Every finding on record at Signature Healthcare at Summit Manor Rehab & Welln

Based on observation, interview, record review and facility policy review, the facility failed to ensure pain management was provided consistent with professional standards of practice for one of 25 sampled residents (Resident (R)22).The findings include: Review of the facility's policy titled Pain Management' last reviewed 01/31/2026, revealed the facility must ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Further review of the policy revealed upon admission, re-admission, and as needed, the Pain Evaluation would be completed for each resident.Review of the facility's policy titled, Notification of Change of Condition dated 07/07/2022 and last reviewed 01/31/2026, revealed the facility must consult with the resident's physician, inform the resident and the resident's representative (consistent with his/her authority), when there was a significant change in the resident's physical, mental, or psychosocial status. Per review, the nurse was to implement interventions and monitoring based on assessment of the resident. Further review revealed if the assessment warranted emergency transfer (to the emergency room), the nurse was to contact Emergency Medical Services (EMS) for emergency transfer for evaluation and treatment (of the resident).Review of the facility's policy titled, Neuro Check Guidelines last reviewed 12/04/2024, revealed with an unwitnessed fall, the fall event (form) was to be completed. Further review revealed neuro (neurological) checks were to be implemented for 72 hours (post-fall), as follows; initiated immediately, then every 15 minutes for one hour, every 30 minutes for 1 hour, every hour for four hours and every four hours for 16 hours.Review of R22's Face Sheet revealed the facility admitted the resident on 09/24/2025, with diagnoses of unspecified dementia, pneumonia, and atherosclerotic heart disease. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference date (ARD) of 01/19/2026, revealed the facility assessed R22 with a Brief Interview for Mental Status (BIMS) score of nine out of 15. This score indicated the resident was moderately cognitively impaired. Further review of the MDS revealed the facility assessed R22 as having the presence of pain.Review of the Fall Event dated 03/21/2026, that was not completed until 03/23/2026, revealed Resident (R)22 had sustained an unwitnessed fall and had no complaints of pain. Per review, neuro checks were initiated immediately, then were performed every 15 minutes for one hour, every 30 minutes for 1 hour, every hour for four hours and every four hours for 16 hours and completed without any concerns noted.Review of R22's Comprehensive Care Plan (CCP) revealed the facility developed a problem area for R22 for the potential for falls and fall related injury due to impaired mobility. Interventions included for R22 to have therapy evaluation and to treat as needed. Review of R22's CCP revealed the facility additionally developed a problem area for pain which was initiated 10/02/2025, related to R22's diagnoses of osteoarthritis, atrial fibrillation, depression, and dementia.During interview on 03/25/2026 at 9:30 PM, State Registered Nurse Aide/Assistant (SRNA) 6 stated he had been on duty on 03/21/2026 when R22 sustained the unwitnessed fall. He stated he had been down the hall when he heard a loud thud, and he and his co-worker SRNA, immediately went to the resident's room. SRNA 6 explained R22 had been lying on his back on the floor in a puddle of urine. He stated he immediately yelled for the UM on duty to come to R22's room, and UM 1 came to the room and asked the resident some questions. He stated UM 1 then instructed him and the other SRNA to assist R22 back to bed. SRNA 6 stated he informed UM 1 he did not feel comfortable moving R22 until the resident had been assessed by the nurse (UM 1). He stated UM 1 left the room and he and the other SRNA assisted R22 up to the chair first due to the resident being saturated in urine. SRNA 6 stated they had to lift R22 up and into the chair and the resident complained of left shoulder pain, left hip pain and pain in the back of his head. The SRNA stated they left R22 sitting up in the chair. He further stated approximately 10 minutes later UM 1 returned to the room to assess R22 and then had them put R22 back into bed.Review of the Progress Note for R22, entered on 03/21/2026 at 9:59 PM, by Unit Manager (UM) 1, revealed staff observed the resident lying on the floor in his room at approximately 9:55 PM. Per review of the Note, R22's fall was unwitnessed, and an assessment of the resident was completed immediately. Continued review of the Note revealed R22 was noted as alert and oriented to person, with pupils equal and reactive, no apparent head injury noted, and a skin assessment revealed no present injuries. The assessment noted R22 had no range of motion (ROM) difficulties and no deformities. Further review revealed neuro checks were initiated as per protocol, and two staff members assisted the resident back to bed. Additional review revealed safety measures implemented were noted as bed in lowest position and non-skid socks applied. The Physician and family were notified, and the UM would continue to monitor R22 closely for any changes in condition, and staff were educated that the resident was to always have non-skid socks on. Review of the Nurse Progress Note entered 03/21/2026 at 10:00 PM, by Licensed Practical Nurse (LPN) 5, revealed R22's Power of Attorney (POA) and Physician had been notified of the resident's fall without noted injury.During interview on 03/25/2026 at 1:49 PM, UM 1 stated he was called to R22's room (regarding the fall) and observed the resident lying on the floor. He stated he assessed R22 by obtaining his vital signs, assessing his ROM, neurological status, and skin. UM 1 explained R22 had no apparent head or other injury after the assessment and had no complaints of pain. He stated R22 was already on every 15-minute checks due to an attempted elopement earlier the same day (of the fall). The UM explained after the resident's fall; neurological checks were implemented per the facility's policy. He stated the neuro checks were initiated immediately, then every 15 minutes for one hour, every 30 minutes for 1 hour, every hour for four hours and every four hours for 16 hours. UM 1 stated the facility's Electronic Medical Record (EMR) system automatically added the neuro checks in as part of the nursing documentation when a fall event report was initiated. He further stated he left shortly after R22's fall and had given report to the oncoming nurse.During interview on 03/25/2026 at 10:05 AM, SRNA 1 stated she worked on 03/22/2026 from 6:00 AM to 2:00 PM and provided care for R22. She stated she was informed by SRNA 7 that R22 had fallen and to observe the resident when she provided care. SRNA 1 stated she had to be very gentle while providing incontinent care for R22 due to the resident having pain whenever he was moved. She explained to LPN3 that R22 did not want to get up to the wheelchair because it caused him so much pain. She stated the LPN informed her it was okay to allow R22 to remain in bed. She further stated throughout her shift she provided care frequently to R22 and had to continue to be very gentle with him due to the pain caused by any movement during care.Review of R22's CCP revealed the facility added to the pain problem area care plan interventions that were initiated on 10/02/2025, included observing R22 for non-verbal signs and symptoms of pain and offering and encouraging medications as ordered. Continued review revealed the care plan for pain was updated on 03/24/2026, to include the use of opioid medication.Review of the Progress Note for R22, entered on 03/21/2026 at 9:59 PM, by Unit Manager (UM) 1, revealed staff observed the resident lying on the floor in his room at approximately 9:55 PM. Per review of the Note, R22's fall was unwitnessed, and an assessment of the resident was completed immediately. Continued review of the Note revealed R22 was noted as alert and oriented to person, with pupils equal and reactive, no apparent head injury was noted, and a skin assessment revealed no present injuries. The assessment noted R22 had no range of motion (ROM) difficulties and no deformities. Further review revealed neuro checks were initiated as per protocol, and two staff members assisted the resident back to bed. Additional review revealed safety measures implemented were noted as bed in lowest position and non-skid socks applied. The Physician and family were notified and the UM would continue to monitor R22 closely for any changes in condition, and staff educated that the resident was to always have non-skid socks on. Review of the Nurse Progress Note entered 03/21/2026 at 10:00 PM, by Licensed Practical Nurse (LPN) 5, revealed R22's Power of Attorney (POA) and Physician had been notified of the resident's fall without noted injury.During interview on 03/25/2026 at 10:42 AM, LPN 3 stated she cared for R22 on 03/22/2026, the morning after his fall. She stated she checked on him several times, and he seemed comfortable, but had not gotten out of bed as usual due to his fall and being sore. During an interview on 03/26/2026 at 10:51 AM, LPN 3 stated she gave R22 Acetaminophen 650 mg (milligrams) as ordered for pain on 03/22/2026, because she felt he was sore due to the fall. However, there was no documented evidence the Acetaminophen was administered to the resident. LPN 3 stated the SRNA informed her R22 did not want to get out of bed due to being sore from the fall, and she informed the SRNA to leave the resident in bed. During interview on 03/25/2026 at 10:05 AM, SRNA 1 stated she worked on 03/22/2026 from 6:00 AM to 2:00 PM and provided care for R22. She stated she had been informed by SRNA 7 that R22 had fallen and to observe the resident when she provided care. SRNA 1 stated she had to be very gentle while providing incontinent care for R22 due to the resident having pain whenever he was moved. She explained R22 did not want to get up to the wheelchair because it caused him so much pain. SRNA1 stated she reported R22's pain and that he did not want to get up to the wheelchair to LPN 3. The LPN informed her it was okay to allow R22 to remain in bed. She further stated throughout her shift she provided care frequently to R22 and had to continue to be very gentle with him due to the pain caused by any movement during care.Review of the Nurse Progress Note dated 03/22/2026 at 4:41 AM, by Licensed Practical Nurse (LPN) 5 revealed no complaints or signs or symptoms of injury were noted related to R22's fall. Review of the Nurse Progress Note dated 03/22/2026 at 10:25 AM, documented by LPN 3, revealed R22 had rested quietly during the shift, without latent injuries or discomfort noted or voiced related to the recent fall. Review of the Nurse Progress Note dated 03/23/2026 at 8:57 AM, documented by the Assistant Director of Nursing (ADON), revealed R22 while in the gym with the Occupational Therapist (OT) had been leaning to the right side and had weakness to the right upper extremity. Further review of the ADON's Note revealed R22 denied pain and his blood pressure was 160/103, and she would notify the Physician. Review of the Nurse Progress Note dated 03/23/2026 at 10:30 AM, documented by the Restorative Nurse, revealed R22 was unable to participate with the restorative program. Continued review of the Restorative Nurse's Note revealed when she attempted to walk R22, the resident was unable to stand and complained of back and knee pain. Further review of the Restorative Nurse's documentation revealed during a second attempt to complete the restorative walking program R22 again complained of pain and was assisted back to bed per his request due to the pain. Per record review R22 had progressed to assist of 1 person for pivot transfers and walking short distances. R22 now required the assistance of two staff to complete the standing pivot transfer to the bed. The Restorative Nurse reported R22's complaints to LPN 6.However, review of the Nurse Progress Note dated 03/23/2026 at 10:37 AM, documented by LPN 6, revealed R22 was resting in bed, denied pain, and had no weakness or facial drooping with his grip noted as equal bilaterally. Further review of LPN 6's Note revealed the Physician was made aware of R22's condition in therapy and Restorative.Review of the Nurse Progress Note dated 03/23/2026 at 3:46 PM, documented by Registered Nurse (RN) 3 revealed the facility's Interdisciplinary Team (IDT) reviewed R22's fall and determined the root cause as the resident not having non-skid socks/shoes in place, and the resident attempted to self-transfer. Per review of RN 3's Note, R22's care plan had been updated related to pain. Further review revealed the IDT attendees were RN 3, the Director of Nursing (DON), ADON, UM, and the Social Services Director (SSD).During interview on 03/26/2026 at 2:04 PM, LPN 6 stated she worked the 6:00 AM to 6:00 PM shift on 03/23/2026. The LPN stated she contacted R22's physician to report the resident had pain of the left hip area when the SRNA's turned him. She stated she received the order for the bilateral hip x-rays, and Hydrocodone/Acetaminophen 7.5/325 mg for pain (narcotic pain med/Norco). LPN 6 further stated she informed LPN 4 of the pending x-ray at shift change.Review of the Medication Administration Record (MAR) for R22 dated March 2026, revealed an order for Acetaminophen 325 milligram (mg) two (2) tabs every 4-6 hours as needed for pain. Per the MAR, a dose of the Acetaminophen was administered to R22 by LPN 4 on 03/23/2026 at 4:50 PM, related to complaints of pain. Continued MAR review revealed an order for Hydrocodone-Acetaminophen (generic for Norco, narcotic pain medication) 7.5-325 mg,1 tablet for pain as needed. The Medication was received from pharmacy on 03/23/2026 at 9:38 PM. However, review of the MAR revealed a dose of the Norco was not administered to R22 until 7:10 AM on 03/24/2026 for his pain. However, review of the Nurse Progress note dated 03/21/2026, revealed an x-ray was not completed until 03/23/2026 at 4:57 PM. Review of the Nurse Progress Note dated for 03/23/2026 at 4:57 PM, entered as a late entry on 03/24/2026 at 5:57 AM by LPN 6, revealed the (bilateral hip) x-ray for R22 had been completed.Review of the x-ray report dated 03/23/2026 at 6:30 PM, revealed an acute left femoral neck fracture with modest displacement and angulation. Further review of the x-ray report revealed it was faxed to the facility on [DATE] at 6:34 PM. However, staff failed to timely retrieve the x-ray results from the facsimile (fax) machine and notify the physician. The fax results were not addressed by the facility until 03/24/2026 at approximately 9:30 AM, approximately 15 hours later.Review of the Nurse Progress Note dated 03/23/2026 at 4:57 PM and entered as a late entry on 03/24/2026 at 5:57 AM by LPN 6, revealed R22 x-rays had been completed. Review of the bilateral hip x-ray report dated 03/23/2026 at 6:30 PM, revealed R22 had an acute left femoral neck fracture with modest displacement and angulation. Further review of the report revealed it had been faxed to the facility on [DATE] at 6:34 PM.Review of the Emergency Medical Services (EMS) Patient Care Record dated 03/24/2026 revealed R22 had complaints of hip pain, and shortening and outward rotation of the left leg. Review of the hospital Emergency Documentation dated 03/24/2026 at 12:23 PM, revealed upon arrival at the emergency department R22 was noted to have his left leg shortened and externally rotated. Per review, the hip x-ray findings noted acute left femoral neck fracture with varus angulation of the distal fracture fragment and foreshortening of the distal femur. Further review of the Emergency Documentation revealed R22 was admitted to the hospital. Review of the hospital Surgical Documentation (Operative Report) dated 03/25/2026 at 3:56 PM, revealed R22 had a hemiarthroplasty surgery (surgery to replace the head and neck of the femur) on the left hip.During interview on 03/26/2026 at 5:09 PM, the Director of Nursing (DON) stated she had been notified of R22's fall at the time of the incident. She stated on 03/23/2026, she met with the Interdisciplinary Team (IDT) to discuss R22's fall. The DON stated she assessed R22 and had not found any decrease in the resident's range of motion, no internal rotation of the legs, or discrepancy in his leg length. She explained it was the responsibility of the nurse on duty to ensure x-ray reports were submitted timely to the Physician. The DON was not aware R22's x-ray report had been sent to the facility on [DATE] at 6:34 PM and the physician was not made aware until 03/24/2026 at 9:30 AM (15 hours later). The DON further stated her expectation was for a complete pain assessment to be completed to ensure residents were not in pain.During interview on 03/26/2026 at 5:40 PM, the Administrator stated her expectation was for x-rays to be reported to the Physician as soon as they were received. She stated she was not aware there had been a delay with R22's x-ray results being reported timely to the Physician. The Administrator stated she was surprised by the results of the x-ray. She further stated if the resident had complained of pain, other than just being sore, they would have sent him out for an x-ray.

Based on observation, interview, and review of the facility's policy, the facility failed to provide a safe, clean, and well-maintained environment. Multiple maintenance concerns were observed throughout the facility that had the potential to all residents. The findings include:Review of the facility's policy titled Home-like Environment, last revised 09/05/2025, revealed the resident has a right to a safe, clean, and homelike environment.Observation, on 03/24/2026 at 8:34 AM, revealed a handrail leading into the kitchen that was not securely attached, with screws coming out of the wall. Also, there was a separate handrail end which was not attached securely to the wall mount and jiggled. Observation on 03/24/2026 at 9:05 AM; 03/25/2026 at 2:45 PM; and 03/26/2026 at 7:25 AM, revealed a water hose lying in the flowerbeds at the entrance to the facility. A white styrofoam cup was observed on the ground outside of a resident's window. Observation, on 03/24/2026 at 9:36 AM, revealed the entry door to the kitchen area on the [NAME] Way Hall revealed scratches and worn areas, and a piece missing from the bottom corner on the handle side. Continued observation revealed the nurses' station had damaged wood paneling, with 11 areas where pieces were chipped or missing. Observation, on 03/24/2026 at 9:47 AM, revealed resident room [ROOM NUMBER]'s flooring where previous heating/cooling units had been removed, had holes and damaged sections that exposed the concrete beneath. Continued observation revealed stained flooring at the base of the toilet and under the sink in the attached bathroom.Observation, on 03/24/2026 at 9:50 AM, revealed the wall paint at the end of the 100 hall was bubbling and chipping. Also, the door frame at the entry to the first floor was observed to be rusted both on the inside and outside. Further observation, at the end of the 100 Hall near the exit door beside resident room [ROOM NUMBER], revealed ceiling tiles were discolored and appeared to be water stained. Observation, on 03/24/2026, at 10:15 AM, revealed the wall leading to the resident dining room on the first floor had visible black scuff marks. Further observation revealed baseboards within the dining room that had black scuff marks. Also, the glass door leading to the residents' smoking area had visible scratches on the surface. Additionally, floor tiles at the exit from the resident dining room to the resident smoke area, were damaged, with one tile missing a corner piece. Observation, on 03/24/2026 at 10:30 AM, revealed a cabinet in a resident shower room on the second floor with a missing handle. Continued observation in the same resident shower room revealed a wall corner guard with multiple strips of tape appearing to be holding it in place. Observation, on 03/24/2026 at 10:45 AM, of a second resident shower room on the second floor revealed a wall clock not mounted to the wall. The clock was resting on two cloth hooks.Observation, on 03/26/2026 at 11:40 AM, revealed an approximate six- inch by six- inch floor tile in resident room [ROOM NUMBER] had been removed. The underlying concrete was exposed.Observation, on 03/26/2026 at 11:50 AM, revealed dried white paint splatter on the floor at the entry to resident rooms [ROOM NUMBERS]. Observation, on 03/26/2026 at 11:57 AM, revealed rust on a heating/cooling unit outside resident room [ROOM NUMBER]. Continued observation revealed discolored paint and chipping off the wall. Observation also revealed rust and chipped paint on the exit door, next to the heating cooling unit. Observation, on 03/26/2026 at 3:25 PM, revealed a pool table in the first-floor resident dining room. The pool table was missing a corner guard leaving exposed edges. Also, the raised garden bed outside of the dining area had structural deterioration, including a failing base. The bottom of the raised garden bed appeared to be rotted and detached from the sides and partially laying on the ground. Observation, on 03/26/2026 at 4:25 PM, revealed a heating and air unit in resident room [ROOM NUMBER] which had a missing bottom door revealing visible dust and debris.In an interview, on 03/26/2026 at 4:25 PM, Resident (R)82, stated the heating and air unit in her room was missing the bottom part exposing the floor underneath. There was a visible area that exposed dust and debris. R82 stated if she were able, she would clean it herself because she liked her home to be clean. In an interview, on 03/24/2026 at 10:55 AM, Certified Nursing Assistant (CNA) 5 stated the cabinet in the residents' shower room had been broken for many years. CNA 5 stated repairs were not consistently completed after being reported to the maintenance department, via the logbooks. During an interview, on 03/26/2026 at 12:18 PM, the Housekeeping Manager stated she was aware of the scuff marks on the walls and baseboards but had not documented the issue in the maintenance logbook to notify the maintenance department. She stated the staff notified her or her team of any areas that needed to be cleaned. The Housekeeping Manager stated scuff marks looked bad, but acknowledged the scuff marks had not been addressed in the facility. The Housekeeping Manager stated it was her expectation for housekeeping staff to maintain a clean environment to ensure resident safety and reduce fall hazards.In an interview, on 03/26/2026 at 2:00 PM, the Dietary Manager (DM) stated she had concerns regarding the safety of the handrails in the kitchen area. She stated the handrails were not useful due to their condition. The DM stated that in the current condition the handrails could pose a fall risk. She stated the issue had been brought to the attention of maintenance; however, repairs had never been carried out.In an interview, on 03/26/2026 at 3:43 PM, the Maintenance Director stated there were no outstanding work orders documented in the maintenance logbook. He stated, any facility staff member could document an issue or concern in the logbook, which was located at each nurse's station for the maintenance department to address. The Maintenance Director stated the department typically painted scuffed walls during the second week of each month; however, as of the interview, painting had not been completed for the month of March. He further stated the facility did not have any documented work orders related to the rusted door frames. The Maintenance Director stated the damage to the raised garden bed had occurred during the winter months and had not yet been removed or repaired. Additionally, he stated there were only two employees in the maintenance department and it was hard to be in every room, every day.In an interview, on 03/26/2026 at 3:59 PM, the Director of Nursing (DON) stated it was her expectation the housekeeping and maintenance departments keep the facility safe and clean for residents. The DON further stated loose, or unsecured handrails could present a safety risk if residents attempted to use them to prevent a fall. Additionally, The DON stated the facility did not have a formal process in place to ensure completion of maintenance work orders. She stated staff was expected to continue monitoring for unresolved issues and notify her if repairs had not been completed, at which time she would follow up with the maintenance department.In an interview, on 03/26/2026 at 5:25 PM, the Administrator stated it was her expectation the facility be maintained in good repair, including routine painting of hallways at least monthly. She stated the facility did not have a formal system to track and ensure completion of maintenance work orders. However, she stated staff was expected to report unresolved maintenance issues, and she would follow up with the maintenance department if concerns were brought to her attention. The Administrator stated she was aware of the unsecure handrails in the kitchen but was not aware if the maintenance department had ever done any repairs to ensure resident safety.

Based on observation, interview, and review of facility policies, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety.The findings include:Review of the facility policy titled, Grooming and Dress Policy, undated, revealed under no circumstance may employees wear oversized clothing. All clothing must be clean, neat, and fit properly.Review of the facility policy titled, Warewashing, last revised 02/2023, revealed all dishware will be air dried and properly stored.On 03/26/2026 at 10:00 AM, the State Survey Agency (SSA) Surveyor asked the Director of Nursing (DON) to provide policies regarding infection control/hand hygiene and glove use/Personal Protective Equipment (PPE) for dietary staff; however, no such policies or procedures were provided.Observation, on 03/24/2026 at 8:45 AM, revealed [NAME] 2 left the tray line area, opened the steamer door, proceeded to the sink area, picked up a plastic water pitcher, turned the faucet on, and added water to the pitcher. [NAME] 2 then returned to the steamer, opened the steamer door, added the water to the base of the steamer, and closed the door to the steamer, before returning to the tray line. Upon returning to the tray line, [NAME] 2 failed to perform hand hygiene and change gloves before placing biscuits into a storage bag.Observation on 03/24/2026 at 8:46 AM, 03/25/2026 at 2:15 PM, and 03/26/2026 at 12:52 PM, revealed a plastic dessert bowl remained in the same location under the sink in the floor, across all three days.Observation, on 03/24/2026 at 9:00 AM, revealed the metal floor surface beneath and surrounding a dietary storage rack in the walk-in refrigerator had multiple dark brown and black stained areas, consistent with accumulated debris and food or liquid residue. There was a buildup of grime along the base of the walk-in refrigerator wall and in the corner areas, with streaking and discoloration extending outward from the wall onto the floor. The area beneath the shelving unit contained scattered debris and residue, including dried spills and dirt.Further observation revealed the kitchen flooring surrounding the walk-in refrigerator and walk-in freezer had visible brown and black debris, including dust build up at the corners of the units and along the ramps.Observation on 03/24/2026 at 12:15 PM, during the lunch tray line, revealed the Dietary District Manager was observed performing food preparation including cutting cake to prep for the next day's meal while wearing false/painted nails. At the same time [NAME] 1 was observed plating food to be served to residents while wearing false/painted nails.Further observation, during the same lunch tray line on 03/24/2026 at 12:15 PM, revealed the Dietary Manager stacked four plastic bowls inside one another, thus allowing the portion of the bowl that would hold food to be exposed.Continued observation, during lunch tray line, on 03/24/2026 at 12:15 PM, revealed [NAME] 1 had visibly soiled gloves with what appeared as food residue while plating food. Also, [NAME] 1 was observed placing a piece of chicken into a divided plate and then removing the chicken. [NAME] 1 then placed the same soiled divided plate back onto a stack of clean plates for use on the tray line. During this observation, the bottom of her shirt was in contact with the food tray line counter surface.Additional observation of tray line, on 03/24/2026 12:24 PM, revealed the tray line team, consisting of Dietary Aide 1, Dietary Aide 2, and [NAME] 1, served six residents with wet trays and one resident with a wet tray and cup.Further observation on 03/24/2026 at 12:25PM, revealed the Dietary Manager used a metal serving spoon to obtain ice from the ice machine located in a hall outside of the kitchen, and placed the ice into a cup for a resident's drink. Following this observation, the Dietary Manager hung the serving spoon back up with the clean serving utensils.Observation on 03/25/2026 at 9:00 AM and 10:39 AM, revealed the ice scoop container lid, beside the ice machine in the hallway beside the kitchen, was open and did not provide coverage for the ice scoop, leaving the scoop exposed to potential contamination.Observation on 03/25/2026 at 2:48 PM, and 03/26/2026 at 1:57 PM, of the dry storage area of the kitchen, revealed what appeared as a cooking oil spill from a visibly discolored cardboard box containing cooking oil, which was pooling around crates on the floor.During interview, on 03/24/2026 at 8:46 AM, [NAME] 2 stated he should wash his hands and don new gloves after leaving the tray line and prior to returning to tray line to prevent the spread of germs and prevent the food items from getting contaminated with bacteria that may be in the kitchen.During interview, on 03/24/2026 at 12:50 PM, the Dietary Manager stated bowls and cups were to be stored upside down to prevent dust and debris from entering food-contact surfaces. The Dietary Manager acknowledged that stacking bowls inside one another could result in contamination of food served to residents. The Dietary Manager further stated wet trays and cups should not be used, as this practice could contribute to the spread of bacteria and did not ensure items remained sanitary for resident use.During interview, on 03/25/2026 at 12:45 PM, the Health Environmentalist III, from the local health department, revealed false nails and nail polish should not be worn in food preparation areas. The Health Environmentalist III stated if false nails and nail polish were worn, staff should be double gloved to prevent nail polish from chipping into food or artificial nails from becoming dislodged. The Health Environmentalist III further stated the local health department did not recommend food service staff wear false nails or nail polish.In a second interview, on 03/26/2026 at 3:00 PM, the Dietary Manager stated staff was expected to perform hand hygiene and change gloves prior to food preparation and tray line service. Further, the Dietary Manager acknowledged that leaving the tray line, touching/contacting other surfaces or equipment, and returning without performing hand hygiene and changing gloves was not acceptable and could result in cross-contamination and increased risk to residents. The Dietary Manager further stated kitchen staff was to ensure the kitchen was thoroughly cleaned nightly; however, acknowledged cleanliness and was not maintained in the kitchen as expected. Further, the Dietary Manager stated necessary standards were not met to ensure a sanitary environment for food preparation and resident safety.In continued interview, on 03/26/2026 at 3:00 PM, the Dietary Manager stated she was not fully aware of local health department guidance regarding nail hygiene. In further interview, the Dietary Manager stated she should not have used the metal serving spoon to scoop ice and then hung it back up because this could create an infection control issue. She additionally stated the dietary and nursing staff's failure to close the lid to the ice scoop cover could allow for dust or other contaminates to fall onto the scoop and contaminate the ice in the machine.During interview, on 03/26/2026 at 3:46 PM, the Dietary District Manager stated staff was expected to follow infection control practices, including proper hand hygiene and glove useage, and acknowledged failure to follow these practices could result in contamination and potential harm to residents. The Dietary District Manager also stated staff should not use wet trays or dishware and items were expected to be fully air dried prior to use to ensure resident safety. Additionally, the Dietary District Manager stated she was not aware of any guidance or expectations from the local health department regarding nail hygiene.During an interview, on 03/26/2026 at 5:25 PM, the Administrator stated she had high expectations for maintaining sanitary conditions in the kitchen and reported utilizing audits, including daily observation of meal service and weekly review of the kitchen and tray line. However, she acknowledged the kitchen was not being maintained in a clean and sanitary manner, as evidenced by observations including a dessert bowl remaining in the same location for three consecutive days. The Administrator stated staff was expected to follow infection control practices, including proper hand hygiene and glove usage to prevent cross-contamination. Further, she acknowledged dishware, and trays were expected to be properly cleaned and fully air dried prior to use. Additionally, the Administrator stated she expected the Dietary Manager and Dietary District Manager to be knowledgeable and adhere to local health department regulations for the safety of the residents.

Based on observation, interview, and review of facility policy, the facility failed to maintain sanitary conditions related to the storage and disposal of garbage and refuse waste to prevent the development of odors, pests, and potential contamination. The findings include:Review of the facility's policy, titled Home-like Environment, last revised 09/05/2025, revealed residents have a right to a safe, clean, and homelike environment.Observation on 03/24/2026 at 8:57 AM, revealed two exterior garbage receptacles with lids left open and refuse waste piled above the top of the containers, preventing proper closure. Continued observation revealed discarded furniture, including upholstered chairs, stored directly behind the exterior garbage dumpsters. The items were placed on the ground near the waste area, creating clutter.Observation on 03/25/2026 at 11:26 AM, revealed an exterior garbage receptacle with the lid open and refuse observed inside the container.In an interview, on 03/24/2026 at 10:37 AM, the Maintenance Director stated the facility's exterior garbage receptacles were emptied three times weekly, on Mondays, Wednesdays, and Fridays, and he could request additional pickups if needed. He further stated he had to use a shovel to move the garbage to prevent it from being piled up around the garbage receptacles daily. Additionally, he stated he had talked to facility staff multiple times, but could not get them to understand they could use the back side of the dumpster for garbage.In an interview, on 03/26/2026 at 12:18 PM, the Housekeeping Supervisor stated she had observed the garbage receptacle lids being left open. She stated it was important to keep them closed and not have garbage piled on them for sanitation purposes, as well as to prevent an eyesore for the residents. Additionally, she stated she was aware the Maintenance Director had spoken to facility staff pretty often to keep the lids closed and she had communicated concerns to the Director of Nursing (DON). However, she stated she was unsure of what steps had been taken to try to alleviate the problem. Further, she stated it was safer for everyone if the lids to the garbage receptacles stayed closed.In an interview, on 03/26/2026 at 2:00 PM, the Dietary Manager stated it was important the garbage receptacle lids remain closed because refuse from the receptacles was unsightly and critters could get into them. She further stated she had brought the issue up during the morning meeting weeks ago.In an interview, on 03/26/2026 at 3:59 PM, the Director of Nursing (DON) stated it was her expectation staff use the empty side of the garbage receptacles and keep the lids closed to prevent animals from getting in and creating a mess. She further stated she was aware the Maintenance Director had been communicating with staff about keeping the lids closed, but she could not recall if she had presented staff with any training related to this herself.In an interview, on 03/26/2026 at 5:25 PM, the Administrator stated it was her expectation staff dispose of refuse waste in the garbage receptacles and then close the lids. She further stated she had older aides who may get lazy and not close the lids when they took the refuse waste out. Additionally, she stated it was important to ensure the lids were always closed to prevent cats from getting in and dragging trash everywhere.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to prepare, distribute, and serve food in a sanitary manner and in accordance with professional standards for food service safety. Dietary staff failed to wash hands and change gloves prior to preparing resident foods and failed to check the temperatures of seven of ten food items on the steam table during the dinner meal on 01/21/2025. The findings include: Review of the facility's policy titled, Food: Preparation revised 09/2017, revealed all foods were prepared in accordance with the Food and Drug Administration (FDA) Food Code. Per the policy, all staff would practice proper hand washing techniques and glove use and the staff would be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. Further review of the policy revealed, all utensils, food contact equipment, and food contact surfaces were required to be cleaned and sanitized after every use. An observation on 01/21/2025 at 5:26 PM, revealed Dietary Aide 1 used a brown paper towel to clean the thermometer in between checking the temperature of the milk and apple juice. Further observation at 5:33 PM, revealed Dietary Aide 1 and [NAME] 1 put gloves on without performing hand hygiene. Continued observation at 5:36 PM on 01/21/2025 revealed, [NAME] 1 rinsed a soiled dish off and put it in the dishwasher, and went back to the steam table without performing hand hygiene or changing gloves. Furthermore, [NAME] 1 put the chopper in the dishwasher wearing the same gloves then, got the chopper out if the dishwasher while it was still wet, and sat it on the counter. Then, [NAME] 1 retrieved the food pusher from the dirty sink to use for the chopper. Continued observation revealed, [NAME] 1 was wearing the same gloves when she put the bread in the chopper and used the dirty food pusher for pureed bread. An observation on 01/21/2025 at 5:41 PM, revealed [NAME] 1 rinsed the thermometer off at the sink under water; [NAME] 1 then proceeded to check the temperature of the chicken breast and pork tenderloin. There were no temperatures taken for the noodles, lima beans, tater tots, cauliflower, salad, gravy, or mashed potatoes that were on the tray line for the evening meal. During an interview with Dietary Manager 1 on 01/22/2024 at 2:12 PM, Dietary Manager 1 stated she was responsible for ensuring dietary staff abided by the guidelines to ensure proper food service to the residents. The Dietary Manager stated she expected the staff to change gloves and wash their hands when leaving the steam table or touching anything they were not cooking. She further stated she expected the staff to use the dishwasher for dirty dishes and let them air dry. Dietary Manager 1 stated staff should use an alcohol pad to wash the thermometer off in-between uses and let air dry before checking the temperatures. During an interview with the Administrator on 01/23/2024 at 2:04 PM, the Administrator stated she expected the Dietary staff to follow the protocols and policies. The Administrator further stated all food temperatures should be checked per the policy.

Based on interview, record review, and facility policy review, it was determined the facility failed to revise the care plan for one (1) of four (4) sampled residents (Resident #1) when the resident exhibited increased wandering and exit seeking behavior symptoms. Following admission on 02/12/2021, the facility addressed Resident #1's elopement risk on the resident's plan of care. The facility readmitted the resident on 03/04/2021 and review of the progress notes revealed the resident displayed wandering and/or exit seeking behaviors twenty (20) times between 03/04/2021 and 03/26/2021. However, the facility failed to revise the resident's plan of care to address the exit seeking and increase in wandering behavioral symptoms. On 03/26/2021, at approximately 11:15 PM, Resident #1 exited the facility without staff knowledge and was outside for approximately 15 minutes. The resident was found off facility property in an adjacent parking lot approximately 125 feet from the exit door. The facility's failure to ensure residents were supervised to prevent accidents/elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/27/21, and determined to exist on 03/26/21 at 42 CFR 483.21 Comprehensive-Person Centered Care plans (F657) and 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on 04/27/21. An acceptable Allegation of Compliance was received on 04/30/21, which alleged removal of the Immediate Jeopardy on 05/01/21. The State Survey Agency determined the Immediate Jeopardy was removed on 05/01/21, prior to exit, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F657) and 42 CFR 483.25 Quality of Care (F689), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Comprehensive Care Plans, revised 07/19/2018, revealed the nurse/Interdisciplinary Team was responsible for the review and updating of care plans. The care plan should reflect the current status of the resident and be updated with changes in the resident status. Further review revealed, the comprehensive care plan would be person-centered to meet the resident's preferences and goals to address the resident's medical, physical, mental and psychosocial needs. Care plan interventions should address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. The interventions would reflect action, treatment, or procedure to meet the objectives toward achieving the resident goals. Review of Resident #1's medical record revealed the facility admitted the resident on 02/10/2021 and readmitted the resident on 03/4/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of seven (4), which indicated severe cognitive impairment. The resident was also assessed to display wandering behavior symptoms on a daily basis. Continued review of the MDS assessment revealed the resident required assistance of one (1) staff member for safety during ambulation. The MDS assessment also revealed the resident utilized a wheelchair. Review of Resident #1 Comprehensive Care Plan dated 02/12/2021, revealed the resident was identified at risk for elopement as evidenced by diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission Elopement assessment dated [DATE], revealed the facility had identified Resident #1 was cognitively impaired, independently mobile (ambulatory or wheelchair), had poor decision making skills, demonstrated exit-seeking behavior, wander oblivious to safety needs and had the ability to exit the facility. However, Resident was determined to not be at risk for elopement. Review of Resident #1 progress notes since re-admission on 03/04/2021 revealed twenty (20) entries with documented wandering and/or exit-seeking behaviors. Review revealed seven (7) days (03/04/2021, 03/05/2021, 03/06/2021, 03/08/2021, 03/15/2021, 03/25/2021 and 03/26/2021), Resident #1 exhibited exit-seeking behaviors including pushing on exit doors and activating exit door alarms. Further review revealed eight (8) days (03/04/2021, 03/05/2021, 03/06/2021, 03/08/2021, 03/09/2021, 03/14/2021, 03/17/2021 and 03/25/2021), Resident #1 exhibiting wandering behaviors including wandering in hallways and wandering in other resident rooms. A progress note on 03/25/2021 at 4:50 PM, revealed Resident #1 was at the end of west unit, got out of wheelchair and pushed on exit door, setting off alarm. On 03/26/2021 at 6:26 AM revealed Resident #1 was exit seeking, beating on doors and windows trying to get out of the facility. However, further review of care plan, revealed the facility failed to revise or update the resident's plan of care to address the resident's exit seeking behaviors and increase in wandering behavior symptoms. Review of a facility investigation revealed, on 03/26/2021 at 11:15 PM, Resident #1 exited the facility through the exterior door located on the west downstairs unit without staff knowledge. According to the investigation, Licensed Practical Nurse (LPN) #2 heard an exit door alarm sound; however, thought the sounding alarm was State Registered Nurse Aide (SRNA) #1 going outside on break. A few minutes later, LPN #2 heard an alarm again and went to the exterior door near the dining room to retrieve SRNA #1 from break to assist her. At this time, the staff identified Resident #1 was not in the facility. The facility staff then began a search of the grounds, in which Resident #1 was located by LPN #2 in the parking lot next door to the facility. The facility investigation revealed that Resident #1 was identified as missing at 11:15 PM and was located by LPN #2 at 11:30 PM. Interview with LPN #1, on 04/26/2021 at 12:15 PM, revealed any behavior like exit-seeking and pushing on doors, should have been on Resident #1 care plan. Interview with LPN #3, on 04/21/2021 at 11:04 AM, revealed Resident #1 had exhibited exit-seeking behaviors during the times she had provided care for him/her. However, she did not feel this was a new onset of the behavior, therefore did not update the care plan. She was unsure if these behaviors were on the care plan. Interview with LPN #4 on 04/26/2021 at 11:07 AM revealed Resident #1s care plan should have included exit-seeking behaviors with interventions because the resident was identified as an elopement risk and he/she was not wanting to stay at the facility. Interview with RN #2, on 04/26/2021 at 11:54 AM, revealed any exit-seeking behavior like pushing on doors should have been on Resident #1 care plan. Interview with the MDS Nurse #1, on 04/21/2021 at 2:44 PM, revealed staff should be revising the care plan any time a change in the resident's condition occurs. Per the MDS nurse, the facility reviews resident care plans in the morning meetings to ensure that changes in resident condition, new orders, etc. were addressed on the plan of care. The MDS Nurse stated she was not working as the MDS Nurse when Resident #1 had an increase in behaviors and eloped from the building. Interview with the Director of Nursing (DON), on 04/26/2021 at 3:52 PM and 04/27/2021 at 5:41 PM, revealed the comprehensive care plan should be resident centered. She revealed the floor nurse were responsible to update the care plans with changes, however, the MDS nurse was ultimately the go to in ensuring care plans were accurately updated. The DON stated she could not recall if staff had discussed Resident #1's increase in wandering and exit seeking behaviors in the morning meeting. Interview with the Regional Nurse Consultant, on 04/26/2021 at 5:02 PM, revealed that if a behavior was not on the comprehensive care plan, it was expected of the staff to update the care plan with the behavior and to add an intervention to address that behavior. ***The facility alleged the following was implemented to remove Immediate Jeopardy on 05/01/2021. 1. Resident #1 was assisted back to the facility on [DATE] by LPN #2 at approximately 11:40 PM. LPN #2 performed an assessment to assure resident # 1 was not harmed. No concerns were noted and resident # 1 did not voice any pain or concerns. Resident #1 was placed on increased supervision at that time per staff. Medical Doctor #1 and Power of Attorney were notified on 3/26/2021 of Resident #1's exit-seeking behavior on 03/26/2021. 2. On 03/28/2021, Resident #1 was re-evaluated for elopement by the DON with a new elopement assessment completed. The elopement care plan was reviewed by the Director of Nursing to reflect resident # 1's current needs to include that Resident #1 currently required increased supervision to include line of sight visualization by a staff member. The SRNA Care Plan was reviewed to ensure that it reflected elopement status. 3. Resident #1 was placed on 1:1 supervision on 03/28/2021 per the DON. Resident remains under 1:1 supervision in the facility at this time. The facility has sent referrals for Resident #1 for a secure unit when a bed is available. 4. On 03/26/2021, all residents residing in the facility were accounted by facility staff performing a head count. 5. All exterior doors in facility were checked by Plant Operator Director and Plant Operator Director Assistant on 03/28/2021 to ensure all doors were locked and secure and that delayed egress was functioning properly. The doors were key coded and only nurses, the Plant Ops Staff, and the Facility Administrator have codes to doors. All doors were working properly. 6. LPN #2 was provided re-education by the DON on 03/28/2021 related to the facility policy and procedure of elopement to included responding to door alarms, assessing the area (including outside) and notification of physician/family when a change in condition occurs. 7. All residents in the facility were re-assessed for elopement risk by Nurse Consultant #1 and other staff member on 03/29/2021. All elopement assessments were completed by 03/29/2021. 8. Based on the elopement assessments completed on 03/29/2021, no new residents were identified to have elopement risk. Nine (9) residents remained to be identified at risk for elopement risk. All elopement assessment were completed by 03/29/ by Nurse Consultant #1 and other staff member. 9. All care plans of the nine (9) residents identified for elopement risk were reviewed and updated by MDS Nursing staff on 03/29/2021, for any changes found on the elopement assessment. 10. The facility elopement binders were reviewed and updated for accuracy by Nurse Consultant #1 on 03/30/2021. 11. All nine (9) residents identified for elopement risk behavioral management plans were updated to include interventions for wandering or exit seeking behaviors by Nurse Consultant #1 on 03/29/2021. 12. On 03/29/2021, the Regional Vice Present and Plant Operation Director Assistant completed environmental rounds to identify any concerns to which included lose floor tiles, damage to windows or doors, faulty equipment and doors. No safety issues or concerns were identified. 13. On 03/29/2021, the Regional Maintenance Director completed 100% audits of all exit doors to ensure all exit doors locked and that the delayed egress was functioning. No concerns were identified. During audit of all exit doors, no mechanical failure of the doors were identified. 14. On 03/29/2021, the Plant Operator Director Assistant #1 ensured the nine (9) residents identified at risk for elopement Wandergaurd was functioning appropriately and system was not outdated. 15. The TELS system (which is a technology based system for managing life safety tasks and general maintenance repairs that assist with tracking of tasks for daily, weekly, monthly, quarterly and annual life safety/regulatory compliance tasks that include routine jobs such as water temperature checks, fire drills, generator checks and door checks) was reviewed to ensure all doors was checked for locking, alarms, mag-lock and delayed egress for the last 30 days by the Regional Vice President and Plant Operation Director on 03/30/2021 with no concerns identified. During rounds made with OIG surveyor and Plant Operation Director Assistant #1 on 04/22/2021, it was noted that the exterior downstairs west door was not visualized on the computer screen. Plant Operation Director Assistant #1 contacted RF Technologies (who maintain the door system) and was directed to place the door in a different section of the computer. After completion of this task and changing a battery, the door showed up on the computer system. Per life safety guidelines, facility utilizes the code alert alarm panel (panel on the wall above the computer) for the purpose of monitoring doors and not the computerized system. Doors alarm at point of contact to notify staff of which door is alarming. Per facility, at no time has staff been instructed to utilize the computer system to determine proper door function. 16. On 03/30/2021, Nurse Consultant #1 reviewed documentation including a 30 day look back period on all event and 24 hour report for exit seeking behaviors. 17. On 03/30/2021, Nurse Consultant #1 reviewed nurses' notes for the last 30 days for exit seeking behavior and/or elopements with wandering behavior for the nine (9) residents identified for elopement risk. 18. On 03/29/2021, Nurse Consultant #1 provided education for administrative staff (Administrator, DON, Unit Managers, ADON, Social services, Admissions Director, Dietary Manager, MDS Coordinators, Plant Ops, and the Quality of Life Director) with post-test including education on the following policies, procedures and processes: Elopement Policy and Procedure; Missing Resident Policy and Procedure; Door Codes/Alarms Process; Accident/Incident Policy and Procedure; Safety and Supervision Procedure; Abuse Policy and Procedure; Resident Rights Policy and Procedure; Care Plan Policy and Procedure; Facility Administration, Change of Condition Procedure; Behavior Management Policy and Procedure and Quality Assurance and Performance Improvement (QAPI) Policy and Procedure. Administrative staff were required to perform at 100% for the post test. Administrative staff were unable to return to work until education was provided and post-test administered. All post-tests were reviewed for compliance by Nurse Consultant #1. 19. Upon receiving education on 03/29/2021 by Nurse Consultant #1, the Administrator, DON, ADON, Staff Development Coordinator, Business Office Manager, Social Services Director, Dietary Manager and/or Rehab Service Manger began provided re-education to facility employees to include nursing, dietary, therapy, housekeeping and administrative staff. The Education provided covered the following policies and procedures on Elopement, Missing Resident, Safety and Supervision, Accident and Incident, Behavior Management and Care Planning. Education also included Resident Rights, Abuse and Neglect, Facility Administration, Quality Assurance and Process Improvement, and the Change of Condition policy and procedure. The Interdisciplinary team (IDT) were educated to review acute resident changes in the morning meeting to ensure appropriate interventions have been added to the resident care plan. The IDT was also educated to review resident care plans weekly to ensure effectiveness of interventions. The IDT members include the Administrator, Director of Nursing, Assistant Director of Nursing, Staff development coordinator, Business office manager, Social Services Director, Dietary manager and/or Rehab Service Manager. The facility does not utilize agency staff prior to or since 03/26/2021. Education continued after 03/29/2021 to ensure all facility staff not educated by 03/31/2021 recieved education prior to working the floor. This education included information regarding the elopement books and the care plan information located within. Employee Staff to include nursing, therapy, dietary, housekeeping and administrative staff (facility does not utilize agency staffing at this time or prior to the incident) were educated by the DON, ADON, and/or Staff Development Coordinator to redirect wandering or exit seeking residents back to their assigned unit and or room and to consult the residents behavioral management care plan for a list of personalized interventions. This education is ongoing, and all employees were be educated prior to working on the floor. 20. Starting on 3/28/2021, all doors were be checked for proper function daily to ensure all doors lock and are secured and that the delayed egress was functioning appropriately. The checks were completed by members of the IDT team to include but not limited the Administrator, DON, ADON, Plant Operation Director, Plant Operation Director Assistant #1 Dietary Director, Social Services Director, and/or Business Office Manager beginning 03/28/21. Any concerns identified would be immediately reported to Administrator and Plant Operation Director. 21. On 03/28/2021, the facility implemented elopement drills by the Director of Nursing. Elopement drills were to be conducted daily on random shifts (including weekends) for one week and then weekly for 4 weeks thereafter conducted by the Administrator, DON or Department Head Managers. During the drills, staff were monitored to ensure they followed the Missing Resident Policy and Procedure with emphasis on actions to take when a door alarm sounds which includes, responding to active door alarms, walking outside perimeter by the alarming door to ensure a resident was not observed outside of a resident care area unattended. Further action includes, reporting to the charge nurse and to initiate a headcount of the residents in the facility. Following the conclusion of the weekly drills, quarterly elopement drills were conducted. 22. On 03/29/2021, audits were initiated that the DON, ADON or Unit Manager monitored all residents (including new admissions) for new or worsening exit seeking and/or wandering behaviors daily for two (2) weeks. Following the conclusion of the two (2) weeks monitoring, ongoing monitoring for three (3) months Monday through Friday was conducted for any new or worsening exit seeking and/or wandering behaviors. New Admissions would be assessed for elopement risk and any resident identified for elopement risk was included in the facility elopement books. Clinical systems including events in event manager to include: a. Events in event manager b. Clinical Summary 24-hour report c. Review new and readmissions for elopement assessments and updated care plans and elopement book as needed d. Nurses notes e. New or worsening exit seeking and/or wandering behavior tracking f. Care plan interventions for any identified new or worsening exit seeking and/or wandering behavior g. EzMAR monitoring The above clinical systems are monitored daily (Monday-Friday) by the DON, ADON, or Unit Manager to ensure no resident is at risk that has not been identified by the facility. The Administrator, DON, and/or members of the Interdisciplinary Team (ADON/Staff Development Coordinator, Dietary Manager, Maintenance Director, Business Office Manager, Social Services Director, and/or Activities Director) has been onsite in the facility (since 03/29/2021) to provide oversight and monitoring of residents at risk for elopement with visual rounding through the facility. 23. Beginning 03/29/2021 through 04/11/2021, five (5) employees per shift (total of ten (10) employees per day) for two (2) weeks an elopement test (written test which includes questions regarding policies on elopement, QAPI, Abuse reporting, Change of condition, Care Plans, Accidents and Incidents, and Safety and Supervision) was required to answer all questions correctly (score of 100%). From 04/12/2021 through 04/18/2021, three (3) employees per shift (total of six (6) employees per day) completed an elopement test and was be required to answer all questions correctly (score of 100%). From 04/19/2021 through 04/25/2021, two (2) employees per shift (total of four (4) employees per day) completed an elopement test to answer all questions correctly (score of 100%). From 04/26/2021 through 05/02/2021, one (1) employee per shift (total of two (2) employees per day) completed an elopement test and was required to answer all questions correctly (score 100%). From 05/03/2021 through 05/30/2021 (total of four (4) weeks), one (1) employee per week completed an elopement test and will be required to answer all questions correctly (score of 100%). From 05/31/2021 through 06/27/2021, one (1) employee every other week completed an elopement test and was be required to answer all questions correctly (score of 100%). If any employee fails to score 100% on the elopement test, the employee was be re-educated and re-tested until all questions were answered correctly (scoring 100%). All employees were selected at random and based on schedule across various shifts. 24. On 04/29/2021, the facility Administrator, DON, ADON, Unit Managers, Staff Development Coordinator, Social Services, Dietary Manager, MDS Coordinators, Plant Operation Director, and the Quality of Life Director were educated by Nurse Consultant #1 on the process of responding to the door when an alarm is heard. They were also educated that the facility does not utilize the computer to validate door checks. Further educating staff that the panel on the wall lights up to indicate which door has been opened. The facility does not utilize the computer for monitoring of any door and is not the facility process for identification of (opened) doors. 25. On 04/29/2021, following the education on the process of responding to the door alarms and the education that staff were not to utilize the computer to validate door checks, Administrator, DON, ADON, Unit Managers, Staff Development Coordinator, Social Services, Dietary Manager, MDS Coordinators, Plant Operation Director, Quality of Life Director and/or Rehab Service Manager re-educated the facility staff (to include nursing, dietary, therapy, housekeeping and administrative staff). This education included the process of responding to the door when an alarm is heard. Further educating staff that the panel on the wall lights up to indicate which door has been opened. The facility does not utilize the computer for monitoring of any door and is not the facility process for identification of (opened) doors. Education was initiated on 04/29/2021 and any employee who had not received the education by 04/30/2021 was educated prior to returning to work. A certified letter was mailed to all employees not educated by 04/30/2021 to notify them that they must receive this education prior to returning to work. 26. Since 03/28/2021, a Regional/Corporate Office Nurse and/or the Vice President of Operatives has been available on-site or by phone. The Administrator and/or Director of Nursing has been on-site daily to ensure continued compliance with audits established by QAPI Committee. The Nurse Consultant and/or RVP have provided regional oversight since 03/29/2021 and until immediacy is lifted. 27. On 03/28/2021, a QAPI meeting was conducted to discuss any immediate actions taken as well as the facility's plan to ensure compliance. In addition, the facility has implemented ongoing weekly QAPI meetings for four (4) weeks. Attendees of the QAPI meetings include the Facility Medical Director, Administrator, DON, Nurse Consultant, ADON, Unit Manager, Social Services Director, MDS Nurse, Plant Operation Employee, and Dietary Manager. ****The State Agency determined Immediate Jeopardy was removed on 05/01/2021 based on the following: 1. Interview with Licensed Practical Nurse (LPN) #2, on 04/20/2021 at 5:05 PM, revealed Resident #1 was assisted back into the facility at approximately 11:30 PM. The resident was assessed to have no new skin areas or other injuries. LPN #2 revealed that she did notify Medical Doctor #1 of Resident #1 exit seeking behaviors. Interview with the Director of Nursing (DON), on 05/04/2021 at 7:28 PM and 8:37 PM, revealed she notified the Medical Director and Resident Representative of the elopement on 03/28/2021. She further revealed the Resident Representative revealed to her that someone had called her about the resident's exit-seeking behaviors, on 03/26/2021. 2. Record review and interview with the DON, on 04/26/2021 at 3:52 PM, 04/27/2021 at 5:41 PM and 05/04/2021 at 7:28 PM, Resident #1 was re-evaluated for risk for elopement. Review of an Elopement Risk Evaluation on 03/29/2021 revealed Resident #1 was determined to be AT RISK for elopement. Further interview revealed the DON updated Resident #1 care plan to reflect the increased supervision. In addition, the SRNA Care Plan was reviewed to ensure it reflected elopement status. Review of Resident #1 Care Plan revealed that the care plan was updated on 03/27/2021 with every 15 minute checks and 03/28/2021 with one (1) to one (1) supervision. Review of Resident #1 SRNA care plan revealed an alert for Elopement Risk with an intervention of one (1) to one (1) supervision on 03/28/2021. 3. Record review and interview with the DON, on 05/04/2021 at 7:28 PM, revealed Resident #1 was placed on one (1) to one (1) supervision on 03/28/2021. Review of record revealed documentation of one to one supervision for Resident #1. Resident #1 discharged to Behavioral Health Facility on 04/14/2021. Resident #1 was readmitted to the facility on [DATE] and was placed on one (1) to one (1) supervision. Observation of Resident #1 on 04/27/2021 at 3:10 PM, revealed the resident sitting on edge of bed and staff at bedside and Wandergaurd to resident's right ankle. 4. Record review and interview with LPN #2, on 04/20/2021 at 5:05 PM, and 05/04/2021 at 5:34 PM and LPN #6 on 05/04/2021 at 7:25 PM, revealed a head count of all residents were performed on 03/26/2021 to account for all residents in the facility. All residents were present in the facility. 5. Record review and interview with Plant Operator Director, on 04/27/2021 at 11:51 AM, and 05/04/2021 at 4:48 PM, and Plant Operator Director Assistant, on 04/22/2021 at 2:45 PM and 3:55 PM and 05/04/2021 at 2:20 PM, revealed all doors were checked on 03/28/2021 to ensure doors were secure and functioning properly. Observation on 05/04/2021, revealed no identified concerns with the exit doors. 6. Interview with the DON, on 05/04/2021 at 7:28 PM, and record review revealed the DON educated LPN #2, on 03/28/2021. The education included following facility policy/procedure and what to do if a door alarm sounded. Interview with LPN #2, on 05/04/2021 at 5:34 PM, revealed she received training after the incident with Resident #1 related to what to do if a door alarm sounded. She further revealed that she received training on missing persons and care planning. 7. Record review and interview with Nurse Consultant #1, on 05/04/2021 at 8:14 PM, revealed all residents were reassessed on 03/29/2021 for elopement risk. Record review of Resident #1, #2, #3, #4, #5, #6 and #7 medical records revealed an Elopement Risk Evaluation had been completed on each resident on 03/29/2021. 8. Record review and interview with Nurse Consultant #1, on 05/04/2021 at 8:14 PM, revealed no new residents were identified as an elopement risk. She stated all four (4) elopement binders were reviewed for accuracy. 9. Record review and interview with MDS Nurse #1, on 05/04/2021 at 6:26 PM, and Nurse Consultant #1, on 05/04/2021 at 8:14 PM, revealed all care plans for the nine (9) residents identified for elopement risk were reviewed and updated as needed on 03/29/2021. Review of Resident #1, #2, #3, #4, #5, #6 and #7's care plan revealed all residents had an elopement care plan in place and with a revision date of 03/30/2021. 10. Record review and interview with Nurse Consultant #1, on 05/04/2021 at 8:14 PM, revealed she reviewed all four (4) elopement binders for accuracy. Review of four (4) of (4) elopement binders on 05/04/2021 revealed seven (7) residents were in each binder. Each of the seven (7) resident pictures were in the binder, in addition to a description of the resident each resident's face sheet with emergency contact information and behavioral management plan were in place. No concerns were identified. 11. Record review and interview with the Nurse Consultant #1, on 05/04/2021 at 8:14 PM, revealed the behavior management care plans were updated on 03/29/2021 for all residents at risk for elopement. 12. Record review and interview with Regional Vice President, on 05/04/2021 at 8:39 PM, and Plant Operation Director, on 05/04/2021 at 4:48 PM, revealed they had completed environmental rounds on 03/29/2021 to identify any concerns with the environment. No concerns were identified. 13. Record review and interview with Regional Maintenance Director, on 05/04/2021 at 8:51 PM, revealed that he completed an audit of all exit doors on 03/29/2021. He further revealed that no concerns were identified and all doors were functioning properly. He further revealed that while in the facility on 03/29/2021, an elopement drill was initiated and staff responded well. 14. Record review and interview with Plant Operation Assistant #1, on 05/04/2021 at 2:45 PM, revealed he check all nine (9) of the residents at risk for elopements Wandergaurd to ensure it was working appropriately on 03/29/2021. No concerns were identified and all were functioning appropriately. Observations on 05/04/2021, during initial tour from 10:20 AM to 11:03 AM revealed seven (7) of seven (7) residents remaining in the facility that were assessed at risk for elopement had Wandergaurds in place. Further observation and tour with Plant Operations Director Assistant #1 on 05/04/2021 at 2:00 PM, revealed Resident #4, #5, #6, #7 and #8 Wandergaurds were functioning appropriately. 15. Record review and interview Regional Vice President, on 05/04/2021 at 8:39 PM, Plant Operation Director, on 05/04/2021 at 4:48 PM, and Plant Operation Assistant #1, on 05/04/2021 at 2:45 PM, revealed no concerns were identified with exit doors that were checked on 03/30/2021. The checks included checking for locking, alarms, mag-lock and delayed egress for the last 30 days. According to Plant Operation Director and Assistant #1, all doors were checked by one (1) or both of them Monday-Friday and by Manager on Duty on weekends. No concerns had been identified. Observation on 05/04/2021, revealed that the door did alert on the computer screen. 16. Record review and interview with Nurse Consultant #1, on 05/04/2021 at 8:14 PM, revealed she conducted a 30-day look back of 24-hour reports and events documented in the Electronic Medical Records (EMRs) for exit-seeking behaviors that occurred in the facility. Record review and interview revealed this was conducted on 03/29/2021 and 03/30/2021 with no concerns identified except with to Resident #1. Nurse Consultant #1 stated that on 03/29/2021 she identified concerns with Resident #1 history of wandering and exit-seeking behaviors. 17. Record review and interview with Nurse Consultant #1, on 05/04/2021 at 8:14 PM, revealed she completed a 30-day look back of Nurses' Notes for exit seeking behavior and/or elopements with wandering behavior. She revealed that she had identified concerns regarding Res [TRUNCATED]

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide supervision to prevent accidents and elopement for one (1) of four (4) sampled residents (Resident #1). The facility identified Resident #1 to be at risk for elopement and placed a Wanderguard alarm bracelet on the resident on 02/12/2021 (after the resident's original admission). On 3/26/2021, at approximately 11:00 PM, staff heard an exit alarm sounding. The staff member who heard the alarm, disabled the alarm; however, failed to follow the facility policy and procedure to determine if a resident had eloped from the facility. Approximately five (5) minutes later, the west gate alarmed and the staff member went to the area to look for a resident but no residents were visualized outside at that time. Staff initiated a head count of residents in the facility and identified that Resident #1 was missing from the facility. Staff located Resident #1 outside of the facility in an adjacent parking lot (approximately 125 feet from the exit door) at approximately 11:18 PM-11:30 PM. Facility staff assisted the resident back inside the facility and assessed the resident to have no new injuries. However, documentation on the following day on 03/27/2020 at 3:39 PM revealed Resident #1 had multiple new bruises to the right knee (inside and outside area of knee), left knee, left back flank, right hip, left hip and left thigh (outside area). The facility's failure to ensure residents were supervised to prevent accidents/elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/27/21, and determined to exist on 03/26/21 at 42 CFR 483.21 Comprehensive-Person Centered Care plans (F657) and 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on 04/27/21. An acceptable Allegation of Compliance was received on 04/30/21, which alleged removal of the Immediate Jeopardy on 05/01/21. The State Survey Agency determined the Immediate Jeopardy was removed on 05/01/21, prior to exit, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F657) and 42 CFR 483.25 Quality of Care (F689), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled, Elopement/Wandering, reviewed on 05/30/2018, revealed, An elopement/wandering assessment will be completed upon admission, located in the nursing admission information packet, and quarterly thereafter. Care plans and individual behavior plans will address wandering as a specific problem. Approaches will be formulated, patterns identified (if any), and the causes determined should be addressed. If a resident is identified as missing, refer to the missing resident procedure. Review of the Missing Resident policy, with a revision date of 1/24/2021, revealed Notify the charge nurse and nursing staff when a resident is suspected of being missing. Notify the supervisor, Director of Nursing, Administrator, RVP, and SCC. Identify the missing resident to stakeholders and a staff member will immediately check all exit doors. Review of the Missing Resident-Code Green policy, undated, revealed The staff member who identified that the resident is suspected missing will immediately notify the charge nurse and inform nursing staff. The Administrator and Director of Nursing (DON) will be notified, staff will announce overhead Code Green to alert facility employees of the missing resident, activate the Incident Command System (ICS) to manage the incident. The policy continues to define the method for searching the facility such as vacant rooms, closets, etc. If the resident has not been found within 15 minutes, or after an exhaustive search of the facility and outside grounds, the person-in-charge shall carry out these steps: notify police or local law enforcement agency, notify family or responsible party (explain what is being done to find the resident, notify Attending Physician and notify appropriate agencies, per state and federal guidelines. The policy reveals when the resident has been found conduct a complete assessment of the resident for injuries, contact the physician and report findings and condition of the resident, notify law enforcement (if applicable) and all previously contacted persons, complete an incident report in event manager and review and update the care plan as indicated. Interview with the Regional Vice President of Operations, on 04/27/2021 at 4:25 PM, and the Director of Nursing (DON), on 04/26/2021 at 3:52 PM, revealed when an exit door alarm sounded, staff were required to respond to the alarm, check the door, look for the resident who activated the alarm, including observing outside the facility and initiate head count of residents in the facility. If staff identify a missing resident, staff are to follow the Missing Resident-Code Green policy. Continued interview revealed staff had been educated on this process and the above policies. Review of Resident #1's medical record revealed the facility readmitted the resident on 03/04/2021, with diagnoses that included Unspecified Dementia with Behavioral Disturbances, Unsteadiness on Feet, Mood Disorder Due to Known Physiological Condition, [CONDITION(S)], Other Specified Depressive Episodes and Other Specified Anxiety Disorders. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of seven (4), which indicated severe cognitive impairment. The resident was assessed to display wandering behavior symptoms on a daily basis. Continued review of the MDS assessment revealed the resident required assistance of one (1) staff member for safety during ambulation. The MDS assessment also revealed the resident utilized a wheelchair. Review of an Admission Elopement Assessment, dated 03/04/2021, revealed the facility had identified Resident #1 was cognitively impaired, independently mobile (ambulatory or wheelchair), had poor decision making skills, demonstrated exit-seeking behavior, wandered oblivious to safety needs and had the ability to exit the facility. The facility assessed the resident as not being at risk for elopement on this Elopement Assessment. However, review of Resident #1's Comprehensive Care Plan, dated 02/12/2021, revealed the facility identified the resident to be at risk for elopement as evidenced by diagnosis of Dementia with behavioral disturbances. Further review of the care plan revealed the facility included the following approaches on the plan of care: check function of wander guard daily; elopement risk assessment completed; observe resident for tailgating; refer to social services as needed; use cues for redirection; use diversionary activities and wander guard to be checked for placement every shift. Interview with State Registered Nurse Aide (SRNA) #1, on 04/20/2021 at 6:35 PM and SRNA #2, on 04/20/2021 at 10:35 AM, revealed Resident #1 could ambulate; however, was unsteady. Further interview, revealed Resident #1 utilized a wheelchair for mobility. On 04/27/2021 at 3:10 PM, Resident #1 was observed sitting on the edge of his/her bed. Further observation, revealed a staff member sitting with the resident one (1) on one (1). Resident #1 was observed to have a Wandergaurd bracelet to right ankle. Review of a facility investigation revealed, on 03/26/2021 at 11:15 PM, Resident #1 exited the facility through the exterior door located on the west downstairs unit without staff knowledge. According to the investigation, Licensed Practical Nurse (LPN) #2 heard the exit door alarm sound; however, thought the sounding alarm was State Registered Nurse Aide (SRNA) #1 going outside on break. A few minutes later, LPN #2 heard an alarm again and went to the exterior door near the dining room to retrieve SRNA #1 from break to assist her. At this time, the staff identified Resident #1 was not in the facility. The facility staff then began a search of the grounds, in which Resident #1 was located by LPN #2 in the parking lot next door to the facility. The facility investigation revealed that Resident #1 was identified as missing at 11:15 PM and was located by LPN #2 at 11:30 PM. Review of the weather from The Weather Channel for the night of 03/26/2021, the temperature was 51 degrees Fahrenheit. Observation of the exit doors and interview with the Plant Operation Assistant, on 04/22/2021 at 2:45 PM and 3:55 PM, revealed the downstairs unit of the facility had four (4) exterior exit doors. Two (2) of the four exit doors were equipped with the Wanderguard sensors which would alarm if a resident with a Wanderguard bracelet attempted to exit the door. All four (4) of the doors were equipped with delayed egress alarms, which would alarm and open if the bar across the door was pressed and held for 15 seconds. The Plant Operation Assistant activated each door alarm with a Wanderguard bracelet and/or by pressing on the egress bar to exit the doors. According to the Plant Operation Assistant, when the door alarms, the box on the wall displayed the alarm and he thought the computer screen at the nurse's station also displayed the location of the exit door alarming. However, observation with the Plant Operation Assistant revealed one of the exit doors (located on the west downstairs area near the Resident #1's room) did not display on the computer screen when activated and alarming. There was a panel observed above the computer screen that indicated the location of the alarming door. The Plant Operation Assistant verified by demonstration that each door required the alarm to be reset by a code at that door. The Plant Operation Assistant stated multiple doors could not be reset at once and that each door alarm must be reset at the individual door. Observation on 04/20/2021 at 7:25 PM of the area outside the exterior door located on the west downstairs unit revealed a sidewalk with a fenced area with a gate located approximately 15 feet from the door. Within the fenced area, a gazebo was located approximately 140 feet from the door. Continued observation revealed a sidewalk from the gate that ran alongside the facility to the front parking lot of the facility and building adjacent to the parking lot. The sidewalk to the parking area was at an uphill incline and there was an area between the parking lots that was uneven with rocks. The area the resident was found was approximately 70 feet from the main highway. Interview with LPN #2, on 04/20/2021 at 5:05 PM and 04/22/2021 at 4:14 PM, revealed she was working the night of 03/26/2021. The LPN stated she was assigned to provide care for Resident #1. According to LPN #2, she last saw Resident #1 at approximately 10:30 PM, and he/she was in bed, resting with eyes closed. At approximately 11:00 PM, SRNA #1 asked to go outside to the gazebo area on break. LPN #2 revealed she was in a resident room when she heard a door alarm sounding but thought it was SRNA #1 leaving for break. A few moments later, she went to the computer to identify which door was sounding; however, no door was indicated on the computer screen as alarming. At this time, she went to the exterior downstairs dining room door, entered the code to the door she was exiting and alerted SRNA #1 about the alarm. Further interview revealed SRNA #1 re-entered the facility with LPN #2 to help identify the alarm. LPN #2 revealed upon entering, both SRNA #1 and herself went to the exterior door across from laundry and entered the code to that door and the alarm ceased. LPN #2 revealed, she went back to the nursing station and at that time did not initiate a head count of residents in the facility. Per the LPN, she had not received a lot of training and was unsure what to do when a door alarm sounded prior to this incident. Approximately 5 minutes later, another alarm sounded at which time LPN #2 checked the computer screen for identification of alarm and it was alerting the west gate. LPN #2 stated she instructed SRNA #1 to perform a head count of the facility residents and she went outside to the west gate to assess the area. At approximately 11:05 PM to 11:10 PM, Resident #1 was identified as missing from the facility. LPN #2 revealed she directed SRNA #2 to alert other staff to help search for Resident #1. Per the LPN, she then left the building to search for Resident #1 in her personal vehicle. She identified that she found Resident #1 at 11:18 PM to be standing in an adjacent parking lot to the facility. LPN #2 was unable to recall the clothing Resident #1 was wearing. LPN #2 assisted Resident #1 into her personal vehicle to transport him/her back to the facility. She revealed that Resident #1 was upset and attempting to get out of the vehicle when Police Officer #1 arrived on scene. She revealed the officer assisted her to get Resident #1 back into the facility through the exterior main entrance. Once LPN #2 assisted him/her in the facility, SRNA #1 assisted Resident #1 into a wheelchair and LPN #2 left the facility to return her personal vehicle to the parking lot. Upon re-entering the facility, LPN #2 revealed she assessed Resident #1 to have old bruising to the left and right anterior face, left and right anterior arms, right posterior arm and a skin tear to the left posterior arm. LPN #2 revealed that she spoke with the Former Administrator who did not provide any instruction about increased supervision. LPN #2 revealed that she did not complete an incident/accident report, notify the physician about Resident #1 exiting the facility, notify Resident #1 representative or review and update the care plan. The LPN stated she should have called the physician when the resident eloped and the former Administrator stated he would call the family. LPN #2 denied any knowledge of Resident #1 having exit-seeking behaviors. LPN #2 did reveal that she notified Medical Doctor #1 later in the shift that Resident #1 was still trying to get out of the facility/exit-seeking but again failed to notify MD #1 that Resident #1 had left the facility unsupervised. Interview with DON, on 04/26/2021 at 3:52 PM and 04/27/2021 at 5:41 PM, Regional Nurse Consultant on 04/27/2021 at 5:02 PM, and Regional Vice President of Operations, on 04/27/2021 at 4:25 PM, revealed it was not possible to turn off any door alarm by entering a code on another door. Therefore, they could not explain how the initial alarm was turned off. Further interview, revealed there was no additional documentation of the elopement to review for clarification. Interview with SRNA # 1, on 04/20/2021 at 6:35 PM and 04/22/2021 at 3:22 PM, revealed she was working the night of 03/26/2021. She stated that she was assigned to provide care for Resident #1. At approximately 11:00 PM, she completed a walking round to check on her residents. At this time, she noted that Resident #1 was in bed with eyes closed and appeared to be resting. She proceeded to notify LPN #2 that she was going to go on break to the gazebo. SRNA #1 stated that she exited the facility through the exterior door located at the downstairs dining area. She recalled entering the code to exit the door and ensured the door closed when leaving the facility. SRNA #1 revealed at this time, no alarm was sounding. Approximately five (5) minutes later (11:05 PM), LPN #2 alerted her (by opening the exterior dining room door and speaking) that an alarm was sounding and she unable to identify where it was. At this time, SRNA #1 stated that she re-entered the facility by entering the exterior door located at the dining room. She did not recall hearing an alarm at this time. She revealed that she and LPN #2 went to the exterior door located across from laundry and checked it; however, no alarm was sounding. SRNA #1 stated that LPN #2 had stated she thought it was the exterior door on the west downstairs unit. At that time, SRNA #1 immediately thought to check if Resident #1 was in his/her room because his/her history of rambling and wandering. At approximately 11:15 PM, Resident #1 was identified as missing from the facility. SRNA #1 initiated a code green at this time. SRNA #1 stated that LPN #2 went outside the facility to search the premises. LPN #2 arrived back to the facility with Resident #1 at approximately 11:30 PM. Resident #1 was wearing jogging pants and yellow non-skid socks. SRNA #1 was unsure about the type of shirt, however, was able to verify that Resident #1 had clothing on his/her upper torso. SRNA #1 revealed she assisted Resident #1 into a wheelchair to assist in transporting Resident #1 to the downstairs floor. SRNA #1 revealed that Resident #1 was combative, agitated and attempting to go to exit doors upon arrival back to the facility. SRNA #1 stated at no time did she look at Resident #'s skin due to the resident's behavioral state. She further revealed at no time did she assist LPN #2 with a skin assessment. According to SRNA #1, Resident #1 went to sleep (time unknown); however, woke up shortly after and was agitated worse than ever and attempting to exit-seek. SRNA #1 stated that SRNA #4 assisted her with supervision of Resident #1. According to SRNA #1, she worked the following evening (3/27/2021) and Resident #1 had new bruising in several different locations on his/her body. She further revealed that she had not observed those areas during care prior to Resident #1 leaving the facility on 03/26/2021. Interview with LPN #4, on 04/26/2021 at 11:07 AM, revealed she was working on the upstairs unit on 03/26/2021. She revealed that at approximately 11:25 PM, SRNA #1 notified the upstairs staff that Resident #1 was unable to be located in the facility. She revealed she attempted to notify the DON but was unsuccessful, notified police for assistance and notified the former Administrator. She stated that the former Administrator stated to let him know when Resident #1 was located. She revealed that LPN #2 brought Resident #1 back in the facility; however, was unable to recall what clothing he/she was wearing but could recall Resident #1 was fully clothed. She revealed that upon Resident #1 arrival back to the facility, she spoke with former Administrator who attempted to give direction about follow up (every 15 minute checks, etc.). However, she revealed that she notified him that she was not Resident #1 nurse. At which time, he instructed her to have LPN #2 follow up with him. Interview with LPN #1, on 04/20/2021 at 5:11 PM and 04/21/2021 at 12:36 PM, revealed she worked on 03/27/2021 at 6:00 AM and received report from LPN #2 that morning. LPN #1 stated that she was notified by LPN #2 that Resident #1 had got outside the facility. However, was not notified that Resident #1 was on increased supervision. LPN #1 revealed that upon learning about Resident #1 getting out of the facility she initiated every 15 minute checks for Resident #1. LPN #1 further revealed Resident #1 did not exhibit exit seeking behaviors or aggressive behaviors on 03/27/2021 during her shift. LPN #1 revealed that she observed Resident #1 to have bright purple bruising after the morning meal. (Review of Resident #1 progress notes revealed a nursing note on 03/27/2021 at 8:39 AM that Resident #1 ate breakfast). LPN #1 stated she identified multiple purple bruises to the right knee inner and outer, left knee, left back flank, right hip, left hip and outer left thigh. She revealed that she notified Medical Doctor #1 office on 03/27/2021. Interview with Chief of Police, on 04/23/2021 at 10:36 AM, revealed based on the dispatch log, the call from the facility was received at 10:54 PM and an officer (Police Officer #1) was dispatched at 10:56 PM. Further interview revealed at 11:01 PM the officer arrived on scene and Resident #1 had been located upon arrival. At 11:03 PM, the officer ensured the resident was back in the building and left the scene. Interview with Police Officer #1, on 04/26/2021 at 10:07 AM, revealed he arrived on scene to find LPN #2 with Resident #1 in her personal vehicle. Resident #1 was attempting to get out of the vehicle, so both LPN #2 and himself assisted Resident #1 back into the facility. Interview with former Administrator, on 04/21/2021 at 4:13 PM, revealed he was notified by LPN #4 that Resident #1 was missing; however, at that time was not notified he/she had exited the facility. Continued interview revealed LPN #2 notified him that Resident #1 had left the facility; however, the LPN informed him that she had eyes on him/her the entire time. The former Administrator revealed that LPN #2 told him Resident #1 had fallen a couple of times; however, the LPN was unable to provide further details. Review of facility documentation revealed no evidence Resident #1 sustained falls. Interview with the Director of Nursing (DON), on 04/26/2021 at 3:52 PM and 04/27/2021 at 5:41 PM, revealed staff had attempted to contact her on the night of 03/26/2021, however, she was unavailable related to sickness. She revealed she was notified by the former Administrator on 03/26/2021 that Resident #1 had exited the facility; however, that staff had eyes on him the entire time. She revealed she was under the impression that the former Administrator had the situation handled and therefore did not implement anything further at that time. She revealed she came into the facility on [DATE], to work at approximately 8:00 AM at which time she started to realize that the staff potentially did not have eyes on Resident #1 when he/she exited the facility. She attempted to find out more information regarding the incident. She then proceeded to notify the Regional Nurse Consultant about the concerns. She revealed that based on the information she discovered Resident #1 had exited the building out the exterior downstairs door on the west unit without staffs' knowledge. She further revealed that based on the investigation initiated on 03/28/2021, she was unsure if LPN #2 responded appropriately based on the policy and procedure to the initial alarm. Per the DON, she had no knowledge of Resident #1 falling when out of the facility. The DON stated she was notified of the bruising on Resident #1; however, contributed the bruising to the combative behavior exhibited by the resident. The DON revealed she notified the Medical Doctor #1 and family representative on 03/28/2021 of the elopement (11:30 AM based on documentation). Interview with the Medical Doctor #1, on 04/21/2021 at 12:43 PM, revealed that she was notified that Resident #1 was exit-seeking on 03/27/2021; however, at that time was not told (or under the impression) that Resident #1 had physically exited that facility. She revealed further that she was notified of the incident when the DON came in the facility to work (03/28/2021). She revealed that she was aware of Resident #1 wandering behaviors and had discussed potential psychiatric treatment. She further revealed she was unaware of any bruising found on Resident #1. Interview with the Regional Nurse Consultant, on 04/27/2021 at 5:02 PM, revealed she was notified by the DON on 03/28/2021 of the call the DON received from the former Administrator stating the resident had left the facility but was not out of staff's eye sight. However, based on the DON findings on 03/28/2021 that was not accurate. She revealed at that time the facility initiated steps to increase supervision and identify any other individuals at risk for elopement. Upon arrival to the facility on [DATE], she and the Regional Vice President of Operations (in addition to another staff member) began interviewing regarding the situation. She revealed that based upon the interviews, it was undetermined if LPN #2 responded to the initial alarm per policy and procedure and was unsure how the alarm was reset. She revealed that based upon interviews, it was determined Resident #1 exited through the exterior door west downstairs unit without staff knowledge. She revealed that LPN #2 stated she looked over Resident #1 upon arrival back to the facility; however, she was unsure if a full skin assessment was completed. She stated that based on information obtained during interview, Resident #1 was placed on increased supervision (line of sight) by LPN #2, SRNA #1 and SRNA #4. Continued interview revealed she was aware of the bruising to Resident #1 extremities; however, was unaware Resident #1 had bruising to left back flank, right hip and left hip. She stated that the bruising (she was aware of) was contributed to the combative behavior (hitting walls, etc). Interview with the Regional Vice President of Operations, on 04/27/2021 at 4:25 PM, revealed he was notified by the Regional Nurse Consultant, on 03/28/2021, around noon, that she was notified of a potential elopement (Resident #1) at the facility, on 03/26/2021. He instructed at this time, staff were to place Resident #1 on increased supervision and investigate the situation. Upon arrival to the facility on [DATE], Regional Nurse Consultant and he (in addition to another staff member) began interviewing regarding the elopement. Based on interviews, it was concluded that LPN #2 heard an alarm at which point she was under the impression it was SRNA #1 leaving to go on break. A couple of minutes later, she heard an alarm again, at which time she went out and notified SRNA #1 she needed assistance. Further interview, revealed he was unsure if LPN #2 responded to the first alarm, how the first alarm was reset or reported that Resident #1 had fallen (per interview with former Administrator). He revealed he was aware of bruising on Resident #1 extremities; however, was unaware of the bruising to the left back flank, right hip and left hip. He revealed the bruising he was aware of was contributed to the combative behavior. ***The facility alleged the following was implemented to remove Immediate Jeopardy on 05/01/2021. 1. Resident #1 was assisted back to the facility on [DATE] by LPN #2 at approximately 11:40 PM. LPN #2 performed an assessment to assure resident # 1 was not harmed. No concerns were noted and resident # 1 did not voice any pain or concerns. Resident #1 was placed on increased supervision at that time per staff. Medical Doctor #1 and Power of Attorney were notified on 3/26/2021 of Resident #1's exit-seeking behavior on 03/26/2021. 2. On 03/28/2021, Resident #1 was re-evaluated for elopement by the DON with a new elopement assessment completed. The elopement care plan was reviewed by the Director of Nursing to reflect resident # 1's current needs to include that Resident #1 currently required increased supervision to include line of sight visualization by a staff member. The SRNA Care Plan was reviewed to ensure that it reflected elopement status. 3. Resident #1 was placed on 1:1 supervision on 03/28/2021 per the DON. Resident remains under 1:1 supervision in the facility at this time. The facility has sent referrals for Resident #1 for a secure unit when a bed is available. 4. On 03/26/2021, all residents residing in the facility were accounted by facility staff performing a head count. 5. All exterior doors in facility were checked by Plant Operator Director and Plant Operator Director Assistant on 03/28/2021 to ensure all doors were locked and secure and that delayed egress was functioning properly. The doors were key coded and only nurses, the Plant Ops Staff, and the Facility Administrator have codes to doors. All doors were working properly. 6. LPN #2 was provided re-education by the DON on 03/28/2021 related to the facility policy and procedure of elopement to included responding to door alarms, assessing the area (including outside) and notification of physician/family when a change in condition occurs. 7. All residents in the facility were re-assessed for elopement risk by Nurse Consultant #1 and other staff member on 03/29/2021. All elopement assessments were completed by 03/29/2021. 8. Based on the elopement assessments completed on 03/29/2021, no new residents were identified to have elopement risk. Nine (9) residents remained to be identified at risk for elopement risk. All elopement assessment were completed by 03/29/ by Nurse Consultant #1 and other staff member. 9. All care plans of the nine (9) residents identified for elopement risk were reviewed and updated by MDS Nursing staff on 03/29/2021, for any changes found on the elopement assessment. 10. The facility elopement binders were reviewed and updated for accuracy by Nurse Consultant #1 on 03/30/2021. 11. All nine (9) residents identified for elopement risk behavioral management plans were updated to include interventions for wandering or exit seeking behaviors by Nurse Consultant #1 on 03/29/2021. 12. On 03/29/2021, the Regional Vice Present and Plant Operation Director Assistant completed environmental rounds to identify any concerns to which included lose floor tiles, damage to windows or doors, faulty equipment and doors. No safety issues or concerns were identified. 13. On 03/29/2021, the Regional Maintenance Director completed 100% audits of all exit doors to ensure all exit doors locked and that the delayed egress was functioning. No concerns were identified. During audit of all exit doors, no mechanical failure of the doors were identified. 14. On 03/29/2021, the Plant Operator Director Assistant #1 ensured the nine (9) residents identified at risk for elopement Wandergaurd was functioning appropriately and system was not outdated. 15. The TELS system (which is a technology based system for managing life safety tasks and general maintenance repairs that assist with tracking of tasks for daily, weekly, monthly, quarterly and annual life safety/regulatory compliance tasks that include routine jobs such as water temperature checks, fire drills, generator checks and door checks) was reviewed to ensure all doors was checked for locking, alarms, mag-lock and delayed egress for the last 30 days by the Regional Vice President and Plant Operation Director on 03/30/2021 with no concerns identified. During rounds made with OIG surveyor and Plant Operation Director Assistant #1 on 04/22/2021, it was noted that the exterior downstairs west door was not visualized on the computer screen. Plant Operation Director Assistant #1 contacted RF Technologies (who maintain the door system) and was directed to place the door in a different section of the computer. After completion of this task and changing a battery, the door showed up on the computer system. Per life safety guidelines, facility utilizes the code alert alarm panel (panel on the wall above the computer) for the purpose of monitoring doors and not the computerized system. Doors alarm at point of contact to notify staff of which door is alarming. Per facility, at no time has staff been instructed to utilize the computer system to determine proper door function. 16. On 03/30/2021, Nurse Consultant #1 reviewed documentation including a 30 day look back period on all event and 24 hour report for exit seeking behaviors. 17. On 03/30/2021, Nurse Consultant #1 reviewed nurses' notes for the last 30 days for exit seeking behavior and/or elopements with wandering behavior for the nine (9) residents identified for elopement risk. 18. On 03/29/2021, Nurse Consultant #1 provided education for administrative staff (Administrator, DON, Unit Managers, ADON, Social services, Admissions Director, Dietary Manager, MDS Coordinators, Plant Ops, and the Quality of Life Director) with post-test including education on the following policies, procedures and processes: Elopement Policy and Procedure; Missing Resident Policy and Procedure; Door Codes/Alarms Process; Accident/Incident Policy and Procedure; Safety and Supervision Procedure; Abuse Policy and Procedure; Resident Rights Policy and Procedure; Care Plan Policy and Procedure; Facility Administration, Change of Condition Procedure; Behavior Management Policy and Procedure and Quality Assurance and Performance Improvement (QAPI) Policy and Procedure. Administrative staff were required to perform at 100% for the post test [TRUNCATED]

Based on observation, interview, and a review of facility policy, it was determined the facility failed to properly prevent the possible spread of COVID-19. On 04/07/2020, the facility chaplain was sitting in the downstairs resident dining room, not wearing a facemask as required in accordance with facility policy and The Centers for Medicare and Medicaid Services (CMS) Guidance. The findings include: A review of COVID-19 Long-Term Care Facility Guidance Dated 04/02/2020 revealed all long-term care facility personnel should wear a facemask while they are in the facility. A review of facility policy titled Novel [MEDICAL CONDITION] (COVID-19) with a revision date of 04/03/2020 revealed all stakeholders should wear a facemask while they are in the facility. Observation during the initial tour on 04/07/2020 at 10:23 AM revealed the facility chaplain was sitting in the downstairs resident dining room with a facemask that was hanging free from one ear, not covering the mouth and nose. Interview with the Chaplain on 04/07/2020 at 10:23 AM revealed he had removed the facemask to get a breath of air. An interview with the Acting Director of Nursing (DON) on 04/07/2020 at 10:46 AM revealed all staff were required to wear a facemask at all times when in the building to help prevent the spread of the Coronavirus. The policy was initiated on 04/03/2020 and all staff were trained. According to the Acting DON, she made rounds to monitor if staff were following the policy and she was providing on-the-spot education if needed. The Acting DON stated she had not identified that the chaplain was removing his mask when in the building. An interview with the Administrator on 04/08/2020 at 9:05 AM revealed the Administrator was aware of the CMS Guidance, had revised the facility policy, and implemented the guidance on 04/03/2020. According to the policy, all staff were required to wear a mask when inside the building. According to the Administrator, the chaplain should wear a mask at all times when in the building to help prevent the spread of the Coronavirus.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to provide two (2) of twenty-eight (28) sampled residents (Resident #57 and Resident #79) with notification regarding bed hold upon transfer out of the facility. Residents #57 and #79 did not receive notifications regarding bed hold when transferred to an acute care hospital. The findings include: Review of the facility policy, Facility Bedhold, dated 11/12/18, revealed the facility would notify the resident/responsible party of the facility's bed hold and readmission policies at time of admission and anytime a resident is transferred to the hospital or goes out on therapeutic leave. The policy further stated the facility would provide a written notice of the bed hold and readmission policies before a resident's transfer to the hospital or for overnight therapeutic leave. 1. Observation of Resident #57 on 10/15/19 during initial tour at approximately 12:00 noon, revealed the resident lying on his/her back in bed with head-of-bed side rails up. Further observation revealed the resident was awake and alert and had an orthotic splint to the right upper arm. Review of the record revealed Resident #57 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) quarterly assessment, dated 09/05/19, revealed a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident had moderate cognitive impairment. The MDS also revealed the resident required extensive assistance of one (1) person for the activities of bed mobility, transfer, ambulation in room, dressing, toilet use, and personal hygiene. Further review of the medical record revealed Resident #57 was transferred to an acute care hospital on [DATE], following a fall with injury while out of the facility with family. The record did not reveal that the resident or family had been provided with notification of bed hold. 2. Observation of Resident #79 on 10/15/19 at 1:29 PM revealed the resident in a wheelchair in the dining room. Further observation revealed the resident was neatly clothed and his/her hair was styled. The resident was being assisted with eating lunch by a State Registered Nurse Aide (SRNA). Review of the medical record revealed Resident #79 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS annual assessment, dated 06/27/19, revealed the resident required extensive assistance of two (2) or more persons for the activities of bed mobility, transfer, and ambulation in room and corridor. Further review of the record revealed Resident #79 had been transferred to the hospital on [DATE] and was readmitted to the facility on [DATE]. The record also revealed the resident was transferred to the hospital on [DATE] and returned to the facility on [DATE]. The record revealed no evidence that a bed hold notification had been provided to the responsible party for either transfer. Interview with the Business Office Manager (BOM) on 10/17/19 at 2:26 PM revealed she had not provided notification of bed holds for Residents #57 or #79 upon transfer to the hospital. She stated the facility did not issue notification of bed holds unless the resident was private pay and neither of these residents were private pay. Interview with the Director of Nursing (DON) on 10/17/19 at 4:34 PM revealed when a resident was transferred from the facility the BOM would call the family to see if they wished to hold the bed. She stated she was not aware the resident/family was required to be notified regarding bed hold upon transfer, nor was she aware the facility policy stated this. Interview with the Administrator on 10/17/19 at 4:54 PM revealed when a resident was transferred the facility was required to issue a notification of bed hold immediately to the resident or responsible party. He stated he was not aware the bed holds were not being issued as per policy and regulation.

Based on observation, interview, record review, facility policy review, and review of the Resident Assessment Instrument (RAI) Manual, it was determined that the facility failed to ensure accuracy of Minimum Data Set (MDS) assessments for one (1) of thirty-two (32) sampled residents (Resident #20). Resident #20 was observed to have limited range of motion to bilateral upper and lower extremities that was not coded on the MDS. The findings include: Review of the facility policy titled Resident Assessment, review date 07/31/18, revealed on page 1, The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. Review of the Resident Assessment Instrument page G-37 revealed specific steps to test the resident's upper and lower extremities for range of motion. For each hand, instruct the resident to make a fist and then open their hand. Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #20's MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 15, indicating the resident had little to no cognitive impairment. Further review of the resident's MDS revealed the resident was coded to need extensive assistance in bed mobility, transfer, dressing, and toileting. Furthermore, the resident was coded as requiring a walker and wheelchair. The resident was coded with having no impairment in range of motion. Review of Resident #20's care plan revealed the resident was at risk for falls related to weakness, unsteady gait, balance problems, and [MEDICAL CONDITION]. Further review of the care plan revealed the resident was at risk for self-care deficit complication - needs or requires assistance with all ADLs (activities of daily living) related to weakness, unsteady gait, balance problems. Observation and interview of Resident #20 on 10/15/19 at 05:52 PM revealed the resident had contractures to bilateral hands, contractures to bilateral feet, and limited range of motion to bilateral shoulders. The resident stated he/she was able to feed himself/herself after tray setup. The resident further revealed he/she needed assistance with toileting and dressing because he/she was not able to open his/her hands. The resident's fingers were observed to be contracted and both wrists were contracted. The resident demonstrated by taking their right hand and lifting the left hand to a straight position; however, when the resident released the left hand it would fall back down. The resident stated the wrist is worn away and the doctors tell me I'm not healthy enough for a joint replacement. The resident further stated he/she had a history of [REDACTED]. The resident further stated that he/she could walk a few steps with a walker but needed a wheelchair to go outside of his/her room. The resident was unable to open his/her hand. Interview on 10/17/19 at 2:02 PM with the MDS Coordinator revealed that she agreed the resident should have been coded with bilateral limitations in range of motion to both upper and lower extremities. The MDS Coordinator further revealed the resident should have a care plan regarding the limitations in range of motion. Interview on 10/17/19 at 4:35 PM with the Director of Nursing (DON) revealed she agreed that the resident had limitations in range of motion and should have been coded as such. She also agreed that the resident should have been care planned to have bilateral limitations to both upper and lower extremities. The DON further stated she did not review MDS's for accuracy.

Based on observation, interview, record review, and facility policy review it was determined that the facility failed to develop a person-centered care plan for one (1) of thirty-two (32) sampled residents (Resident #20) that met the resident's needs. Resident #20 was observed to have limited range of motion to bilateral upper and lower extremities that was not addressed on the resident's care plan. The findings include: Review of the facility policy titled Comprehensive Care Plans, reviewed 07/19/18, revealed on page 1, The Comprehensive Care Plan is based on a thorough assessment that includes, but is not limited to the Resident Assessment Instrument. Review of the Resident Assessment Instrument page G-37 revealed specific steps to test the resident's upper and lower extremities for range of motion. Review of #20's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #20's Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 15, indicating the resident had little to no cognitive impairment. Further review of the resident's MDS revealed the resident was coded to need extensive assistance in bed mobility, transfer, dressing, and toileting. Furthermore, the resident was coded as requiring a walker and wheelchair. The resident was coded with having no impairment in range of motion. Review of Resident #20's care plan revealed the resident was at risk for falls related to weakness, unsteady gait, balance problems, and [MEDICAL CONDITION]. Further review of the care plan revealed the resident was at risk for self-care deficit complication - needs or requires assistance with all ADLs (activities of daily living) related to weakness, unsteady gait, balance problems. Further review of the care plan revealed the care plan did not address the resident's limitations in range of motion. Observation and interview of Resident #20 on 10/15/19 at 5:52 PM revealed the resident had contractures to bilateral hands, contractures to bilateral feet, and limited range of motion to bilateral shoulders. The resident further revealed he/she needed assistance with toileting and dressing because he/she was not able to open his/her hands. The resident demonstrated by taking his/her right hand and lifting the left hand to a straight position; however, when the resident released the left hand it would fall back down. The resident stated the wrist is worn away and the doctors tell me I'm not healthy enough for a joint replacement. The resident further stated he/she had a history of [REDACTED]. Interview on 10/17/19 at 2:02 PM with the MDS Coordinator revealed that she agreed the resident should have been coded with bilateral limitations in range of motion to both upper and lower extremities. The MDS Coordinator further revealed the resident should have a care plan regarding the limitations in range of motion. The MDS Coordinator stated that anyone can update the care plan but the IDT team develops and maintains a comprehensive care plan for each resident. Interview on 10/17/19 at 4:35 PM with the Director of Nursing (DON) revealed she agreed that the resident had limitations in range of motion and should have been coded as such. She also agreed that the resident should have been care planned to have Bilateral Limitations to both upper and lower extremities. The DON further stated the care plan was reviewed upon admission and should have included the limitation in range of motion.

Based on observation, interview, and record review, it was determined the facility failed to ensure expired medication was not available for use and was identified timely and removed from the current medication supply. Observation of the nurses cart on Sunset Blvd. on [DATE] at 11:34 AM revealed an open bottle of [MEDICATION NAME] R dated as opened on [DATE] for unsampled Resident #72. Review of Resident #72's Physician's Orders revealed [MEDICATION NAME] R insulin had been discontinued on [DATE]. The findings include: Review of facility policy, Medication Administration, dated (MONTH) (YEAR), revealed the policy did not address insulin but on Page 4, Section 8.c stated, Certain products or package types such as multi-dose vials and ophthalmic drops have specific shortened end-of-use dating once opened, to ensure medication purity and potency (Refer to Section 9.10-Medication With Shortened Expiration Dates). Further review of the policy revealed there was no Section 9.10. Further review of the facility policy, Medication Administration, revealed the policy did not address removal of discontinued medication. Although the facility policy did not address expiration dates for opened multi-dose vials of medications, interview with the Unit Manager on [DATE] at 11:35 AM revealed insulin should be pulled and discarded after it had been opened for 30 days. Observation of the nurses cart on Sunset Blvd. on [DATE] at 11:34 AM revealed 1 bottle of [MEDICATION NAME] R with an opened date of [DATE] and still available for use on [DATE] for Resident #72. Review of Resident #72's Physician's Order revealed [MEDICATION NAME] R had been discontinued on [DATE]. Interview on [DATE] at 11:35 AM with the Unit Manager revealed that each nurse is responsible for checking the dates on medication prior to dispensing them. She further stated that the medication should have been pulled on [DATE] by the nurse that took the order to discontinue the medication and insulin should have been pulled after it had been opened for 30 days. The Unit Manager stated that the cart was checked a day earlier, [DATE], for expired medication. Interview on [DATE] at 4:44 PM with the Director of Nursing (DON) revealed when medications are expired they should be pulled and if medications are discontinued they should be pulled from the cart. The DON continued by saying it is the Unit Manager's responsibility to check the medication cart. She further stated that she had not identified any concerns with medication carts.

Based on record review, interview, and review of the facility policy, it was determined the facility failed to ensure the physician and responsible party were notified of an accident with injury for one (1) of three (3) residents (Resident #1). Resident #1 fell on [DATE] at 1:40 AM, and the facility failed to notify the physician and responsible party of the fall. The findings include: Review of the facility policy, Change in Condition, revised 07/10/18, revealed the facility would evaluate and document changes in a resident's health, mental, or psychosocial status in an efficient and effective manner. The policy further stated the information would be relayed to the physician, and any actions. Review of Resident #1's closed medical record revealed the facility admitted the resident on 06/28/19 following a hospitalization for a left [MEDICAL CONDITION] repair. Further review revealed the resident had other [DIAGNOSES REDACTED]. Review of Resident #1's discharge Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident had severe cognitive impairment. Review of an Event Report dated 06/29/19 for Resident #1 revealed the resident fell on [DATE] at 1:40 AM. The report stated the resident was found sitting on the floor in another resident's room. Resident #1's back was against a bedside table and items from the table were on the floor. The report also revealed there was water on the floor and under the resident's legs. According to the report, Resident #1 had a skin tear to the right elbow, a skin tear above and below the elbow, and an abrasion to the upper back between the shoulders. The event report stated the resident was noted to be restless during the shift prior to the fall. Interview with Licensed Practical Nurse (LPN) #1 on 07/09/19 at 12:55 PM, revealed a nurse aide called her to a resident room at approximately 1:30 AM. She stated the resident was found on the floor in another resident's room. She stated she assessed the resident, but did not notify the resident's physician or family member regarding the fall. Interview with Resident #1's Family Member on 07/10/19 at 9:20 AM, revealed the facility did not notify him that the resident had fallen on 06/29/19. He stated when he arrived at the facility on 06/29/19 at approximately 7:00 AM, the resident told him that he/she had fallen the previous night. Interview with the Director of Nursing on 07/10/19 at 10:00 AM, revealed Resident #1's physician and the family member should have been contacted regarding the fall at the time of the fall.

Based on observation, interviews, record review, and policy reviews, it was determined the facility failed to ensure that an alleged violation of abuse regarding Resident #1 was reported immediately to the administrator of the facility and to other officials in accordance with federal and state law. The findings include: Review of the facility's policy entitled Abuse, Neglect and Misappropriation of Property, revealed that all alleged violations of federal or state laws which involved abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property were investigated and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate state and local agencies in accordance with federal and state law. Review of the Minimum Data Set (MDS) for Resident #1 dated 02/01/19 revealed the resident was admitted to the facility on [DATE]. Further review of the MDS revealed the facility was unable to complete a Brief Interview for Mental Status (BIMS) because the resident was rarely or never understood and was severely cognitively impaired. Review of the MDS revealed Resident #1 had active [DIAGNOSES REDACTED]. Further review of the MDS revealed the resident did not exhibit any physical behavioral symptoms directed toward others. Observation of Resident #1 on 05/08/19 at 11:29 AM revealed Resident # 1 was sitting in a wheelchair in his/her room, and the resident was coloring. Further observation revealed the resident was alert and made eye contact when spoke to; however, the resident did not respond verbally. Observation of Resident #1 on 05/08/19 at 1:23 PM revealed Resident #1 was sitting at a dining room table attempting to eat independently with a spoon. Further observation revealed staff was sitting next to the resident, encouraging the resident to eat, and occasionally intervening to assist with feeding the resident. Continued observation revealed Resident #1 put his/her spoon into a bowl of applesauce that belonged to the resident sitting next to him/her and staff intervened. Interview with State Registered Nurse Aide (SRNA) #2 on 05/08/19 at 3:18 PM revealed on 04/15/19 she was assisting two residents during the evening meal. According to the interview, SRNA #2 witnessed Resident #1 get a handful of mashed potatoes and place them on the table. The interview revealed that SRNA #1 took Resident #1's hand, put it over the potatoes, and told the resident to pick up the potatoes. Further interview revealed that Resident #1 attempted to put his/her hand in the mashed potatoes again and SRNA #1 took the resident by the arm and stated, Don't you dare. According to the interview, this incident occurred at approximately 6:00 PM on 04/15/19. However, SRNA #2 stated she did not report the incident to anyone until 04/16/19 prior to beginning the 2:00 PM shift, when she reported the incident to the Administrator. According to the interview, the facility provided education regarding the abuse policy, and she was aware she should immediately report allegations of abuse; however, the SRNA failed to follow the facility policy. Further interview revealed that SRNA #2 had worked at another facility previously that allowed staff to report allegations the next day. Interview with SRNA #1 on 05/09/19 at 10:15 AM confirmed the SRNA worked on 04/15/19 and was in the dining room during the evening meal to assist residents with eating. According to the interview, Resident #1 started to put food down his/her shirt and then on the table. The resident then started to get into the food again, and SRNA #1 put her hand around the resident's wrist and told the resident to pick it up and put it back in the bowl. Further interview revealed SRNA #1 did not feel like his/her actions were abusive. According to the interview, SRNA #1 left the faciity on [DATE] at 6:00 PM and returned to the facility on [DATE] at approximately 2:00 PM to work the second shift. The interview revealed that the Administrator talked to the SRNA at the beginning of the shift, prior to providing any patient care, and removed SRNA #1 from direct care. Interview with the Director of Nursing (DON) on 05/08/19 at 3:45 PM revealed SRNA #1 had worked at the facility for five months and no issues had been identified related to the care the SRNA provided. Further interview revealed the Administrator made the DON aware of the allegation of abuse on 04/16/19. According to the interview and review of the SRNA's time report, SRNA #1 left the faciity on [DATE] at 5:55 PM, and was clocked in for thirty-four minutes on 04/16/19 (1:56 to 2:30 PM). Further interview with the DON revealed that SRNA #2 should have immediately reported the incident on 4/15/19. Interview with the Administrator on 05/08/19 at 4:38 PM revealed that all staff received training on the facility's abuse policy, including reporting all allegations immediately. Further interview revealed that SRNA #2 came to the Administrator's office on 04/16/19 at approximately 2:00 PM, prior to starting the second shift, and reported the incident that occurred on 04/15/19 involving Resident #1 and SRNA #1. According to the interview, SRNA #2 reported that she worked at another facility previously that allowed reporting within 24 hours. The interview revealed the Administrator had provided education during orientation for SRNA #2 on the facility's abuse policy that included timely reporting.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of one (1) resident assessment was transmitted within 14 days after Resident #1's discharge to an acute care hospital on [DATE], with no return anticipated. The findings include: Review of the facility's policy, Resident Assessment, with a revision date of (MONTH) (YEAR), revealed a return not anticipated Minimum Data Set (MDS) discharge assessment would be transmitted within fourteen (14) days of the completion date. Review of Resident #1's medical record revealed the facility admitted the resident on 04/29/18, with [DIAGNOSES REDACTED]. Review of Resident #1's discharge MDS completed by the facility on 05/20/18, revealed the resident had been discharged from the facility to an acute care hospital on [DATE], with no return anticipated. However, there was no evidence the facility had transmitted the assessment as of 09/13/18. Interview conducted with the MDS Coordinator on 09/13/18 at 9:15 AM, revealed the MDS had not been transmitted. The MDS Coordinator stated the assessment was required to be transmitted within fourteen (14) days, but it had been missed. Interview with the Director of Nursing (DON) on 09/13/18 at 4:17 PM, revealed the MDS Coordinator was responsible for ensuring MDS assessments were transmitted timely. The DON stated Resident #1's assessment had been missed. The DON stated she routinely received a report from the MDS Coordinator and had not identified any previous concerns with MDS assessments not being transmitted timely.

Based on interview, record review, and facility policy review, it was determined the facility failed to complete a Level II Preadmission Screening and Resident Review (PASARR) for one (1) of twenty-five (25) sampled residents. Resident #6 was diagnosed with [REDACTED]. The findings include: Interview with the Director of Nursing revealed the facility did not have a policy regarding the completion of PASARR assessments. Review of Resident #68's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the resident's medical record revealed [REDACTED].#68 on 09/30/08. Further review revealed Resident #68 received a new [DIAGNOSES REDACTED]. According to the resident's physician orders [REDACTED]. Review of Resident #68's quarterly Minimum Data Set (MDS) Assessments dated 06/23/18 and 08/06/18 revealed the resident was unable to complete the Brief Interview for Mental Status due to being severely cognitively impaired. Further review of the MDS Quarterly Assessments revealed Resident #68 had a [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan for Resident #68 revealed the facility identified the resident was at risk for adverse effects of [MEDICAL CONDITION] medications used to treat [MEDICAL CONDITION] and would receive continued monitoring through 11/06/18. There was no documented evidence that Resident #68 had a Level II PASARR assessment when the resident was newly diagnosed with [REDACTED]. Interview with the Social Service Worker on 09/13/18 at 5:17 PM revealed he/she was aware Resident #68 had received a new [DIAGNOSES REDACTED]. The Social Service Worker further stated she was aware a Level II PASARR was required due to the [DIAGNOSES REDACTED].#68 received the Level II PASARR assessment.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to follow the care plan for one (1) of twenty-five (25) sampled residents related to bowel and bladder. The facility staff failed to provide the assistance Resident #63 required for bed mobility as required on the Comprehensive Care Plan. The findings include: Review of the facility policy titled, Comprehensive Care Plans, not dated, revealed a person-centered Comprehensive Care Plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs was developed for each resident and included how the facility would assist the resident to meet their needs, goals, and preferences. Review of Resident #63's medical record revealed the facility admitted the resident on 07/22/13 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #63 had a Brief Interview for Mental Status (BIMS) score of three (3), indicating the resident was severely cognitively impaired and not interviewable. Further review of the assessment revealed Resident #63 was frequently incontinent of bowel and bladder and required the extensive assistance of two (2) persons for toileting and bed mobility. Review of Resident #63's Comprehensive Care Plan initially dated 07/28/16 revealed the facility identified that the resident had a self-care deficit with activities of daily living and developed a care plan with interventions for the resident to have the assistance of two (2) persons for toileting and bed mobility. However, observation of incontinence care for Resident #63 on 09/12/18 at 10:47 AM revealed State Registered Nurse Aide (SRNA) #1 assisted the resident with bed mobility while providing incontinence care, without the assistance of another staff person. Interview with SRNA #1 on 09/13/18 at 2:55 PM revealed she was aware Resident #63 required assistance of two (2) persons for bed mobility. SRNA #1 stated she got in a hurry and did not wait for a second staff person to assist. Interview with the Director of Nursing (DON) on 09/13/18 at 5:48 PM revealed staff were required to follow residents' care plans. The DON stated SRNA #1 should have waited for the assistance of another person to assist Resident #63 with bed mobility and incontinence care.

Based on observation, interview, record review, and a review of the facility's incontinence care policy, it was determined the facility failed to ensure one (1) of twenty-five (25) sampled residents (Resident #59) with urinary incontinence received appropriate treatment and services to prevent urinary tract infections. Observation revealed staff failed to provide incontinence care for Resident #59 on 09/12/18 in accordance with the facility's policy. The findings include: A review of the facility's policy titled Perineal Care Male or Female, undated, revealed the penis and scrotum were required to be cleaned and dried for male residents who were incontinent. A review of the medical record for Resident #59 revealed the facility admitted the resident on 01/26/18 with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to be frequently incontinent of urine and always incontinent of bowel. A review of the plan of care for Resident #59 revealed the facility identified that the resident had the potential for complications associated with incontinence of bowel and bladder and required peri-care after incontinence episodes. Observation conducted during a skin assessment for Resident #59 on 09/12/18 at 3:55 PM revealed the resident was incontinent of both urine and stool; however, Licensed Practical Nurse (LPN) #1 was observed to only cleanse stool from the resident's buttocks area, and did not cleanse the resident's penis or scrotum as required by the facility's policy. Interview with LPN #1 on 09/12/18 at 4:00 PM, revealed the LPN did not clean and dry the resident's genitalia because she did not notice the resident was incontinent of urine. An interview with the Director of Nursing (DON) on 09/13/18 at 3:07 PM revealed she monitored incontinence care and had not identified any concerns. Further interview with the DON revealed if a resident was incontinent, the entire peri-area should be cleansed to ensure the resident's skin was clean and dry.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to maintain the kitchen environment and equipment in a sanitary manner. Observation revealed the drip pan on the range had a buildup of food debris and dried stains, the can opener had a buildup of dried food debris on the cutting blade and stains on the base of the unit, and the bottom of the plate warmer was soiled with food and liquid stains. The findings include: 1. Review of the facility's kitchen sanitation policy, dated 02/19/15, revealed the drip pan underneath the range top was to be removed and cleaned after each evening shift. Observation of the drip pan under the range top at 8:35 AM on 09/11/18 revealed the drip pan was soiled with a buildup of food debris and burnt grease. Review of the weekly cleaning schedule revealed the range drip pan had been cleaned on Friday (no date or initials) and was wiped off on Monday (no date or initials). Interview with the Dietary Manager (DM) at 8:40 AM CDT on 09/11/18 revealed it had been a few days since the range drip pan had been cleaned. The DM stated the range drip pan should be cleaned after the evening shift. 2. Review of the facility policy for the can opener, dated 09/01/11, revealed the can opener was to be cleaned after each meal preparation and more frequently if needed. Observation of the can opener at 8:45 AM on 09/11/18 revealed there was a buildup of dried food on the cutting blade of the can opener. Further observation revealed there was dried food debris and dried liquid stains on the base plate of the unit. Review of the daily cleaning schedule revealed the can opener had been cleaned on Monday (no date or initials). Review of the weekly cleaning schedule revealed the can opener had been thoroughly cleaned on Wednesday (no date or initials). Interview with the DM at 8:45 AM CDT on 09/11/18 revealed the can opener did not appear to have been cleaned. The DM stated the can opener should be cleaned after each meal. 3. Review of the facility policy for the lowerator (plate warmer and storage) revealed the lowerator was to be wiped down daily and thoroughly cleaned every week. Observation of the lowerator at 8:40 AM CDT on 09/11/18 revealed there was dried food and liquid stains on the outside and inside surfaces of the lowerator. Review of the daily cleaning schedule revealed the lowerator was checked off to have been cleaned on Monday (no date or initials). Review of the weekly schedule revealed the lowerator was not listed to be cleaned weekly. Interview with the cook at 8:40 AM CDT on 09/11/18 revealed the lowerator was supposed to be wiped down at the end of each day, but had not been wiped off in a while.

Based on observation, interview, record review, and a review of the facility policy it was determined the facility failed to maintain an infection control program to prevent the development and transmission of infectious disease for two (2) of twenty-five (25) sampled residents (Resident #15 and Resident #70). Staff failed to utilize standard precautions of changing gloves and performing hand hygiene after performing incontinence care for Resident #15 and performing wound care treatment for [REDACTED]. The findings include: A review of the facility's infection control policy titled Standard Precautions, with a revision date of (MONTH) 2007, revealed staff were required to change gloves and perform hand hygiene as necessary during care of a resident to prevent cross-contamination and when performing wound care and moving from a dirty site to a clean site. 1. A review of Resident #15's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was assessed to be incontinent of bladder and frequently incontinent of bowel. Review of Resident #15's plan of care dated 06/20/18 revealed the resident was to be checked/changed and/or toileted every two hours and as needed. Observation of incontinence care provided to Resident #15 on 09/12/18 at 3:05 PM revealed State Registered Nurse Aide (SRNA) #2 provided incontinence care for Resident #15. However, SRNA #2 failed to change gloves and perform hand hygiene prior to applying a clean incontinence brief on the resident. In addition, observation revealed the SRNA then repositioned the resident in bed and touched the resident's linens while wearing the soiled gloves. Interview with SRNA #2 on 09/12/18 at 3:15 PM revealed the SRNA stated she was nervous and did not realize that she did not change her gloves and wash her hands after she had cleaned the resident's perineal area prior to applying a clean brief and repositioning the resident in bed. 2. Review of Resident #70's medical record revealed the facility admitted the resident on 07/11/18 with [DIAGNOSES REDACTED]. Review of Resident #70's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed to utilize a urinary catheter and to be incontinent of bowel. Review of Resident #70's care plan dated 08/24/18 revealed staff were to provide urinary catheter care as indicated. Observation of a skin assessment and catheter care for Resident #70 was conducted on 09/12/18 at 2:35 PM. The observation revealed SRNA #3 failed to remove contaminated gloves and perform hand hygiene after completing catheter care for the resident. Interview with SRNA #3 on 09/12/18 at 3:00 PM revealed she forgot to change gloves and perform hand hygiene after providing catheter care to Resident #70. Interview with the Director of Nursing (DON) on 09/13/18 at 3:07 PM revealed she monitored resident care by making rounds and was not aware of any concerns with SRNAs not using standard precautions when providing care to residents.

Based on interview and record review it was determined the facility failed to immediately consult with the resident's physician for a change of condition for one (1) of six (6) sampled residents (Resident #6). Review of Resident #6's clinical record revealed the resident sustained [REDACTED]. However, there was no documented evidence Resident #6's physician was immediately contacted or consulted when the resident sustained [REDACTED].#6 had complaints of pain; x-rays were ordered which revealed the resident had a right humerus fracture. Refer to F323. The findings include: Review of the facility's policy titled Change of Condition, undated, revealed the facility would assess and document changes in a resident's health, mental, or psychosocial status in an efficient and effective manner. The policy further stated the physician would be notified of a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment. Review of the policy guidelines revealed licensed staff was to assess any change in condition through direct observation, physical examination, and vital signs at the onset of the change. Further review of the policy revealed the Situation, Background Assessment Response (SBAR) form was to be completed and the physician and responsible party notified of the resident's change of condition. Review of the closed medical record for Resident #6 revealed the facility admitted the resident on 02/14/14 with [DIAGNOSES REDACTED]. Additional review of the record revealed the resident sustained [REDACTED]. According to the facility's SBAR and fall investigation documentation, the resident slid from the toilet and had an abrasion to the right eyebrow and bruising and a raised area to the forehead. Further review of the SBAR revealed the resident complained of right shoulder pain. However, there was no documented evidence in the record that the resident's physician was contacted related to this fall with injury until 10:00 AM on 12/05/15 (eleven hours after the fall occurred). Record review revealed the physician was again contacted at 1:30 PM on 12/05/15 due to the resident's complaints of pain; x-rays were ordered which revealed the resident had a right humerus (bone in the upper arm) fracture. The resident was ordered a sling/immobilizer for the right arm and scheduled to see an orthopedic physician. Review of the clinical record revealed there was no documented evidence the resident's physician was contacted related to the resident's decline and of the increased pain with movement until 12/07/15, when a request was made to change the resident's pain medication from as needed to scheduled. Further record review revealed the resident continued to decline, not eating and drinking as usual on 12/08/15 and 12/09/15. The resident's family requested the resident be transferred to the emergency roiagnom on [DATE] for evaluation and treatment of [REDACTED]. There was no documented evidence the resident received treatment for [REDACTED]. Interview with Registered Nurse (RN) #1 on 01/13/16 at 12:52 PM revealed she had been notified by staff that the resident was on the floor of his/her bathroom on 12/04/15. According to RN #1, the resident was sitting on his/her buttocks on the floor of the bathroom with his/her legs stretched out and was upset. RN #1 stated she assessed the resident and the resident had no visible injuries at that time or any complaints of pain at that time. Further interview with RN #1 revealed the resident was assisted up to a chair by RN #1 and a State Registered Nurse Aide (SRNA) with the use of a gait belt. The resident was further assessed and it was discovered the resident had an abrasion to the right eye and a red area to the forehead. During interview with RN #1 she stated she had contacted the resident's family and the family member came to the facility and stayed with the resident. According to RN #1, she thought she contacted the resident's physician, but she could not remember. RN #1 stated she administered Tylenol (pain medication) to the resident for complaints of pain to the right arm and general pain at approximately 12:30 AM and 4:30 AM on 12/05/15. RN #1 stated she was not aware the resident had a fractured right humerus until returning to work on the evening of 12/05/15, and she became aware the resident had a [MEDICAL CONDITION] after the resident was sent to the hospital on [DATE]. Interview with RN #2 on 01/13/16 at 2:50 PM revealed she contacted the resident's physician via fax on 12/05/15 at 10:00 AM to inform the physician that Resident #1 had fallen, as there was no documented evidence that RN #1 had notified the physician. Further interview revealed after the resident's family had informed the nurse the resident was having arm, leg, and knee pain, the physician was contacted at 1:30 PM by phone and orders were received for x-rays to be completed. Further interview revealed the x-rays revealed the resident had a fractured humerus. Interview with Resident #1's physician on 01/13/16 at 2:20 PM revealed the physician could not remember being notified of the resident's fall. According to the physician, if he had been notified of a suspected injury he would have ordered the resident to be transferred to the hospital for evaluation and treatment. Interview with the Director of Nursing (DON) revealed the facility was under new management that started on 12/01/15. The DON stated that some of the facility's documentation forms had changed, but standard procedures for notifying the resident's physician for falls and change of condition were the same as before 12/01/15. According to the DON, it was facility policy to notify the resident's physician of a fall or a change of condition. Further interview revealed the DON had reviewed the fall investigation on 12/07/15 and discussed the facility's failure to notify the physician with RN #1.

Based on interview, record review, and review of the facility's care plan policy/procedure it was determined the facility failed to revise the care plan for one (1) of six (6) sampled residents (Resident #6). Resident #6 went to the hospital on [DATE] for an amputation of the right great toe. The resident was previously assessed by the facility to be at risk for falls and was noncompliant with asking for assistance to ambulate. The facility failed to revise the resident's care plan to reflect an increased risk for falls after the amputation of his/her great toe. Resident #6 ambulated to the bathroom without assistance on 12/04/15 and sustained a fall with injury (a fractured right humerus and fractured right hip). Refer to F323. The findings include: Review of the facility's policy titled Care Plans-Comprehensive, dated 06/01/15, revealed an individualized comprehensive care plan including measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs was developed for each resident. Review of the policy's guidelines revealed care plans were revised as information about the resident and the resident's condition changed. Further review of the guidelines revealed the nurse/interdisciplinary team was responsible for reviewing and updating care plans with changes in the resident's status when there was a significant change of condition, when a desired outcome was not met, and when the resident had been readmitted to the facility from a hospital stay. Review of Resident #6's medical record revealed the facility admitted the resident on 02/14/14 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to be severely impaired for cognition with a Brief Interview for Mental Status (BIMS) score of 6. The facility assessed the resident to require the extensive assistance of one person for ambulation. Review of the resident's Comprehensive Care Plan dated 11/06/15 revealed the facility care planned the resident for potential for falls related to weakness, unsteady gait, balance problems, history of [MEDICAL CONDITION], and noncompliance with calling for assistance. Review of the interventions developed to prevent falls revealed staff was to encourage the resident to use the call light for assistance, remind the resident to ask for assistance, and to provide routine care according to the nurse aide care plan which indicated the resident was to be assisted with ambulation. Further review of the care plan revealed the facility did not review or revise the interventions related to falls after the resident had the amputation of the right great toe on 12/04/15 related to the resident requiring more assistance with ambulation and supervision related to a history of not calling for assistance. Review of nurse's notes dated 12/04/15 revealed Resident #6 was transported to the hospital at 7:20 AM for surgery to have the right great toe amputated and returned to the facility at 11:45 AM the same day after the procedure. Further review of the nurse's notes revealed the resident sustained [REDACTED]. Review of the fall investigation revealed it was determined the resident slid from the toilet. According to the nurse's notes, the resident was found to have a right humerus fracture the next day on 12/05/15. Further review of the notes revealed the resident was transferred to the hospital at the request of the family on 12/09/15 and was diagnosed with [REDACTED]. Interview with Family Member (FM) #1 on 01/12/16 at 2:05 PM revealed the family member was at the facility on 12/04/15 when Resident #6 returned from surgery. The family member stayed with the resident and had assisted the resident to ambulate to the bathroom. According to FM #1, the resident was unsteady and required more assistance than usual when ambulating due to the toe ambulation and the surgical dressing on his/her right foot. Interview with Registered Nurse (RN) #2 on 01/13/16 at 2:50 PM revealed she assessed Resident #6 after the resident returned from surgery on 12/04/15. According to the RN, the resident's right foot was bandaged, the dressing was clean, dry, and intact, and the resident had no complaints of pain. RN #2 stated she did not assess the resident's gait when the resident returned to the facility, nor had she considered the resident to be at increased risk for falls due to the toe amputation. RN #2 stated she discussed with the State Registered Nurse Aides (SRNAs) to watch the resident more closely, but she did not revise the resident's plan of care to include any interventions for increased supervision related to the resident's potential change in his/her gait. Interview with the MDS Nurse on 01/15/16 at 2:20 PM revealed the MDS Nurse revised Resident #6's pressure ulcer plan of care to include interventions to leave the resident's surgical dressing in place and to wear a surgical shoe when ambulating when the resident had surgery on 12/04/15. However, she did not revise the resident's fall care plan because the resident was already care planned to be at risk for falls. According to the MDS Nurse, she was not aware the amputation of the right great toe would affect the resident's balance and she had not considered any increased supervision even though the resident was not compliant with asking for assistance with ambulation. Interview with the Director of Nursing (DON) on 01/12/16 at 4:00 PM revealed when a resident returned from the hospital after a procedure, the resident was to be assessed by the nurse and the resident's care plan updated with interventions the resident would require to meet his/her needs related to the assessment. According to the DON, she was not aware the resident's falls care plan had not been updated or any interventions considered related to the resident ambulating unassisted after the amputation of his/her right great toe.

Based on interview, record review, hospital emergency room record, and review of the facility's falls policy it was determined the facility failed to ensure one (1) of six (6) sampled residents (Resident #6) received adequate supervision and assistance to prevent accidents. Resident #6 had an amputation of the right great toe on 12/04/15 and returned to the facility the same day. The facility failed to assess the resident's need for assistance with ambulation and develop a care plan to address the risks related to the amputation of the toe. As a result, Resident #6 ambulated to the bathroom without assistance and sustained a fall with injury fracturing the right humerus and the right hip on 12/04/15. The findings include: Review of the facility's policy for falls with a revision date of 06/01/15 revealed all residents would have a comprehensive fall risk assessment completed with a significant change of condition, and appropriate care plan interventions would be implemented and evaluated as indicated by the assessment. Further review of the policy revealed if a resident sustained [REDACTED]. Further review of the policy revealed the resident would be assessed every shift for 72 hours after the fall and pain would be evaluated for 72 hours for all residents who experienced a fall. Review of the closed medical record for Resident #6 revealed the facility admitted the resident on 02/14/14 with [DIAGNOSES REDACTED]. Further review of the record revealed the resident had [DIAGNOSES REDACTED]. Review of the resident's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to be severely impaired for cognition with a Brief Interview for Mental Status (BIMS) score of 6. The facility assessed the resident to require the extensive assistance of one person for ambulation. Review of the resident's Comprehensive Care Plan dated 11/06/15, revealed the resident was care planned for potential for falls related to weakness, unsteady gait, balance problems, history of vertigo, and noncompliance with calling for assistance. Further record review revealed the resident had surgery for [REDACTED]. There was no documented evidence the resident was assessed upon his/her return to the facility for increased fall risks. There was no documented evidence of any additional interventions added to the resident's fall care plan. Record review revealed Resident #6 was found on the floor of his/her bathroom at 11:20 PM on 12/04/15. The resident was assessed to have an abrasion to the right eyebrow and a raised area to the forehead and no other injuries. There was no documented evidence the physician was immediately notified of the fall. Further review revealed staff assisted the resident back to bed. The resident had complaints of right arm pain and was given Tylenol (pain medication) on 12/05/15 at 12:20 AM, and again at 4:45 AM. Record review revealed the physician was not notified of the fall until 12/05/15 at 10:00 AM. According to the record, the resident continued to complain of pain and the physician was contacted again at 1:30 PM on 12/05/15 and ordered x-rays that revealed a fracture to the right humerus. Orders were received for the resident to have a sling/immobilizer and follow up with an orthopedic physician. According to nurse's notes, pain flow sheets, dietary intake record, and the resident's care flow record, Resident #6 continued to have pain and declined in eating and drinking and activities of daily living. On 12/09/15 at 5:30 PM, the resident's family requested the resident be sent to the hospital for evaluation and treatment. Review of the emergency room hospital record revealed the resident was admitted and diagnosed with [REDACTED]. Interview with State Registered Nurse Aide (SRNA) #1 on 01/13/16 at 12:10 PM revealed she was passing ice on night shift (10:00 PM to 6:00 AM) on 12/04/15, when she heard Resident #6 call for help. According to the SRNA, she found Resident #6 on the bathroom floor and immediately notified Registered Nurse (RN) #1. Further interview with the SRNA revealed RN #1 checked the resident and the resident did not complain of pain; staff assisted the resident back to bed. SRNA #1 stated prior to Resident #6's surgery on 12/04/15, the resident could ambulate independently and did not ask for assistance in going to the bathroom. The SRNA stated the resident was modest and she would check on him/her every two hours. SRNA #1 stated she was not aware of the resident having any complaints of pain. Interview with SRNA #2, who was assigned to Resident #6 on 12/05/15 and who routinely was assigned to care for the resident, revealed on 12/05/15 the resident was not able to perform activities of daily living, ambulate, and transfer the same as before the surgery on 12/04/15. According to the SRNA, the resident was provided a bedside commode and would complain of pain with movement and transfers. The SRNA further stated that the resident was care planned to have assistance with ambulation to the bathroom, but the resident would normally ambulate without assistance to the bathroom prior to 12/04/15. The SRNA stated Resident #6 continued to decline to the point of not getting out of bed and was complaining of more pain. SRNA #2 stated on 12/09/15, the resident was sent to the hospital and it was discovered the resident had a fractured hip. Interview with RN #2 on 01/13/16 at 2:50 PM revealed RN #2 assessed Resident #6 when the resident returned from surgery on 12/04/15. According to RN #2, the resident was sitting in the recliner in the room with his/her feet elevated. The resident's right foot was bandaged and the dressing was clean, dry, and intact and the resident had no complaints of pain. RN #2 stated she did not assess the resident's gait, but she did discuss with the SRNAs to watch the resident more. RN #2 stated she did not revise the resident's plan of care to include any interventions for increased supervision related to the resident's amputation. Interview with RN #1 on 01/13/16 at 12:52 PM revealed the nurse had been notified by staff that Resident #6 was on the floor of the bathroom on 12/04/15. According to RN #1, the resident was sitting on his/her buttocks on the floor of the bathroom with his/her legs stretched out and was upset. RN #1 stated she assessed the resident and the resident had no visible injuries and no complaints of pain at that time. According to RN #1, she had the resident move his/her upper and lower extremities, but did not do range of motion or palpate the resident's joints for any deformities during the assessment. Further interview revealed RN #1 and SRNA #1 with the use of a gait belt assisted the resident up to a chair. The resident was further assessed and it was discovered the resident had an abrasion to the right eye and a red area to the forehead. RN #1 stated she contacted the resident's family and the family member came to the facility and stayed with the resident. According to RN #1, she thought she contacted the resident's physician, but could not remember. RN #1 stated that she would have documented the notification if she had notified the physician. She stated she was not aware the resident had a fractured right humerus until returning to work on the evening of 12/05/15, and she became aware the resident had a fractured hip after the resident was sent to the hospital on [DATE]. According to RN #2, she notified the resident's physician of the fall via fax on 12/05/15 at 10:00 AM because the physician had not been notified. Further interview with RN #2 revealed the family notified her that the resident was having arm, leg, and knee pain and the resident's physician was contacted again on 12/05/15 at 1:30 PM by phone. RN #2 stated the physician ordered x-rays to be completed and it was discovered the resident had a fractured humerus. RN #2 stated on 12/09/15 the resident was scheduled for an orthopedic appointment due to the fractured humerus, but the family declined and the physician was contacted because the resident was having pelvic/hip pain and additional portable x-rays were ordered. RN #2 stated the family did not want to wait on the x-rays and requested the resident be transferred to the hospital. The resident was sent to the hospital and was diagnosed with [REDACTED]. Interview conducted with Family Member (FM) #1 on 01/12/16 at 2:05 PM revealed the facility contacted him/her when the resident sustained [REDACTED]. FM #1 stated she came to the facility and stayed with the resident the rest of the night. According to FM #1, the resident complained of pain and was administered medication that did not relieve his/her pain; the resident cried and moaned the rest of the night. Further interview with FM #1 revealed she noticed the resident's pain was getting worse on 12/05/15 and reported this to RN #2; the resident was later found to have a fractured humerus. Additional interview with FM #1 revealed the resident continued to have pain and was not improving and she noticed the resident's right leg was turned in on 12/09/15. FM #1 stated this concern was reported to RN #2 on 12/09/15. According to the family member, portable x-rays were ordered but the x-rays could not be completed timely so the family requested the resident be sent to the hospital on [DATE] where the resident was diagnosed with [REDACTED]. Interview with the Director of Nursing (DON) on 01/12/16 at 4:00 PM revealed if the resident had a fall, the resident should have been assessed at the time of the fall, the physician and family contacted, and if the resident had injuries requiring treatment the resident should have been transferred to the hospital. The DON further stated if the resident had no injuries at the time of the fall, the resident was to be monitored for 72 hours for any further complications, and the physician notified of any changes of condition. According to the DON, when a resident returned from the hospital after a procedure, the resident was to be assessed and the resident's care plan updated with any interventions the resident would require related to the assessment.

Based on interview, record review, and a review of facility policy, it was determined the facility failed to ensure services were provided according to the plan of care for one of four sampled residents (Resident #1). On 06/01/12, the facility failed to lower Resident #1's bed to the floor in accordance with the resident's plan of care. Resident #1 sustained a fall resulting in a pelvic fracture and bruise to the resident's head. The findings include: A review of facility's care plan policy, dated 04/20/12, revealed all residents were to be "Care Planned" according to the Resident Assessment Instrument (RAI) per the RAI manual. A review of the Falls Management Policy, dated 01/01/02, revealed the facility was to screen all residents for their risk for falls, evaluate those risks, implement interventions to reduce those risks, and monitor those interventions. A review of the medical record for Resident #1 revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A comprehensive significant change assessment completed on 05/21/12, revealed the facility assessed the resident was at risk for falls due to impaired mobility, weakness, and impaired cognitive status, the utilization of antidepressants, cardiovascular medications, and diuretics. In addition, internal risk factors for falls included cardiac [MEDICAL CONDITIONS], Depression, and Dementia. A care plan, dated 05/22/12, was reviewed/revised to address the resident's risk for falls. A review of the plan of care for Resident #1 revealed interventions that included placing the resident's bed on the floor and a body alarm. An interview with State Registered Nurse Aide (SRNA) #1 on 06/05/12, at 2:10 PM, revealed SRNA #1 had been an employee of the facility for eleven years and had received education regarding nurse aide care plans. SRNA #1 stated SRNAs were required to check the nurse aide care plan at the beginning of the shift to ensure they were aware of each resident's care needs. SRNA #1 stated she had not checked the nurse aide care plan for Resident #1 on 06/01/12, although she knew she was supposed to review it. SRNA #1 stated she and SRNA #2 checked Resident #1's brief for incontinence and then turned and repositioned the resident. SRNA #1 stated the two nurse aides had completed care for Resident #1 and SRNA #2 left the room. SRNA #1 stated she began caring for Resident #1's roommate when she heard a loud noise and when she looked, Resident #1 was on the floor. SRNA #1 stated she had not checked the nurse aide care plan and was not aware the bed was to be lowered to the floor and she failed to lower Resident #1's bed to the floor. An interview with SRNA #2 on 06/05/12, at 2:00 PM, revealed SRNA #2 had been employed by the facility for twelve years and had been educated in the use of the nurse aide care plan and that she was to check it daily at the beginning of the shift. SRNA #2 stated she helped SRNA #1 to provide care for Resident #1. SRNA #2 stated she had checked the nurse aide care plan and was aware that Resident #1's bed was required to be on the floor, but SRNA #2 stated she "just forgot" and left the resident's room without lowering the bed. An interview with Registered Nurse (RN) #2 on 06/05/12, at 3:00 PM, revealed she was called to Resident #1's room immediately following the fall. The RN stated when she assessed the resident and attempted range of motion, the resident complained of pain. The RN notified the physician and the resident was transported to the Emergency Department of the hospital. A review of the Emergency Department record revealed Resident #1 sustained a pelvic fracture and a bruise to the head.

Based on observation, interview, record review, and a review of facility policy, it was determined the facility failed to provide adequate supervision to prevent accidents for one of four sampled residents (Resident #1). Resident #1 was assessed to be at risk for falls and required the bed to be lowered to the floor. On 06/01/12, staff failed to lower the resident's bed to the floor and the resident fell from the bed and sustained a fractured pelvis and bruise to the head. The findings include: A review of the facility's Fall Management Policy, dated 01/01/10, revealed the facility would screen all residents to identify fall risk, evaluate those risks, implement interventions to reduce risks, and monitor the interventions. A review of the medical record for Resident #1 revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A comprehensive significant change assessment completed on 05/21/12, revealed the facility assessed the resident to be totally dependent on staff for all activities of daily living and was at risk for falls due to impaired mobility, weakness, and impaired cognitive status, the utilization of antidepressants, cardiovascular medications, and diuretics. In addition, internal risk factors for falls included cardiac dysrhythmias, Parkinson's Disease, Depression and Dementia. A care plan, dated 05/22/12, was developed to address the resident's risk for falls which included an intervention to place the resident's bed on the floor. A review of the nurse's notes dated 06/01/12, at 3:45 PM, revealed Registered Nurse (RN) #2 was called to the resident's room and found the resident lying on the floor between the bed and the wall with the resident's upper body noted to be lying on the stand for the overbed table. Resident #1 was alert and oriented to name only and screamed when the right leg was touched. The RN noted the right foot displayed an outward rotation. The physician and the responsible party were notified and orders were received to transport the resident to the Emergency Department for evaluation. A review of the hospital admission history and physical revealed Resident #1 sustained a pelvic fracture and a bruise to the head. Observation of Resident #1 at the hospital on [DATE], at 12:00 PM, revealed the resident was awake and alert but nonverbal and was turned to the left side with bilateral half side rails in the elevated position. A hospital staff member was sitting with the resident at the bedside. An interview conducted with the Registered Nurse Manager at the hospital on [DATE], at 11:30 AM, revealed the resident was being discharged to another long term care facility and there was a sitter with the resident at all times until transfer. An interview with State Registered Nurse Aide #1 (SRNA #1) on 06/05/12, at 2:10 PM, revealed SRNAs were required to check the nurse aide care plan at the beginning of the shift to ensure they were aware of each resident's care needs. SRNA #1 stated she had not checked the nurse aide care plan on 06/01/12, although she knew she was supposed to review it. SRNA #1 stated she and SRNA #2 checked Resident #1's brief for incontinence and then turned and repositioned the resident. SRNA #1 stated the two nurse aides had completed care for Resident #1 and SRNA #2 left the room. SRNA #1 stated she began caring for Resident #1's roommate when she heard a loud noise and when she looked, Resident #1 was on the floor. SRNA #1 stated she was not aware the bed was to be lowered to the floor and she failed to lower Resident #1's bed to the floor. An interview with SRNA #2 on 06/05/12, at 2:00 PM, revealed SRNA #2 was aware she was to check the nurse aide care plan daily at the beginning of the shift. SRNA #2 stated she helped SRNA #1 to provide care for Resident #1. SRNA #2 stated she had checked the nurse aide care plan and was aware that Resident #1's bed was required to be on the floor, but SRNA #2 stated she "just forgot" and left the resident's room without lowering the bed. An interview conducted with the Director of Nursing (DON) on 06/05/12, at 1:30 PM, revealed the nurses on the floor were responsible to update the nurse aide care plan as needed and to check them daily. The DON further stated the SRNAs were to check their residents' nurse aide care plans prior to beginning the shift to obtain information related to each resident's care needs and to check for any changes that may have been added. According to the DON, the nurses were required to ensure SRNAs cared for residents as directed by the nurse aide care plan and the DON was responsible to ensure nurses followed the resident's plan of care. The DON stated she made frequent rounds daily throughout the facility.