social services intervened to ensure mental health services were followed through. During a telephone interview on 8/03/15 at approximately 2:40 PM with the Psychiatric Nurse Practitioner (PNP) it was confirmed that Resident #32 was not evaluated until January 2015. The PNP further stated he/she did not recall the reason for the 9/10/14 mental health services physician's orders [REDACTED]. The PNP indicated he/she relied on a blue book used by the nurses to document resident concerns, but the blue book was a hit or miss book. Further review of psychiatric notes dated 4/01/15, 4/13/15, 4/27/14, 5/04/15, 5/13/15, and 5/27/15 indicated Resident #32 had no anxiety. A psychiatric note dated 6/19/15 indicated known dementia with no anxiety. The facility admitted resident #38 with [DIAGNOSES REDACTED]. Record review of the Social Progress Notes on 7/28/2015 at approximately 2:35 PM revealed that on 5/6/2015 the Social Services Director (SSD) met with Resident #38 for the resident's quarterly assessment. The resident's PHQ-9 (depression scale) score was noted to be 18, indicating moderately severe depression, This was an increase from a PHQ-9 score of 6 (mild depression) per the Social Progress Notes on 2/23/2015. The SSD documented she/he would get a psychiatric (psych) evaluation (eval) for the resident due to the increased PHQ-9 score. There was no indication in the clinical record that the resident's physician was notified of the increased PHQ-9 score. Record review of a Progress Note by the Medical Director, dated 5/21/2015, on 07/29/2015 at 8:48 AM revealed that the resident was seen by the Medical Director, but the resident's depression was not addressed. There were no progress notes to indicate that the resident had received a psych eval. Record review of the Physicians Orders and Telephone Orders on 07/28/2015 at 2:55 PM revealed no orders for a psych eval. Record review of the Nurse's Notes on 7/28/2015 at 1:56 PM revealed: On 5/23/2015 at 12:30 AM, the resident had increased anxiety and was crying due to an ill family member. The resident was medicated with [MEDICATION NAME] (anti-anxiety medication). At 11:00 AM, the resident was noted to have increased anxiety and did not want to get out of bed. The resident stated her mother was sick and in the hospital. The resident was medicated with [MEDICATION NAME]. A Nurse's Note from 7/10/2015 at 6:20 PM revealed that the resident was noted crying when the nurse entered her/his room. The resident stated she was crying because she wants to go home but there was no one at home that could take care of her. She/he also stated his/her kidney doctor had given him/her bad news. The resident was comforted by staff and given [MEDICATION NAME]. On 7/25/2015 at 1:30 AM, the resident was noted to be crying and stated she was upset. The resident did not give a reason why she/he was upset. The nurse documented that [MEDICATION NAME] was given for the crying episode. On 7/25/2015 at 9:30 AM, the resident was noted to be crying and upset and stated, I just want to go home. The resident was medicated with [MEDICATION NAME]. Record review of the Care Plan on 07/28/2015 at 3:31 PM revealed that the resident's Depression, [MEDICAL CONDITION], and Anxiety were care planned, but the Care Plan was not reviewed and revised after the resident was assessed with [REDACTED]. During an interview with the SSD on 07/28/2015 at 3:43 PM, the SSD was informed there was no documentation to indicate that the resident received a psych eval related to increased depression per her/his quarterly assessment on 5/6/2015. The SSD states she/he would have to look at the psych consults to see if the appointment had been made for the resident. During an interview with the SSD on 07/29/2015 at 8:54 AM, the SSD confirmed that the resident did not get the psych eval. The SSD stated that psych appointments were made by the MDS (Minimum Data Set) nurse and that an appointment was not made for the resident. The SSD stated that several psych appointments were made on 5/7/2015, but not for Resident #38. The SSD director also confirmed that the Care Plan had not been reviewed and revised related to the increased depression and need for a psych consult. The facility admitted Resident #74 with [DIAGNOSES REDACTED]. Review of the social service notes on 7/28/2015 at approximately 3:24 PM states,Resident has a history of disrobing and throwing himself in the floor, kicking, yelling, screaming and becomes combative at times. An interview on 7/29/2015 at approximately 9:28 AM revealed that he/she did not know that Resident #74 was not being followed by Mental Health per his/her family. The medical record contained only one evaluation dated 2/17/2015. The social worker continued to list Resident #74 on the list to be seen by mental health. The list of residents to be seen by mental health had a note beside resident #74, and states not seen per PCP requests. During an interview on 7/30/2015 at approximately 9:16 AM with the Nurse Manager of the Home, he/she stated, this resident does not see the psychiatrists because his/her family does not think he/she needs to. During an interview on 7/30/2015 at approximately 10:25 AM with the Licensed Social Worker Consultant, he/she stated, The facility has finally gotten this resident to the place he/she is doing better. He/she also stated the resident's family will not agree to a lot of interventions that the resident could possibly benefit from. When asked if the facility had any written documentation where the family was counseled, the response indicated this had not been done as of this date. An interview on 7/30/2015 at approximately 12:25 PM with the Nurse Practitioner verified that the family had called the Psychiatrist and stated he/she did not want this resident seen by them anymore. He/she thinks this resident does not have any behaviors. The Nurse Practitioner stated, We are trying to give a combination of medications that will keep him/her from hurting himself/herself and others. No documentation could be found in Resident #74's medical record to ensure this issue was discussed with the family and Psych services were denied by the family. An interview on 7/30/2015 at approximately 2:29 PM with the Medical Director and physician for Resident #74, he/she stated, This resident's behavior has been better with less episodes of impulsive behaviors. He/she also stated that he/she is not sure that this resident would benefit form psych services. He/she went on to say, that if anything changes with the resident he/she would be open to getting a psych consult or sending him/her out for a psych evaluation. He/she stated as for now this resident is doing well with the present medication regime. Review on 7/30/2015 at approximately 3:00 PM of the Clinical Summaries dated 1/7/2015 states, .continues to have behavior issues and outbursts. Medication tweaked, increased and changed. Can be combative. Anxious and verbally abusive. Family will not let Mental Health evaluate. The clinical summary dated 2/11/2015 states, .continues to have behavior issues and outbursts. Can yell and cuss at staff. Needs constant redirection and monitoring. The clinical summary dated 5/20/2015 states, .has been combative and abusive with staff. Crawling out of bed. Tore off some of his/her right big toe nail. Family has refused mental health evaluation in the past. The clinical summary dated 5/21/2015 states, seeing patient to follow up on behaviors. Had been well managed but had difficulties this weekend. The clinical summary dated 6/15/2015 states, Has had increasingly agitation and behavior issues. Also had a couple of falls where he/she throws themselves out of the geri chair. Recommended mental health for evaluation but family is against by reports. Review on 7/30/2015 at approximately 3:28 PM of the facility policy titled, Behavior Management Program, under Purpose states, Residents who display mental and psychosocial adjustment difficulty should receive appropriate services in an attempt to correct the problem. The facility admitted Resident #79 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#79 was not seen by the psychiatrists until 3/16/2015. Review of the psych consult scheduling book on 7/31/2015 at approximately 9:35 AM revealed a visit from the Psychiatrist on 3/16/2015, 5/11/2015, and 5/21/2015. An interview on 7/31/2015 at approximately 10:30 AM with the Social Services Worker, he/she verified that Resident #7 had a physician's orders [REDACTED]. He/she also verified that Resident #79 had not been seen by the psychiatrist until 3/16/2015. Review of a fax on 7/31/2015 at approximately 1:22 PM dated 7/31/2015 revealed Resident #79 was not seen by the Psychiatrists until 3/16/2015. No records were found dating back to 2014. On 7/30/15 at approximately 5:20 PM, the Administrator and Director of Nursing was notified that Immediate Jeopardy and/or Substandard Quality of Care existed. 483.54 (a) Provision of Services, F-406 was identified as Immediate Jeopardy at a scope and severity of L. The Immediate Jeopardy and/or Substandard Quality of Care was not removed at the time the surveyors completed the Recertification and Extended Survey.

Based on record reviews, interviews and review of facility policies, the facility Administration failed to implement its resources effectively and efficiently to attain or maintain the highest practicable mental and psychosocial well being for Resident #32, #38, #74, & #79, who did not receive mental health services timely. The facility further failed to identify additional residents who did not receive medically related social services through effective coordination of mental health services (Residents #25, #35, #57, #58, #62, #77, #82, & #116). The findings included: Cross Refer Social Services, F-250. The facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility failed to adequately assess, monitor and evaluate Resident #32's psychosocial needs related to a physician's orders [REDACTED]. A psychological evaluation was ordered 9/10/14 and there was no documentation to indicate services were provided until 1/12/15; failed to ensure the physician was notified of an increase in depression score and a recommendation for a psych evaluation for Resident #38; Resident #74 exhibiting inappropriate behaviors failed to have consistent coordination of care with facility staff, mental health staff, physician and the responsible party to ensure appropriate treatment was administered; Resident #79, with a physician's orders [REDACTED].#25, #35, #57, #58, #62, #77, # 82, & #116 noted with [DIAGNOSES REDACTED]. Care Plan, F-280. The facility failed to update, review and revise Resident #32, #25, #35, #38, #57, #58, #62, #77, & #116's Plan of Care related to physician ordered mental health services to include goals and coordination of care interventions. Provision of Services, F-406. The facility failed to ensure that physician ordered mental health services were provided timely and/or coordinated as part of the plan of care for Residents #32, #38, #74, & #79. Cross refers to F-520 Quality Assurance. The facility failed to ensure the Quality Assurance process was utilized to identify, clarify, and implement a plan of action related to medically related social services being coordinated and implemented timely to ensure the residents receive mental health services as ordered. On 7/30/15 at approximately 5:20 PM, the Administrator and Director of Nursing was notified that Immediate Jeopardy and/or Substandard Quality of Care existed. 483.75 Effective Administration, F-490 was identified as Immediate Jeopardy at a scope and severity of L related to the failure of the Administration to identify that physician's orders [REDACTED]. The Immediate Jeopardy and/or Substandard Quality of Care was not removed at the time the surveyors completed the Recertification and Extended Survey.

Based on interview, review of facility policy and record review, the Medical Director failed to ensure implementation of facility policies and coordinate mental health services in an effective and efficient manner to maintain the highest practicable physical, mental, and psychosocial well-being for residents in the facility with physician ordered psychological evaluations and treatment for 12 of 12 residents reviewed for mental health services. The findings included: Cross Refer Social Services, F-250. The facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility failed to adequately assess, monitor and evaluate Resident #32's psychosocial needs related to a physician's order for mental health services that was not provided timely. A psychological evaluation was ordered 9/10/14 and there was no documentation to indicate services were provided until 1/12/15; failed to ensure the physician was notified of an increase in depression score and a recommendation for a psych evaluation for Resident #38; Resident #74 exhibiting inappropriate behaviors failed to have consistent coordination of care with facility staff, mental health staff, physician and the responsible party to ensure appropriate treatment was administered; Resident #79, with a Physician's order for a Psych eval related to a gradual dose reduction of medication, failed to be evaluated until 6 months after the order; Resident #25, #35, #57, #58, #62, #77, # 82, & #116 noted with [DIAGNOSES REDACTED]. Cross refer Provision of Services, F-406. The facility failed to ensure that physician ordered mental health services were provided timely and/or coordinated as part of the plan of care for Residents #32, #38, #74, & #79. Cross refers to F-520 Quality Assurance. The facility failed to ensure the Quality Assurance process was utilized to identify, clarify, and implement a plan of action related to medically related social services coordination and timely implementation of care to ensure the residents receive mental health services as ordered. The facility admitted Resident #32 with [DIAGNOSES REDACTED]. During an interview on 7-30-15 at approximately 2:21PM, the Medical Director stated, I was not made aware of the mental health issues for Resident #32. The Nurse Practitioner comes to the facility to see residents at least 2 times a week. I am not aware of the mental health issues that Resident #32 is having about panic attacks. I do not know why [MEDICATION NAME] was ordered for the resident on July 8, 2015 by the Nurse Practitioner for anxiety. The Physician had not been told about the resident having panic attacks or wanting help for anxiety and panic attacks. The staff did not inform me about the resident and that there was a lack of coordination of mental health services. Review of the facility policy on August 5, 2015, at 2:30PM on Behavior Management Program revealed The physician should be informed of a change in the resident's condition and new orders should be documented'. On 7/30/15 at approximately 5:20 PM, the Administrator and Director of Nursing was notified that Immediate Jeopardy and/or Substandard Quality of Care existed Responsibilities of the Medical Director, F-501 was identified as Immediate Jeopardy at a scope and severity of L related to the failure of the Medical Director to ensure coordination and implementation of care for residents requiring mental health evaluations. The Immediate Jeopardy and/or Substandard Quality of Care was not removed at the time the surveyors completed the Recertification and Extended Survey.

Based on record reviews, interviews and review of facility policies the facility failed to identify quality deficiencies to ensure medically related Social Services were provided timely and consistently. The facility failed to identify, clarify, and implement a plan of action related to physician's orders [REDACTED]. Medically related Social Services failed to implement, coordinate and ensure mental health services were provided as needed. The findings included: Cross Refer Social Services, F-250. The facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility failed to adequately assess, monitor and evaluate Resident #32's psychosocial needs related to a physician's orders [REDACTED]. A psychological evaluation was ordered 9/10/14 and there was no documentation to indicate services were provided until 1/12/15; failed to ensure the physician was notified of an increase in depression score and a recommendation for a psych evaluation for Resident #38; Resident #74 exhibiting inappropriate behaviors failed to have consistent coordination of care with facility staff, mental health staff, physician and the responsible party to ensure appropriate treatment was administered; Resident #79, with a physician's orders [REDACTED].#25, #35, #57, #58, #62, #77, # 82, & #116 noted with [DIAGNOSES REDACTED]. Cross Refer Care Plan, F-280. The facility failed to update, review and revise Resident #32, #25, #35, #38, #57, #58, #62, #77, & #116's Plan of Care related to physician ordered mental health services to include goals and coordination of care interventions. Cross Refer Provision of Services, F-406. The facility failed to ensure that physician ordered mental health services were provided timely and/or coordinated as part of the plan of care for Residents #32, #38, #74, & #79. Based on record reviews and interviews, the facility failed to identify a concern related to physician ordered mental health services not being provided timely and consistently. There was no coordination of services through medically related social services and Care Plans were not completed, reviewed or revised as needed with changes identified in resident behavior or mood related to mental health issues. During an interview on 07/31/15 at approximately 2:19 PM, the facility Administrator, Director of Nursing, Facility Consultant and Charge Nurse confirmed the facility had not identified that medically related social services was not provided timely and/or consistently due to lack of coordination and system failure. On 7/30/15 at approximately 5:20 PM, the Administrator and Director of Nursing was notified that Immediate Jeopardy and/or Substandard Quality of Care existed. 483.75(o) F-520 Quality Assurance was identified at a scope and severity level of L. The facility failed to ensure the Quality Assurance process was utilized to identify, clarify, and implement a plan of action related to residents requiring Mental health services and to ensure these services were coordinated appropriately and care needs were implemented timely. The Immediate Jeopardy and/or Substandard Quality of Care was not removed at the time the surveyors exited the facility.

Based on review of facility files and interview, the facility failed to ensure services provided meet professional standards of quality. Resident #2 displayed signs of pain on 8/4/14 and there was no documentation the resident was assessed by the nurse until 8/5/14. One of two residents reviewed for fractures. The findings included: The facility submitted a reportable incident to the State Agency on 8/6/14 for Resident #2. Resident #2 was noted to have a tibial plateau fracture. Review of the Five-Day Follow-Up Report dated 8/13/14 revealed Resident #2 sustained a fracture that was not reported by the Certified Nurse Aide (CNA). Licensed Practical Nurse (LPN) #1 was made aware of the resident's complaints of pain, but failed to report, document, or notify the physician. Review of the Physician Clinical Summary dated 8/5/14 completed by the nurse practitioner revealed Resident #2 complaints of right hip/knee pain per staff. Examination revealed the right knee had inflammation, warmth and [DIAGNOSES REDACTED]. Tenderness to palpation was noted over the entire knee. Review of the physician's orders [REDACTED].#2's right tibia and right fibula. The last order prior to this order was dated 6/5/14. Review of the Nurses' Notes dated 8/5/14 at 7:30 AM revealed the Certified Nurse Aide (CNA) called the nurse into Resident #2's room. The nurse noted the resident had increased agitation and was yelling out. LPN #1 and LPN #2 were in the room and assessed the resident. Resident #2 was noted to yell out in pain when his/her right leg and hip area were touched. The CNA stated that Resident #2 allowed him/her to perform care to their upper body and left side. Resident #2 started yelling out when the CNA attempted to turn the resident over touching the right hip area. The nurse noted swelling to the right thigh and leg. Further review revealed there were no Nurses' Notes documented for 8/4/14. Review of Resident #2's August Medication Administration Record [REDACTED]. LPN #1's facility-obtained statement indicated CNA #3, the 3:00 - 11:00 PM CNA, told him/her Resident #2 was acting like his/her side was hurting at approximately 10:50 PM on 8/4/14. LPN #1 told CNA #2, the 11:00 PM - 7:00 AM CNA, to pay attention to the resident and see if the resident acted like s/he was in any pain or discomfort. CNA #2 informed LPN #1 that it seemed like Resident #2 was hurting at approximately 5:30 AM. CNA #2 stated Resident #2's right knee looked like it was swollen. CNA #3's facility-obtained statement indicated on 8/4/14 s/he went into Resident #2's room to give care. As s/he reached over the resident to pull the resident toward him/her the resident started to scream. In an interview with the surveyor on 9/24/14 at approximately 3:12 PM, CNA #3 stated s/he worked the 3-11 shift on 8/4/14. CNA #3 stated it was approximately 4:30 PM when s/he went to Resident #2's room to give care. CNA #3 asked Resident #2 if s/he was hurting and the resident nodded yes. The CNA asked where and the resident pointed to his/her right side. CNA #3 stated s/he did not talk with the 7:00 AM - 7:00 PM nurse about the resident yelling out while providing care. CNA #3 stated s/he told the 7:00 PM - 7:00 AM nurse about Resident #2 yelling out at approximately 9:30 PM. CNA #2's facility-obtained statement indicated that s/he told LPN #1 the resident's knee was swollen and the resident yelled out when turning over. CNA #2 told LPN #1 about Resident #2 after finishing his/her rounds. In a telephone interview with the surveyor on 10/1/14 at approximately 10:18 AM, CNA #2 stated that when s/he changed Resident #2 the resident yelled out. CNA #2 noted the resident's knee was swollen. CNA #2 stated that the first time s/he provided care to Resident #2 was between 4:00-6:00 AM. LPN #2's facility-obtained statement indicated s/he worked the 7:00 AM - 7:00 PM shift on 8/4/14 and was not aware in any change in Resident #2's condition. LPN #2 was called into the resident's room on 8/5/15 at 7:30 AM and noted the resident had increased agitation and was yelling out. LPN #2 noted swelling to the resident's right thigh and leg. LPN #2 notified the nurse practitioner about the resident's condition at approximately 10:15 AM. In a telephone interview with the surveyor on 10/1/14 at approximately 10:47 AM, LPN #2 stated that LPN #1 told him/her Resident #2 was fussier but was not sure if the resident was in pain. LPN #2 heard Resident #2 yell out and was called to the room by the CNA. LPN #2 assessed the resident and noted the resident was experiencing pain when moved. In an interview with the surveyor on 9/25/14 at approximately 1:45 PM, the Director of Nursing (DON) stated that Resident #2's pain was identified at approximately 7:00 AM on 8/5/14. The DON started an investigation and found that both CNA #2 and CNA #3 reported Resident #2's complaints of pain to LPN #1. The DON stated that when questioned LPN #1 stated s/he checked on Resident #2. Resident #2 was sleeping so LPN #1 didn't think the resident could be in pain.

Based on review of facility files and interviews, the facility failed to provide each resident the necessary care and services to maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Resident #2 was noted to display signs of pain and the Certified Nurse Aide did not tell the nurse until five hours later. The nurse did not complete an assessment of the resident upon being notified the resident was displaying signs of pain. One of two residents reviewed for fractures. The findings included: The facility submitted a reportable incident to the State Agency on 8/6/14 for Resident #2. Resident #2 was noted to have a tibial plateau fracture. Review of the Five-Day Follow-Up Report dated 8/13/14 revealed Resident #2 sustained a fracture that was not reported by the CNA. LPN #1 was made aware of complaints of pain, but failed to report, document, or notify the physician. Review of the Clinical Summary dated 8/5/14 completed by the nurse practitioner revealed Resident #2 had complaints of right hip/knee pain per staff. Examination revealed the right knee had inflammation, warmth and [DIAGNOSES REDACTED]. Tenderness to palpation was noted over the entire knee. Review of the physician's orders [REDACTED].#2's right tibia and right fibula. The last order prior to this order was dated 6/5/14. Review of the Nurses' Notes dated 8/5/14 at 7:30 AM revealed the Certified Nurse Aide (CNA) called the nurse into Resident #2's room. The nurse noted the resident had increased agitation and was yelling out. Licensed Practical Nurse (LPN) #1 and LPN #2 were in the room and assessed the resident. Resident #2 was noted to yell out in pain when his/her right leg and hip area were touched. The CNA stated that Resident #2 allowed him/her to perform care to their upper body and left side. Resident #2 started yelling out when the CNA attempted to turn the resident over touching the right hip area. The nurse noted swelling to the right thigh and leg. Further review revealed there were no Nurses' Notes documented for 8/4/14. Review of Resident #2's August Medication Administration Record [REDACTED]. Review of Resident #2's care plan revealed at risk for alteration in comfort was identified as a problem area. Approaches for the problem were noted on the care plan and included to assess resident's level of pain and document and administer medication as ordered/ needed. LPN #1's facility-obtained statement indicated CNA #3 told him/her Resident #2 was acting like his/her side was hurting at approximately 10:50 PM on 8/4/14. LPN #1 told CNA #2 to pay attention to the resident and see if the resident acted like s/he was in any pain or discomfort. CNA #2 informed LPN #1 that it seemed like Resident #2 was hurting at approximately 5:30 AM. CNA #2 stated Resident #2's right knee looked like it was swollen. CNA #3's facility-obtained statement indicated on 8/4/14 s/he went into Resident #2's room to give care. As s/he reached over the resident to pull the resident toward him/her the resident started to scream. In an interview with the surveyor on 9/24/14 at approximately 3:12 PM, CNA #3 stated s/he worked the 3-11 shift on 8/4/14. CNA #3 stated it was approximately 4:30 PM when s/he went to Resident #2's room to give care. CNA #3 asked Resident #2 if s/he was hurting and the resident nodded yes. The CNA asked where and the resident pointed to his/her right side. CNA #3 stated s/he did not talk with the 7:00 AM - 7:00 PM nurse about the resident yelling out while providing care. CNA #3 stated s/he told the 7:00 PM - 7:00 AM nurse about Resident #2 yelling out at approximately 9:30 PM. CNA #3 stated s/he did not see the 7-3 shift CNA during shift change. CNA #3 stated they are supposed to do report but that they don't always. CNA #2's facility-obtained statement indicated that s/he told LPN #1 the resident's knee was swollen and the resident yelled out when turning over. CNA #2 told LPN #1 about Resident #2 after finishing his/her rounds. In a telephone interview with the surveyor on 10/1/14 at approximately 10:18 AM, CNA #2 stated that when s/he changed Resident #2 the resident yelled out. CNA #2 noted the resident's knee was swollen. CNA #2 stated that the first time s/he provided care to Resident #2 was between 4:00-6:00 AM. LPN #2's facility-obtained statement indicated s/he worked the 7:00 AM - 7:00 PM shift on 8/4/14 and was not aware in any change in Resident #2's condition. LPN #2 was called into the resident's room on 8/5/15 at 7:30 AM and noted the resident had increased agitation and was yelling out. LPN #2 noted swelling to the resident's right thigh and leg. LPN #2 notified the nurse practitioner of the resident's change in condition at approximately 10:15 AM. In a telephone interview with the surveyor on 10/1/14 at approximately 10:47 AM, LPN #2 stated that LPN #1 told him/her Resident #2 was fussier but was not sure if the resident was in pain. LPN #2 heard Resident #2 yell out and was called to the room by the CNA. LPN #2 assessed the resident and noted the resident was experiencing pain when moved.

Based on review of facility files and interviews, the facility failed to ensure that each resident received adequate supervision to prevent accidents. Resident #2 and Resident #4 were transferred without appropriate staff assistance which resulted in fractures for both residents. 2 of 2 residents reviewed for fractures. The findings included: The facility submitted a Reportable Incident to the State Agency for Resident #2 on 8/6/14. Resident #2 was noted to have a tibial plateau fracture. Review of Resident #2's medical record revealed a Nurses' Note dated 8/5/14 that indicated the Certified Nurse Aide (CNA) called the nurse into Resident #2's room and the nurse noted increased agitation and yelling out. The nurse assessed the resident and noted the resident yelling out in pain when his/her right leg and hip area were touched. The nurse noted swelling to the right thigh and leg. Review of the Clinical Summary completed by the nurse practitioner on 8/5/14 revealed Resident #2 had complaints of right hip/knee pain per staff. Staff was unsure of any recent injuries or falls, but the resident reported a fall that occurred yesterday. Resident #2 was unable to rate the pain or describe due to global aphasias, however the resident was able to respond yes or no to simple closed ended questions. Review of the hospital final report dated 8/6/14 revealed Resident #2 had a right tibial plateau fracture. Review of the facility's Five-Day Follow-Up Report dated 8/13/14 indicated that it was discovered that Resident #2's assigned CNA failed to use the hoyer lift with 2 person assist during transfer. Per the resident the CNA dropped him/her on the floor. The CNA failed to report the incident to the nurse. LPN #1's facility-obtained statement indicated on 8/4/14 CNA #3 told him/her at approximately 11:00 PM Resident #2 was acting like his/her side was hurting. LPN #1 told the 3rd shift CNA to monitor the resident when s/he changed the resident to see if s/he acted like s/he was in any pain or discomfort. At approximately 5:30 PM the 3rd shift CNA said it seemed like Resident #2 was hurting on his/her right hip or knee and that the knee looked like it was swollen. CNA #2's facility-obtained statement dated 8/8/14 indicated s/he worked with Resident #2 on 8/4/14. The nurse informed him/her that the previous CNA said the resident was acting strange and yelling out. CNA #2 noted the resident's knee was swollen and s/he yelled when turned. LPN #2's facility-obtained statement indicated on 8/5/14 s/he was called into the resident's room by the CNA. Resident #2 was noted with increased agitation and yelling. Upon observation the nurse noted swelling to the right thigh and leg. Resident #2 was also noted to yell out when his/her right side was touched to perform morning care. The nurse noted the resident to only be in pain when being moved around. CNA #3's facility-obtained statement dated 8/6/14 indicated that on 8/4/14 s/he went to Resident #2's room to provide care. The resident was already in the bed. Resident #2 yelled out before s/he touched the resident. CNA #3 asked the resident if s/he was hurting and the resident nodded yes. CNA #3 asked her where s/he was hurting and the resident pointed to his/her stomach and side. In an interview with the surveyor on 9/24/14 at approximately 3:12 PM, CNA #2 confirmed the accuracy of his/her statement as written. CNA #3 indicated she worked 3:00 PM - 11:00 PM on 8/4/14. CNA #3 stated s/he worked with the resident that previous weekend on Saturday and Sunday and Resident #2 was not yelling out with care. CNA #4's facility-obtained statement dated 8/8/14 indicated s/he worked 7:00 AM until 3:00 PM on 8/4/14. CNA #4 indicated s/he did not assist with transferring Resident #2. In an interview with the surveyor on 9/24/14 at approximately 1:55 PM, CNA #4 confirmed the accuracy of his/her statement as written. CNA #4 stated s/he did not have any contact with Resident #2 on 8/4/14. CNA #4 stated s/he did not assist CNA #1 with the resident. CNA #4 stated that CNA #1 sent him/her a text message and told him/her s/he had used his/her name in his/her statement. CNA #1's facility-obtained statement dated 8/6/14 indicated s/he worked with Resident #2 on 8/4/14. CNA #1 got the resident out of the bed and CNA #4 was in the room to assist him/her in the morning. Then around 2:00 s/he put the resident back to bed and CNA #4 was in the room again to assist him/her. The facility submitted a Reportable Incident to the State Agency for Resident #4 on 9/10/14. Resident #4 was noted to have a left femur fracture with minimal displacement. Review of the Five -Day Follow-Up Report dated 9/16/14 indicated Resident #4 was being transferred by CNA #5 on 9/8/14. Resident #4 lost their balance and CNA #5 was unable to prevent the resident from falling. Review of the Corrective Action Form for CNA #5 reveled the employee failed to maintain safety precautions with transferring a resident. As a result, the resident was transferred with the assistance of one employee instead of two. The resident sustained [REDACTED]. Resident #4 was admitted to the facility on [DATE]. Review of the Nursing Admission Screen dated 8/28/14 revealed the transfer section of the assessment was not completed. Review of Resident #4's Plan of Care Kardex for September 2014 revealed the transfer section indicated the resident required assist of 1 person. The form was provided to the surveyor on 9/25/14 and was initialed by staff from 9/1-9/25/14. Review of the resident's Initial Minimum (MDS) data set [DATE] revealed the resident required extensive assistance with assist of two people for transfers. In an interview with the surveyor on 9/25/14 at approximately 2:20 PM, the Director of Nursing (DON) stated that Resident #4 was a two person assist at the time of the incident on 9/8/14.

On the days of the complaint and extended survey, based on record review and interview, the facility failed to ensure that the resident environment remains free of accident hazards as is possible; and each resident received adequate supervision to prevent accidents. Resident #4 was found with a lighter on 12/8/13 and was observed by the staff outside smoking unsupervised behind the facility at night on 11/14/13 and 12/9/13. One of 17 residents reviewed for smoking. The findings included: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Initial Minimum Data Set coded Resident #4 as having a Brief Interview for Mental Status (BIMS) of "15". Resident #4 coded as requiring extensive assistance with transfers, dressing, hygiene, bathing and s/he used a motorized wheelchair for ambulation. Review of Resident #4's Medication Administration Record (MAR) on 12/9/13 revealed an audit sheet that included "any smoking items noted?" and was initiated on 11/26/13. At the top of the sheet was typed Audit Sheet for (Resident #4) and please complete every shift. Review of the form revealed the form was completed on the following dates and times: 11/26/13 at 4 PM; 11/27/13 at 6 AM, 5 PM and 11 PM; 11/28/13 at 5 PM and 9 PM; 11/29/13 at 9 PM; 11/30/13 at 5 PM; 12/1/13 at 10 PM; 12/2/13 at 5 PM and 10 PM; 12/3/13 at 5 PM; 12/4/13 at 5 PM and 11 PM; 12/5/13 at 11 PM and 4 PM; 12/6/13 5 PM; 12/7/13 at 1 AM, 5 PM and 10 PM; 12/8/13 at 1230 AM, 5 PM and 9 PM; and 12/9/13 at 11:30 PM. Further review of the form revealed an entry on 12/8/13 at 12:30 AM "smelled smoke" and "stated was last cigarette." During an interview with the surveyor on 12/9/13 at approximately 3:10 PM, the Director of Nursing (DON) stated that Resident #4 was found smoking behind the building by staff, not in the designated smoking area (unknown date). The nurse went out and talked with the resident to educate him/her about the smoking schedule. The resident was found behind the building by staff a second time on 11/14/13 and the Administrator, DON and Social Worker talked with him/her about the incident. Resident #4 read and signed the smoking policy on 11/15/13 and said s/he understood. Review of the resident's care plan revealed at risk for injury related to smoking (can be noncompliant with smoking rules at times) was identified as a problem area on 11/6/13. Interventions and approaches to this problem area were documented on the care plan and included to enforce safe smoking per policy and keep cigarettes and lighter in locked location. The interventions on Resident #4's care plan were updated on 11/15/13 and 11/26/13. The intervention on 11/15/13 was to re-educate the resident on the smoking policy. The interventions on 11/26/13 were to discuss the smoking policy with visitors as needed, encourage family to assist facility with smoking policy compliance and nurses to observe resident for smoking material. Review of the Nurse's Notes on 11/14/13 at 1:40 AM revealed "Res(ident) up in motorized w/c (wheelchair) @ this time, went to back door, turned off alarm on door and was sitting in w/c on sidewalk. Explained to resident that s/he cannot be outside in backyard at night because it is unsafe, that if s/he wants to go outside s/he may go on front porch. Res(ident) on front porch at this time." Review of an Incident Report dated 11/14/13 at 1:40 AM indicated "Resident noted sitting in w/c (wheelchair) on side walk behind building without assist/ supervision." The intervention implemented to prevent recurrence was "Resident educated on alerting staff the need to go outside for supervision." During an interview with the surveyor on 12/10/13 at approximately 12:10 PM, the Director of Nursing stated there was no Incident Report completed for Resident #4 smoking behind the building on 11/14/13. The Incident Report completed only addressed the resident being outside at 1:40 AM. Review of the Safe Smoking Program form signed by Resident #4 on 11/15/13 indicated s/he had the smoking policy and safe smoking program reviewed with him/her. The form included "1. All lighters and/ or matches will be kept at the nurses' desk in a box and not in my room. 2. I will only smoke in the designated smoking area at the designated smoking times with a facility staff member present to supervise. 3. I will wear a smoking apron while smoking. 4. My room shall be inspected for smoking materials as supervision deems necessary. All such materials shall be removed from my room, inventoried and kept in a secured location at the nurses' desk. 5. I understand the risks and hazards not only to myself but to the other residents associated with non compliance to the program..." Review of the Nurse's Notes from 11/24/13 through 12/9/13 revealed the following: 11/24/13 as a late entry for 11/23/13 at 4:15 AM indicated "During resident assessment after fall this nurse noted cigarette lighter on floor near resident. Cigarette lighter removed from room and secured by this nurse...". 11/25/13 at 4:20 PM revealed an entry by the facility's administrator "Resident's RP (responsible party) contacted related to resident not following smoking policy. RP appreciated call and stated that s/he would speak with resident via telephone to encourage him/her on adhering to smoking policy." There was a Nurse's Note on 11/25/13 that indicated the resident was discussed during the Interdisciplinary Team meeting related to the resident attempting to ambulate unattended and fell . There was no documentation of discussion related to the lighter found on the resident. 12/8/13 at 1230 indicated "Medicated resident with PRN (as needed) pain med(ication)s and I smelled smoke. I asked him/her to give me the cigarettes and lighter and he replied "That was my last cigarette". S/he never acknowledged having the lighter." 12/9/13 at 10:20 PM indicated "Res(ident) observed going out back door - res(ident) stated when asked where s/he was going & s/he stated to find shoe s/he left outside & persisted to go outside - res(ident) kept in eye view & noted to pull out cigarette & lighter & light cigarette - res(ident) smoked 3 puffs & came back in facility - res(ident) followed to room & asked if staff could retrieve lighter & cigarettes - res(ident) stated s/he knew I was watching him/her - res(ident) gave staff the lighter s/he had but no cigarettes obtained - res(ident) educated on multiple occasions of smoking policy & risks - res(ident) alert & oriented x 3 - will cont(inue) to encourage res(ident) to follow smoking policy." Review of an Incident Report dated 12/9/13 at 10:30 PM indicated "Res(ident) noted out back smoking x 2 times. Went outside stating s/he left a shoe - resident kept in eye view & noted to light cigarette & take 3 puffs then put out." Witnesses listed on the Incident Report were Licensed Practical Nurse (LPN) #2 and LPN #3. The intervention implemented to prevent recurrence included "Re-educated resident on smoking policy & risks of smoking without supervision." During a telephone interview with the surveyor on 12/10/13 at approximately 3:14 PM, LPN #2 the Unit Manager for Home Unit, stated that s/he worked the night of 12/9/13 but was not assigned to Resident #4. LPN #3 was assigned to the resident that night. LPN #2 stated that LPN #3 observed Resident #4 go outside and come right back in. The resident later came up the hall and said s/he was going outside to get his/her shoe s/he left outside. The resident exited the facility through the therapy room door. LPN #2 stated that LPN #3 came to the 100 hall to find him/her to ask about getting Resident #4 back inside because it was so cold outside. LPN #2 stated that s/he was on the 100 hall and s/he and LPN #3 looked out the window of a resident's room and saw Resident #4 light a cigarette and take 3 puffs. LPN #2 did not remember the number of the room s/he and LPN #3 were in at the time. LPN #2 stated that s/he took off to go outside. As s/he came down the hall, Resident #4 was coming back inside. LPN #2 went to the resident's room to ask for the cigarettes and lighter. Resident #4 gave her/him the lighter. LPN #2 stated there were no cigarettes in the pocket with the lighter. LPN #2 stated that Resident #4 sometimes goes out to the smoking porch to use his/her cell phone. During an interview with the surveyor on 12/11/13 at approximately 12:01 PM, LPN #2 stated that when s/he looked out the window on 12/9/13 and saw Resident #4 smoking s/he did not see any staff outside with the resident. During a telephone interview with the surveyor on 12/10/13 at approximately 3:40 PM, LPN #3 stated that s/he was assigned to Resident #4 the night of 12/9/13. LPN #3 stated that the resident went toward the back door and outside. LPN #3 followed the resident outside and tried to get him/her to come back inside. Resident #4 came back inside after a few minutes. The resident came back and said s/he left his shoe outside. LPN #3 stated that s/he went to get LPN #2 to go with her/him to get Resident #4 to come back inside. LPN #3 was with LPN #2 on the 100 hall in a resident' room when they looked outside and saw Resident #4 light a cigarette. LPN #3 did not remember the number of the room they were in. When LPN #3 went to go outside to the resident s/he was already back inside. Resident #4 was out back at the employee smoking area off to the side of the building beside the therapy room. S/he was not at the resident's smoking area. LPN #2 and LPN #3 went and got the lighter from the resident when s/he came back inside. LPN #3 stated that s/he has talked to the resident before about not going outside at night by him/herself. LPN #3 stated that s/he found Resident #4 outside smoking by him/herself one time before. LPN #3 stated that it was documented in the Nurse's Notes and s/he did not remember the date. Review of the facility layout revealed that the 100 hall was parallel to the area where Resident #4 was observed outside smoking. The area where the resident was observed smoking was visible from the back side of the 100 hall. Review of the facility layout revealed there was no exit door from the back side of the 100 hall that overlooked the area where the resident was smoking. The surveyor observed the Maintenance Director measure the distance from the 100 hall to the exit door in the Therapy room on 12/11/13 at approximately 12:05 PM. The distance from the entrance door to the 100 hall to the Therapy room exit door was noted to be 119 feet and it would take several minutes to reach the resident if necessary from where LPN's #2 and #3 were located. Review of the facility Safe Smoking Policy dated July 2013 revealed the policy included "...3. Residents who desire to smoke will be provided and encouraged to use a smoking apron. 4. Residents will be supervised by staff while smoking. 5. Residents are required to smoke in designated areas only. 6. Cigarettes and lighters will be kept locked at nurses' stations. No smoking materials will be allowed in a resident's room..." Review of the Scheduled Smoke Break Times provided by the Director of Nursing indicated the following times: 7:00 - 7:15 AM, 9:30 - 9:45 AM, 11:30 - 11:45 AM, 2:30 -2:45 PM, 4:00 - 4:15 PM, 6:30-6:45 PM and 9:00 - 9:15 PM. During a telephone interview with the surveyor on 12/10/13 at approximately 3:14 PM, LPN #2 Unit Manager for Home unit, stated that the smoking audit form on Resident #4's MAR was to be used if staff noted smoking material. Staff was not looking for/ searching for smoking materials. During a telephone interview with the surveyor on 12/10/13 at approximately 3:40 PM, LPN #3 stated that the smoking audit form was used if Resident #4 was seen with cigarettes or lighter. LPN #3 stated that when s/he was told about the audit s/he was told to write down if "see something, don't ask him/her and don't go plundering through his/her stuff". During an interview with the surveyor on 12/10/13 at approximately 4:30 PM, the DON stated that Resident #4 was educated on the smoking policy when s/he was admitted . The DON provided a copy of the facility Rules and Regulations related to smoking that was signed by the resident on admission. The DON stated that on 11/23/13 Resident #4 went out to the hospital after the fall so the nurse did not check the resident's room after finding the lighter. The DON stated that on 12/8/13 the nurse who smelled smoke did not search the resident's room to look for smoking materials. The DON stated that s/he would have asked the resident to search the room and if the resident said no s/he would monitor the resident closely and document it. There was no documentation that the resident was asked about a room search or monitored closely. The DON stated that s/he had told the nurses on the floor that if they need to search the resident's room s/he needs to be in the room. The DON said that staff should search the room if they suspect s/he had smoking materials. The DON stated that s/he did not know of any searches of Resident #4's room. No documentation provided by the facility documented any room searches for smoking materials. During an interview with the surveyor on 12/10/13 at approximately 10:25 AM, Certified Nurse Aide (CNA) #1 stated that the resident smoking area was located through the dining room and out the Therapy room door. It was noted by the surveyor that there was a porch outside the Therapy room door that was designated as the resident's smoking area. During an interview with the surveyor on 12/11/13 at approximately 11:35 AM, CNA #2 stated that while supervising smoke breaks Resident #4 wears the smoking apron and has never refused to wear or complained to her/ him about wearing it. During an interview with the surveyor on 12/11/13 at approximately 11:40 AM, Rehab Tech #1 stated that s/he often goes out to supervise smoke breaks for the residents. Rehab Tech #1 stated that Resident #4 never gives her/ him any problems with putting on the smoking apron. On 12/10/2013 at 5:00 PM the Administrator was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-323 and F-490 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 12/08/2013 related to Resident #1's smoking unsupervised as required per the facility policy. An Allegation of Compliance (AOC) was submitted by the facility on 12/10/2013. The actions listed in the AOC included the following: 12-10-13 Order for Wanderguard to be applied to Resident #4's wheelchair 12-10-13 Initiated Q (every) 15 minute checks 12-10-13 100% audit completed of smokers to check for screen, care plan, security of smoking materials, and resident checks for smoking materials 12-10-13/12-11-13 education initiated with staff on smoking policy and procedure; 100% of staff will be educated by 12-11-13. No staff member will be allowed to work until receiving this education on the smoking policy 12-10-13 IDT (Interdisciplinary Team) met and discussed the next intervention for resident: To contact the Ombudsman and responsible party for meeting date to discuss potential 30-day notice to discharge related to non-compliance 12-11-13 Left message for Ombudsman to contact Executive Director for meeting date 12-11-13 Medical Director met with the resident to discuss smoking policy and procedure 12-11-13 Letter drafted to send to families that residents are not allowed to have smoking materials (all materials to be kept secured in lock box with Nurse) (to be mailed 12-11/13) Allegation of Compliance completion date 12-11-13 Observations, interviews, and review of policy revealed the AOC submitted by the facility on 12/11/2013 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the policy regarding the resident's smoking at the facility. The Administrator was informed of this on 12/11/2013 at 5:45 PM. The Immediate Jeopardy at F-323 and F-490 were removed but the citation at F-323 and F-490 remained at a lower scope and severity of "D".

NOT CORRECTED On the days of the Follow-up and Extended survey, based on record review and interview, the facility failed to ensure that the resident environment remains free of accident hazards as is possible; and each resident received adequate supervision to prevent accidents. The facility failed to be in compliance with the Plan of Correction (Completion date 12/18/2013) developed after the 12/11/2013 Complaint Survey that resulted in Immediate Jeopardy related to resident smoking hazards. Resident #4, cited in the 12/11/2013 survey, was observed unsupervised outside with a lighter on 1/18/14. One of 18 residents reviewed for smoking. The findings included: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Initial Minimum Data Set coded Resident #4 as having a Brief Interview for Mental Status (BIMS) of "15". Resident #4 was coded as requiring extensive assistance with transfers, dressing, hygiene, bathing and s/he used a motorized wheelchair for ambulation. Review of the resident's care plan revealed at risk for injury related to smoking (can be noncompliant with smoking rules at times) was identified as a problem area on 11/6/13. Interventions and approaches to this problem area were documented on the care plan and included to enforce safe smoking per policy and keep cigarettes and lighter in locked location. The interventions on Resident #4's care plan were updated on 12/10/13 to include wanderguard applied to wheelchair to alert staff of attempts to go out on smoking area without supervision. Resident #4's care plan was updated on 1/18/14 with resident noncompliant with smoking policy. Review of the Nurse's Notes on 1/18/14 at 11:20 AM indicated, "Resident observed in courtyard by RN (Registered Nurse) Supervisor "flicking a lighter". RN Supervisor immediately removed the lighter. No cigarette was observed. Resident returned inside the facility and received a body search & room search. DON (Director of Nursing) notified of event and Executive Director. Resident placed on 1:1 monitoring." Review of the Incident Report indicated that the incident happened on 1/18/14 at 11:20 AM. Review of the Social Progress Notes dated 1/18/14 at 2:44 PM indicated, "SW (Social worker) counseled with resident about failure to follow smoking policy as agreed. Resident stated that his visitor on 1/17/14 afternoon gave him (2) cigarettes and lighter. Resident was placed on 1:1 with nursing staff....". Review of Resident #4's Medication Administration Record (MAR) revealed wanderguard to wheelchair, check placement and function every shift. The MAR was signed for the 7 A-7P shift and 7P - 7 A shift every day in January. Observation of Resident #4 on 1/23/14 at 2:22 PM revealed a wanderguard attached to the resident's electric wheelchair. The wandergaurd was checked and was functioning. Review of the Audit Sheet for Resident #4 that was located in the Medication Administration Record indicated that on 1/18/14 during the 7 A - 7P shift no smoking items were noted. Review of the Safe Smoking Program form signed by Resident #4 on 11/15/13 indicated s/he had the smoking policy and safe smoking program reviewed with him/her. The form included "1. All lighters and/ or matches will be kept at the nurses' desk in a box and not in my room. 2. I will only smoke in the designated smoking area at the designated smoking times with a facility staff member present to supervise. 3. I will wear a smoking apron while smoking. 4. My room shall be inspected for smoking materials, as supervision deems necessary. All such materials shall be removed from my room, inventoried and kept in a secured location at the nurses' desk. 5. I understand the risks and hazards not only to myself but to the other residents associated with non compliance to the program..." Review of the facility Safe Smoking Policy dated July 2013 revealed the policy included "...3. Residents who desire to smoke will be provided and encouraged to use a smoking apron. 4. Residents will be supervised by staff while smoking. 5. Residents are required to smoke in designated areas only. 6. Cigarettes and lighters will be kept locked at nurses' stations. No smoking materials will be allowed in a resident's room..." Review of the Scheduled Smoke Break Times provided by the Director of Nursing indicated the following times: 7:00 - 7:15 AM, 9:30 - 9:45 AM, 11:30 - 11:45 AM, 2:30 -2:45 PM, 4:00 - 4:15 PM, 6:30-6:45 PM and 9:00 - 9:15 PM. In an interview with the surveyor on 1/23/14 at approximately 12:20 PM, the Director of Nursing and Executive Director (ED) stated that on 1/18/14 the weekend supervisor was in his/her car on a break. The weekend supervisor was coming back into the facility and observed Resident #4 flicking a lighter. Resident #4 was in the courtyard at the employee smoking area. The weekend supervisor called the DON and ED about the incident. Resident #4 was placed on 1:1 monitoring. Resident #4 was interviewed and stated that s/he received the lighter from a visitor. In an interview with the surveyor on 1/23/14 at approximately 2:30 PM, the ED stated that with the wanderguard the door alarms but does not lock. The ED stated that staff should have checked when Resident #4 exited the facility on 1/18/14. The ED stated that s/he did not ask staff about the door alarming when s/he talked with them about the incident. In an interview with the surveyor on 1/23/14 at approximately 2:30 PM, the DON said the door alarms if a code is not entered before it is opened. The DON stated that the door alarm and wandergaurd alarm would stop sounding at a certain point. On 1/23/2014 at 2:45 PM the Administrator was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-323 and F-490 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 1/18/2014 related to Resident #4's smoking unsupervised. FOLLOW-UP VISIT 2/16/2014 On 2/16/2014 an unannounced follow-up visit was made to evaluate the facility's Credible Allegation of Compliance (AOC) for the Immediate Jeopardy identified during a Complaint Survey Revisit. Actions listed included: Lighter removed from Resident #4 by Registered Nurse Supervisor immediately on 1/18/2014. Resident #4 did reveal the lighter was given to him by a visitor, but would not reveal a name or contact information. 1:1 staff supervision implemented 1/18/2014 immediately following the incident. Supervised visitation ongoing starting 1/18/2014. No visitors received from 1/18/2014 through discharge date of [DATE]. Body and Room search completed on Resident #4 by the Director of Nursing on 1/18/2014. Licensed nurses continued to complete room and body searches on Resident #4 from 1/18/2014 through 1/24/2014. Re-education completed by Executive Director and Director of Nursing related to smoking policy on 1/18/2014 with Resident #4. Thirty day letter of discharge issued to Resident #4 by Executive Director on 1/20/2014. Therapy assessing level of function (currently on caseload) on Resident #4 to determine appropriate discharge environment. Therapy assessment revealed that Resident #4 could be safely discharged to an independent community setting on 1/20/2014. Resident #4 was encouraged to increase participation in activities in the facility. Resident #4 was involved regularly in games, social events, exercises, conversation and music. Executive Director and Director of Nursing monitored Resident #4's 1:1 documentation weekly from 1/18/2014 through 1/24/2014. Resident #4 discharged from the facility on 1/24/2014. Residents who smoke have received weekly room and body searches by licensed nurses beginning 12/24/2013 and this will continue until 2/28/2014. Beginning March 2014 room and body searches will be completed monthly x3 months and quarterly x3 for residents residing at the facility that desire to smoke. Any resident that exhibits non-compliance with the facility smoking policy will receive re-education, 1:1 supervision, and supervised visitation until the facility determines resident is not at risk or resident is discharged from the facility. Re-education provided to staff by Executive Director, Director of Nursing, and the Corporate Clinical Team related to 1:1 observation, supervised visitation, smoking policy, and resident/room checks beginning on 1/18/2014 and will be ongoing. Smoking policy will be reviewed with the staff on a quarterly basis going forward by the Executive Director and/or Director of Nursing. Education regarding the revised smoking policy interventions has been reviewed with agency staff that is currently working at the facility by the Executive Director and will be reviewed with any agency staff scheduled to work going forward by the Manager on Duty. Newly hired licensed and non-licensed staff will receive this education during orientation. The door exit's security system was audited by Administrative facility staff and Corporate Clinical staff. The wanderguard system key pads are being updated. Three of the doors are completed and the remaining three have been ordered and will be installed upon delivery to the facility. The Clinical Corporate Team audited 100% of door alarms and all are functioning properly. The codes to the exit door alarms will be changed on a monthly basis by the Maintenance Director. 100% audit completed on the wanderguard and secure care bracelets by the Corporate Clinical Team and all were functioning properly. The wanderguard/secure care system will be audited and assessed by the Executive Director/Director of Nursing, and/or Maintenance Director weekly x4, monthly x3, and then quarterly to ensure proper functioning. Residents who smoke will have smoking policy and procedure reviewed with them during the quarterly care plan meetings starting with the next scheduled care plan meeting date by the MDS Nurse and/or Social Worker. Family members attending the care plan meeting will also receive education on the facility smoking policy. A copy of the letter mailed to families on 12/11/2013 discussing smoking policy compliance was added to the admission packet for future admissions starting with the next facility admission. The facility is currently not admitting any new residents. Signage was placed on entrance doors alerting visitors that residents can not keep smoking materials on their person or in the room and to please give all materials to the nurse on duty. The Smoking policy was revised to include the following: Failure to comply with the smoking program may result in discharge planning being implemented within the guidelines of federal regulations. Residents observed to be non-compliant with the facility smoking policy will receive 1:1 staff supervision and supervised visitation until facility deems resident not at risk or resident is discharged from the facility. Management to review placement of security camera monitors to ensure that they are in the best location to provide and monitor safety and security of the residents residing in the facility. The cameras will be moved if determined that a different location will allow for increased monitoring of security. Alleged Compliance Date: 1/28/2014 Findings included: Resident #4 was discharged to an Independent Living facility on 1/24/2014. Prior to discharge the resident had all smoking materials removed from his/her person. One to one staff supervision was implemented 1/18/2014 and remained until resident discharge. Resident #4 was educated again on 1/18/2014 about the facility smoking policy and a thirty day discharge notice was given to the resident on 1/20/2014. Resident #4 was assessed by physical therapy to ensure he/she could be safely discharged to an independent living community. Until discharge the facility did continue searches of the resident and his/her room for smoking materials. Residents in the facility identified as smokers received weekly room and body searches by licensed staff to continue through 2/24/2014. At the time of the visit all smokers were compliant with the policy. All staff received re-education on 1:1 observation, supervised visitation, smoking policy, and resident/room checks on 1/18/2014. Agency staff were included in the training. The smoking policy was reviewed with all residents identified as smokers and the policy was signed off and dated when reviewed. Family/responsible party members were also educated on the smoking policy. Exit doors were functioning properly. Signage related to smoking materials was posted on facility entrance doors and a letter was placed in the admission packet to inform any new residents of facility rules related to smoking. It was determined by the State Agency on the Follow-Up visit of 2/16/2014 that the AOC submitted by the facility on 2/12/2014 had been implemented and was in practices as of 1/28/2014, removing the immediacy of the deficient practice. The citations at F- 323 and F- 490 remained but were lowered in scope and severity to a "D". The facility will be in compliance with F-323 and F-490 when an acceptable Plan of Correction (POC) is submitted and a second follow-up visit is conducted to determine that the facility has implemented their POC.

On the days of the complaint and extended survey the facility Administration failed to implement it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility administration, failed to implement and follow up on imposed interventions related to Resident #4's failure to follow the facility smoking policy to smoke with supervision. Resident #4 was found with a lighter on 12/8/13 and was observed by the staff outside smoking unsupervised behind the facility at night on 11/14/13 and 12/9/13. The findings included: Resident #4 was found with a lighter on 12/8/13 and was observed by the staff outside smoking unsupervised behind the facility at night on 11/14/13 and 12/9/13. One of 17 residents reviewed for smoking. During an interview with the surveyor on 12/9/13 at approximately 3:10 PM, the Director of Nursing (DON) stated that Resident #4 was found smoking behind the building by staff, not in the designated smoking area (unknown date). The nurse went out and talked with the resident to educate him/her about the smoking schedule. The resident was found behind the building by staff a second time on 11/14/13 and the Administrator, DON and Social Worker talked with him/her about the incident. Resident #4 read and signed the smoking policy on 11/15/13 and said s/he understood. Resident #4 was noted to smell like smoke on 12/8/13 and stated s/he had smoked his/her last cigarette; s/he was observed on 12/9/13 outside at night smoking unsupervised. Cross Refers to the following citation: 483.25(k) Supervision to Prevent Accidents, F-323 was identified at Substandard Quality of Care and Immediate Jeopardy at a scope and severity of "J". The facility failed to provide the necessary care and services to prevent accidents and failed to provide the necessary supervision to a resident with a known history of smoking without the required supervision. Resident #1 was observed, suspected of smoking or with smoking materials at least 3 times with staff knowledge of the occurrences. Resident #4 was found with a lighter on 12/8/13 and was observed by the staff outside smoking unsupervised behind the facility at night on 11/14/13 and 12/9/13. The facility failed to provide random room checks to ensure no smoking materials were in the resident's possession. On 12/10/2013 at 5:00 PM the Administrator was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-323 and F-490 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 12/08/2013 related to Resident #1's smoking unsupervised as required per the facility policy. An Allegation of Compliance (AOC) was submitted by the facility on 12/10/2013. The actions listed in the AOC included the following: 12-10-13 Order for Wanderguard to be applied to Resident #4's wheelchair 12-10-13 Initiated Q (every) 15 minute checks 12-10-13 100% audit completed of smokers to check for screen, care plan, security of smoking materials, and resident checks for smoking materials 12-10-13/12-11-13 education initiated with staff on smoking policy and procedure; 100% of staff will be educated by 12-11-13. No staff member will be allowed to work until receiving this education on the smoking policy 12-10-13 IDT (Interdisciplinary Team) met and discussed the next intervention for resident: To contact the Ombudsman and responsible party for meeting date to discuss potential 30-day notice to discharge related to non-compliance 12-11-13 Left message for Ombudsman to contact Executive Director for meeting date 12-11-13 Medical Director met with the resident to discuss smoking policy and procedure 12-11-13 Letter drafted to send to families that residents are not allowed to have smoking materials (all materials to be kept secured in lock box with Nurse) (to be mailed 12-11/13) Allegation of Compliance completion date 12-11-13 Observations, interviews, and review of policy revealed the AOC submitted by the facility on 12/10/2013 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the policy regarding the resident's smoking at the facility. The Administrator was informed of this on 12/10/2013 at 5:45 PM. The Immediate Jeopardy at F-323 and F-490 were removed but the citation at F-323 and F-490 remained at a lower scope and severity of "D".

NOT CORRECTED On the days of the Follow-up and Extended survey the facility Administration failed to implement it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility administration, failed to implement and follow up on imposed interventions related to Resident #4's failure to follow the facility smoking policy to smoke with supervision. Resident #4 was found with a lighter on 1/18/14, 1 of 18 residents reviewed for smoking. The findings included: Resident #4 was found on 1/18/14 outside with a lighter unsupervised in the employee smoking area. During an interview with the surveyor on 1/23/14 at approximately 12:20 PM, the Director of Nursing (DON) and Executive Director stated that Resident #4 was found flicking a lighter. Resident #4 was outside unsupervised in the courtyard where employees smoke. Cross Refers to the following citation: 483.25(k) Supervision to Prevent Accidents, F-323 was identified at Substandard Quality of Care and Immediate Jeopardy at a scope and severity of "J". The facility failed to provide the necessary care and services to prevent accidents and failed to provide the necessary supervision to a resident with a known history of smoking without the required supervision. Resident #4 was observed, suspected of smoking or with smoking materials at least 1 time with staff knowledge of the occurrences. Resident #4 was found with a lighter on 1/18/14 outside in the employee smoking area. On 1/23/2014 at 2:45 PM the Administrator was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-323 and F-490 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 1/18/2014 related to Resident #4's smoking unsupervised as required per the facility policy.

NOT CORRECTED On the days of the Follow-up and Extended survey the facility Administration failed to implement it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility administration, failed to implement and follow up on imposed interventions related to Resident #4's failure to follow the facility smoking policy to smoke with supervision. Resident #4 was found with a lighter on 1/18/14, 1 of 18 residents reviewed for smoking. The findings included: Resident #4 was found on 1/18/14 outside with a lighter unsupervised in the employee smoking area. During an interview with the surveyor on 1/23/14 at approximately 12:20 PM, the Director of Nursing (DON) and Executive Director stated that Resident #4 was found flicking a lighter. Resident #4 was outside unsupervised in the courtyard where employees smoke. Cross Refers to the following citation: 483.25(k) Supervision to Prevent Accidents, F-323 was identified at Substandard Quality of Care and Immediate Jeopardy at a scope and severity of "J". The facility failed to provide the necessary care and services to prevent accidents and failed to provide the necessary supervision to a resident with a known history of smoking without the required supervision. Resident #4 was observed, suspected of smoking or with smoking materials at least 1 time with staff knowledge of the occurrences. Resident #4 was found with a lighter on 1/18/14 outside in the employee smoking area. On 1/23/2014 at 2:45 PM the Administrator was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-323 and F-490 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 1/18/2014 related to Resident #4's smoking unsupervised as required per the facility policy. FOLLOW-UP VISIT 2/16/2014 On 2/16/2014 an unannounced follow-up visit was made to evaluate the facility's Credible Allegation of Compliance (AOC) for the Immediate Jeopardy identified during a Complaint Survey Revisit. Actions listed included: Lighter removed from Resident #4 by Registered Nurse Supervisor immediately on 1/18/2014. Resident #4 did reveal the lighter was given to him by a visitor, but would not reveal a name or contact information. 1:1 staff supervision implemented 1/18/2014 immediately following the incident. Supervised visitation ongoing starting 1/18/2014. No visitors received from 1/18/2014 through discharge date of [DATE]. Body and Room search completed on Resident #4 by the Director of Nursing on 1/18/2014. Licensed nurses continued to complete room and body searches on Resident #4 from 1/18/2014 through 1/24/2014. Re-education completed by Executive Director and Director of Nursing related to smoking policy on 1/18/2014 with Resident #4. Thirty day letter of discharge issued to Resident #4 by Executive Director on 1/20/2014. Therapy assessing level of function (currently on caseload) on Resident #4 to determine appropriate discharge environment. Therapy assessment revealed that Resident #4 could be safely discharged to an independent community setting on 1/20/2014. Resident #4 was encouraged to increase participation in activities in the facility. Resident #4 was involved regularly in games, social events, exercises, conversation and music. Executive Director and Director of Nursing monitored Resident #4's 1:1 documentation weekly from 1/18/2014 through 1/24/2014. Resident #4 discharged from the facility on 1/24/2014. Residents who smoke have received weekly room and body searches by licensed nurses beginning 12/24/2013 and this will continue until 2/28/2014. Beginning March 2014 room and body searches will be completed monthly x3 months and quarterly x3 for residents residing at the facility that desire to smoke. Any resident that exhibits non-compliance with the facility smoking policy will receive re-education, 1:1 supervision, and supervised visitation until the facility determines resident is not at risk or resident is discharged from the facility. Re-education provided to staff by Executive Director, Director of Nursing, and the Corporate Clinical Team related to 1:1 observation, supervised visitation, smoking policy, and resident/room checks beginning on 1/18/2014 and will be ongoing. Smoking policy will be reviewed with the staff on a quarterly basis going forward by the Executive Director and/or Director of Nursing. Education regarding the revised smoking policy interventions has been reviewed with agency staff that is currently working at the facility by the Executive Director and will be reviewed with any agency staff scheduled to work going forward by the Manager on Duty. Newly hired licensed and non-licensed staff will receive this education during orientation. The door exit's security system was audited by Administrative facility staff and Corporate Clinical staff. The wanderguard system key pads are being updated. Three of the doors are completed and the remaining three have been ordered and will be installed upon delivery to the facility. The Clinical Corporate Team audited 100% of door alarms and all are functioning properly. The codes to the exit door alarms will be changed on a monthly basis by the Maintenance Director. 100% audit completed on the wanderguard and secure care bracelets by the Corporate Clinical Team and all were functioning properly. The wanderguard/secure care system will be audited and assessed by the Executive Director/Director of Nursing, and/or Maintenance Director weekly x4, monthly x3, and then quarterly to ensure proper functioning. Residents who smoke will have smoking policy and procedure reviewed with them during the quarterly care plan meetings starting with the next scheduled care plan meeting date by the MDS Nurse and/or Social Worker. Family members attending the care plan meeting will also receive education on the facility smoking policy. A copy of the letter mailed to families on 12/11/2013 discussing smoking policy compliance was added to the admission packet for future admissions starting with the next facility admission. The facility is currently not admitting any new residents. Signage was placed on entrance doors alerting visitors that residents can not keep smoking materials on their person or in the room and to please give all materials to the nurse on duty. The Smoking policy was revised to include the following: Failure to comply with the smoking program may result in discharge planning being implemented within the guidelines of federal regulations. Residents observed to be non-compliant with the facility smoking policy will receive 1:1 staff supervision and supervised visitation until facility deems resident not at risk or resident is discharged from the facility. Management to review placement of security camera monitors to ensure that they are in the best location to provide and monitor safety and security of the residents residing in the facility. The cameras will be moved if determined that a different location will allow for increased monitoring of security. Alleged Compliance Date: 1/28/2014 Findings included: Cross Refer To findings listed in citation F-323. Resident #4 received additional education from Administration on 1/18/2014 related to the facility's Policy on smoking. The resident also was issued a 30 day letter of discharge on 1/20/2014 based on continued non-compliance with the facility's smoking policies. Documentation of 1:1 supervision was monitored weekly by Administration to ensure ongoing compliance by facility staff. Administration participated in education of all facility staff on smoking, 1:1 supervision, supervised visitation, smoking policy, and room checks. The facility security system was audited by Administration and changes were made to ensure compliance and increased safety for residents. Administration had the smoking policy included in the Admission packet to be reviewed prior to any new admission. Security cameras and placement were audited and the company has been contacted to review the system and the facility has been authorized to make changes of location if needed to allow for the most benefit to resident safety. It was determined by the State Agency on the Follow-Up visit of 2/16/2014 that the AOC submitted by the facility on 2/12/2014 had been implemented and was in practices as of 1/28/2014, removing the immediacy of the deficient practice. The citations at F- 323 and F- 490 remained but were lowered in scope and severity to a "D". The facility will be in compliance with F-323 and F-490 when an acceptable Plan of Correction (POC) is submitted and a second follow-up visit is conducted to determine that the facility has implemented their POC.

On the day of the complaint inspection, based on observation, record review and interview the facility failed to assess 1 of 5 residents receiving diabetic tube feedings. Resident #1 received non-diabetic tube feeding for three days and was admitted to the hospital with [REDACTED]. The findings included: Cross refers to F-309 as it relates to the failure of the facility to provide the necessary care and services to 1 of 1 diabetic residents hospitalized for [REDACTED]. The Administrator and Director of Nurses were not informed. On 4/27/12 the physician wrote an order for [REDACTED]. Begin [MEDICATION NAME] 2.0 @ 69 cc/hr via [DEVICE]. DC (discontinue) [MEDICATION NAME] 2.0 when [MEDICATION NAME] is available." On 4/28, 4/29, and 4/30/12 the resident's 6:30 AM and 6:00 PM fasting blood sugars were elevated above her normal, the physician was not notified or the resident assessed related to the change in blood sugars. Documentation failed to show that the Registered Dietician was notified regarding the nutritional needs provided by the change in tube feeding from [MEDICATION NAME] to [MEDICATION NAME] 2.0. Resident #1 was admitted to the hospital on [DATE] with a documented blood sugar of 641. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. A Discharge Summary from the hospital, dated 5/4/12, under the section Hospital Course stated, "...presented with a blood glucose of 641, sodium of 150, physical signs of dehydration and a serum osm (osmalarity) of 355..." Review of the Cumulative physician's orders [REDACTED]. "A Physician's Telephone order dated 4/27/12, stated, "Hold [MEDICATION NAME] until available. Begin [MEDICATION NAME] 2.0 @ 69 cc/hr. via [DEVICE]. DC (discontinue) [MEDICATION NAME] 2.0 when [MEDICATION NAME] is available." Review of the MD (Medical Doctor) Progress Notes revealed no progress note for April. A progress note dated 5/4/12 stated, "readmitted p (after) hosp for [MEDICAL CONDITION]." Review of the Dietary Notes revealed on 4/10/12, the dietician reviewed the resident's nutritional needs and the use of [MEDICATION NAME]. "...TF (tube feeding) provides 1656 cal (calories), 75 grams of protein, 1651 ml total fluid. Currently meeting needs." On 5/3/12 the Registered Dietician (RD) stated, "Resident currently in hospital. Will assess next visit." There were no notes related to the change of tube feeding from [MEDICATION NAME] to [MEDICATION NAME]. Review of the resident's Nurse's Notes revealed there were no daily notes from March 30 through April 30, 2012. On 4/30/12 at 5:30 AM, the Nurse's Note stated, "Resident observed vomiting small amount, HOB (head of bed) elevated... GT (gastrostomy tube) feeding off..." 3:15 PM Nurse's Note stated "Resident's daughter in to visit states she wants her mother sent to ER (emergency room ) vitals obtained 160/101, HR (heart rate) 136, R (respirations) 14. Resident more lethargic than usual. Dr. called and notified of resident's RP (Responsible Party) wishes. New order received to send resident to ER of choice..." Review of the MAR/TAR (Medication Administration Record/Treatment Administration Record) revealed an order for [REDACTED]. She continued to receive the [MEDICATION NAME] tube feeding through the morning shift of 4/30/12. Review of the FSBS (Fingerstick Blood Sugars) revealed FSBS done at 6:30 AM and 6 PM each day. On the morning of 4/28/12, the resident's blood sugar was 290 and she received 9 units of [MEDICATION NAME] Insulin. At 6:00 PM her blood sugar was recorded at 219 and received 6 units of [MEDICATION NAME]. On 4/29/12 at 6:30 AM her blood sugar was recorded at 333 and she received 12 units of [MEDICATION NAME]. At 6:00 PM the blood sugar was recorded as 289 and she received 9 units of insulin. On 4/30/12 at 6:30 AM, her blood sugar was recorded to have been 313 and she received 12 units of [MEDICATION NAME] insulin. Licensed Practical Nurse (LPN) #1 was interviewed on 5/22/12 at approximately 3:00 PM. She stated the resident's daughter came in and said her mama didn't look right. "I went and checked her vital signs. She was not totally lethargic, but she was a little harder to arouse than usual." The LPN stated she called the doctor and gave the doctor the vital signs and told him the family wanted her to go to the hospital. "I didn't check her blood sugar"... Resident #1 received [MEDICATION NAME] 2.0 tube feeding instead of the [MEDICATION NAME] for 3 1/2 days. Following the tube feeding change the resident's blood sugars increased. She developed lethargy, elevated blood pressure and pulse. Although the nurse checked her blood pressure and pulse she did not check her blood sugar or assess her mental status change. A thorough assessment was not conducted at the facility. The Nurse's Note dated 4/30/12 stated the family insisted the resident be sent to the hospital. Her blood sugar at the hospital was recorded to be 641.

On the day of the complaint inspection, based on observation, record review and interview, the facility failed to provide the necessary care and services for 1 of 1 diabetic resident hospitalized for [REDACTED]. The findings included: Cross refers to F-281 Professional Standards, Resident #1 received [MEDICATION NAME] 2.0 tube feeding instead of the [MEDICATION NAME] for 3 1/2 days. Following the tube feeding change the resident's blood sugars increased. She developed lethargy, elevated blood pressure and pulse. Although the nurse checked her blood pressure and pulse she did not check her blood sugar or assess her mental status change. A thorough assessment was not conducted at the facility. The Nurse's Note dated 4/30/12 stated the family insisted the resident be sent to the hospital. Her blood sugar at the hospital was recorded as 641. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. A Discharge Summary from the hospital, dated 5/4/12, under the section Hospital Course stated, " ...presented with a blood glucose of 641, sodium of 150, physical signs of dehydration and a serum osm (osmalarity) of 355... Her hospital course has since been relatively unremarkable. She had a consultation by the hospital nutritionist, who recommended that she receive tube feeds with diabetic formula, [MEDICATION NAME], at a rate of 60cc/hr with 60cc free water flush every 4 hours. This regimen was started, and she was given 10 units [MEDICATION NAME] with low-dose sliding scale coverage, never needing more than 3 units of [MEDICATION NAME] coverage per day. She had a repeat urinalysis to rule out UTI. This showed budding yeast microscopically. She has been treated in the past for [MEDICAL CONDITION] UTI. Since she is asymptomatic, afebrile, and complains of no urinary pain,[MEDICAL CONDITION], or suprapubic tenderness, and her final culture report is negative at 48 hours today, treatment for [REDACTED]. This is likely just secondary to her recent glucosuria, which should now be resolved with good glycemic control..." Review of Resident #1's Cumulative physician's orders [REDACTED]." A Physician's Telephone order dated 4/27/12, stated, "Hold [MEDICATION NAME] until available. Begin [MEDICATION NAME] 2.0 @ 69 cc/hr. via [DEVICE]. DC (discontinue) [MEDICATION NAME] 2.0 when [MEDICATION NAME] is available." Review of the MD (Medical Doctor) Progress Notes revealed no progress note for April. A progress note dated 5/4/12 stated, "readmitted p (after) hosp for [MEDICAL CONDITION]." Review of the Dietary Notes revealed the dietician on 4/10/12 reviewed the resident's nutritional needs and the use of [MEDICATION NAME] "TF (tube feeding) provides 1656 cal (calories), 75 grams of protein, 1651 ml total fluid. Currently meeting needs." On 5/3/12 the Registered Dietician (RD) stated, "Resident currently in hospital. Will assess next visit." There were no notes related to the change of tube feeding from [MEDICATION NAME] to [MEDICATION NAME]. Review of the resident's Nurse's Notes revealed no daily notes from March 30 through April 30, 2012. On 4/30/12 at 5:30 AM, the Nurse's Note stated, "Resident observed vomiting small amount, HOB (head of bed) elevated... GT (gastrostomy tube) feeding off ..." 3:15 PM Nurse's Note stated, "Resident's daughter in to visit states she wants her mother sent to ER (emergency room ) vitals obtained 160/101, HR (heart rate) 136, R (respirations) 14. Resident more lethargic than usual. Dr. called and notified of resident's RP (Responsible Party) wishes. New order received to send resident to ER of choice..." Review of the Medication Administration Record/Treatment Administration Record (MAR/TAR) revealed Resident #1's Finger Stick Blood Sugar (FSBS) were check each day at 6:30 AM and 6:00 PM during March 2012: 04/01/12 6:30 AM 123 6:00 PM 194 04/02/12 6:30 AM 133 6:00 PM 147 04/03/12 6:30 AM 158 6:00 PM 165 04/04/12 6:30 AM 134 6:00 PM 127 04/05/12 6:30 AM 149 6:00 PM 140 04/06/12 6:30 AM 185 6:00 PM 126 04/07/12 6:30 AM 212 6:00 PM 198 04/08/12 6:30 AM 134 6:00 PM 70 04/09/12 6:30 AM 216 6:00 PM 143 04/10/12 6:30 AM 263 6:00 PM 118 04/11/12 6:30 AM 143 6:00 PM 128 04/12/12 6:30 AM 227 6:00 PM 131 04/13/12 6:30 AM 121 6:00 PM 146 04/14/12 6:30 AM 144 6:00 PM 139 04/15/12 6:30 AM 158 6:00 PM 215 04/16/12 6:30 AM 272 6:00 PM 182 04/17/12 6:30 AM 132 6:00 PM 134 04/18/12 6:30 AM 201 6:00 PM 118 04/19/12 6:30 AM 167 6:00 PM 107 04/20/12 6:30 AM 151 6:00 PM 116 04/21/12 6:30 AM 179 6:00 PM 123 04/22/12 6:30 AM 153 6:00 PM 122 04/23/12 6:30 AM 149 6:00 PM 76 04/24/12 6:30 AM 136 6:00 PM 108 04/25/12 6:30 AM 109 6:00 PM 121 04/26/12 6:30 AM 181 6:00 PM 184 04/27/12 6:30 AM 177 6:00 PM 177 04/28/12 6:30 AM 290 6:00 PM 219 04/29/12 6:30 AM 333 6:00 PM 289 04/30/12 6:30 AM 313 6:00 PM at hospital The MAR/TAR indicated Resident #1 received [MEDICATION NAME] 2.0 instead of [MEDICATION NAME] starting on 4/27/2012. She continued to receive the [MEDICATION NAME] tube feeding through the morning of 4/30/12. The order on the MAR/TAR stated, "hold [MEDICATION NAME] until available begin [MEDICATION NAME] 2.0 @ 69 cc/hr (centimeter/hour) vial [DEVICE]. DC [MEDICATION NAME] 2.0 when [MEDICATION NAME] is available." Further review of the MAR/TAR showed an increase in the resident's 6:30 AM and 6:00 PM FSBS on 4/28 - 4/30/12 after the [MEDICATION NAME] was substituted for [MEDICATION NAME]. The tube feeding was given over 20 hours, from 6:00 AM until 2:00 AM. During an interview with Medical Supply Clerk (MSC) #1 on 5/22/12 at approximately 2:15 PM, she stated the [MEDICATION NAME] tube feeding was not delivered on Thursday (April 26, 2012). "I went to check and discovered I had a missing palette". She stated when she discovered the missing palette the supplier was closed. On Friday morning she called about the missing supplies, she was missing the first page of the order that included the [MEDICATION NAME]. The MSC thought the truck would deliver it on Saturday (April 28, 2012). She reported to the Unit Manager and Human Resources the truck would be in on Saturday. There was no delivery on Saturday. She stated the tube feeding was delivered on Tuesday, May 1, 2012. The MSC did not notify the Director of Nursing or the Administrator that the facility was out of [MEDICATION NAME] tube feeding. The Unit Manager was interviewed on 5/22/12 at 3:30 PM. She stated she was notified of the [MEDICATION NAME] not being available after the nurses had obtained orders for alternate tube feedings until the [MEDICATION NAME] was available. I was told the feeding would be in on Saturday. "On Monday, I brought it up in the morning meeting ... It didn't come until Tuesday." The Certified Dietary Manager (CDM) was interviewed on 5/22/12 at 3:20 PM. She stated the Registered Dietician was notified by e-mail regarding the changes in the tube feeding. She was no able to produce the e-mail. "It was Friday and we were told the tube feeding would be in on Saturday." Licensed Practical Nurse (LPN) #1 was interviewed on 5/22/12 at approximately 3:00 PM. She stated the resident's daughter came in and said her mama didn't look right. I checked her vital signs. She was not totally lethargic, but she was a little harder to arouse than usual." The LPN stated she called the doctor and gave the doctor the vital signs. "I didn't check her blood sugar ..."