Every finding on record at Solaris Healthcare Pensacola

Based on observation, interviews and record review, the facility failed to ensure the interdisciplinary team assessed and determined a resident was capable of self-administration of medications prior to allowing 1 of 28 sampled residents to self-administer medications. (Resident #80) The findings include: On 3/18/24 at approximately 1:08 PM, an observation of Resident #80 was conducted. A 30-milliliter medicine cup containing three pills, a small drinking cup containing a cloudy liquid with a plastic spoon, and a 30-milliliter cup containing a clear salve were observed on the over the bed table. The resident indicated she fell asleep and forgot to take her pills and confirmed the nurse left the medications for her to self-administer. The resident also indicated the nurse leaves the medications on occasion if the resident is not ready to take the medications or if the resident is sleeping. On 3/18/24 at approximately 1:15 PM, an interview was conducted with Staff B, a Licensed Practical Nurse (LPN). The LPN indicated she did not know where the medications came from. She indicated she administered and watched the resident take her medications this morning and could not recall a specific time. The LPN indicated she thought perhaps the overnight shift left the medications. She indicated she did not notice the medications this morning on the resident's over the bed table. The LPN is not sure if Resident #80 has been evaluated to self-administer her medications. She confirmed the facility does not allow nurses to leave medications unlocked at the bedside. On 3/18/24, a review of the resident's electronic medical record did not reveal a physician order for the resident to self-administer her medications. A review of the resident's medication administration record for 3/17/24 revealed no medications were administered during the overnight shift. A review of the admission minimum data set with an assessment date of 9/12/23 reveals the resident has a BIMS (brief interview of mental status) of 15 indicating she is cognitively intact. There was no documentation to verify if self-administration of medications had been reviewed and/or approved. On 3/19/24 at approximately 10:12 AM, an interview was conducted with the Director of Nursing (DON) regarding nurses leaving medications at the bedside for residents to self-administer. The DON was shown the photo of the medications left on the over the bed table. The DON indicated, per facility policy, the nurse should have watched the resident take the medications and should have applied any topical medications as ordered.

Based on observations, record reviews, and interviews, the facility failed to develop an accurate care plan for 1 of 1 residents sampled for dental concerns. (Resident #100) The findings include: On 3/18/24 at approximately 12:00 PM, Resident #100 was observed during the initial tour. The resident was observed to have no natural teeth and no dentures. A subsequent record review was conducted for Resident #100. The plan of care did not address the resident's dental status. A review of the resident's annual Minimum Data Set (MDS) assessment from 5/14/23 addressed the resident's dental status but did not document the resident was edentulous (no teeth). On 3/20/24, at approximately 10:57 AM, an interview was conducted with Staff G, a registered nurse and MDS coordinator. Staff G reviewed the MDS from 5/14/23 and agreed the dental status was not done correctly. Staff G stated the quarterly assessments do not address dental issues, only the annual assessment. Staff G stated she started in the position in July 2023 and would not have noticed the MDS was incorrect until the next annual assessment due in May 2024. The staff member stated because the MDS was incorrect, it did not trigger the dental issues for the plan of care.

Based on observation, record review and interview the facility failed to provide a respiratory care and services for 1 of 1 resident sampled. (Resident #104) The findings include: On 03/19/24 at approximately 01:39 PM, it was observed that Resident #104 did not have a date on her oxygen tubing (Photographic evidence obtained). When asked, the resident stated that it had never been changed since admission to the facility in mid-January. On 03/19/24 at approximately 01:51 PM, an interview with the respiratory therapist was conducted. When asked how often oxygen tubing should be changed, he stated it should be done twice a week and it should be dated every time. When asked when the last time the tubing had been changed for Resident #104, he stated that resident was not on his list, and he had never had the oxygen tubing changed. On 03/19/24 at approximately 01:55 PM, Staff E, a Registered Nurse (RN), came in Resident #104's room. When asked about changing out the oxygen tubing, she stated I had no idea they (the oxygen tubing) needed to be changed. When the resident goes to therapy. I wipe it down with alcohol. On 03/19/24 at approximately 01:59 PM, the Director of Nursing (DON) was interviewed. When asked how respiratory therapy gets a list of residents on oxygen, she stated, Respiratory Therapy gets a list from central supplies once a concentrator is issued. Respiratory Therapy then has to change tubing and filters regularly. When asked about Resident #104 not receiving new tubing, the DON stated, Our supply person changed over in the last couple of month that was probably the issue.

Based on observation, record review, staff interview, and policy review, the facility failed to honor a resident's request for a different meal choice for 1 of 2 sampled residents reviewed for food. (Resident #88) The findings include: An observation of Resident #88 was conducted on 3/19/24 at 12:41 PM. The resident was served the lunch tray, tasted the food consisting of beef tips with noodles and gravy and broccoli, and stated he did not like it. The resident initiated the call light and Employee A, a Certified Nursing Assistant, answered the call light. The resident requested a hot dog and chips to replace his lunch meal. An interview was conducted with Resident #88 on 3/19/24 at 1:11 PM. He stated Employee A came back and offered him a sandwich, stating the kitchen would not make him a hot dog. He stated he did not want a sandwich. Observation of his lunch tray revealed he ate 2 ice creams for lunch. An interview was conducted with Employee A on 3/19/24 at 1:15 PM. She stated she asked the kitchen staff for a hot dog for Resident #88 and the kitchen staff told her they did not have any at that time, but he could have a hot dog for dinner. They offered a sandwich instead. An observation of the kitchen on 3/19/24 at 1:45 PM revealed hot dogs were available in the freezer. A further interview was conducted with Resident #88 on 3/19/24 at 2:53 PM. He stated he has had difficulty obtaining alternate food from the kitchen many times. He stated, you can even order an alternate ahead of time and you still will not receive the alternate. A review of Resident #88's electronic medical record revealed a nutritional assessment dated [DATE], indicating the resident was underweight with a weight gain regimen and goal weight of 155 pounds. The current weight was 113 pounds. A review of the quarterly minimum data set from 12/22/23 revealed the resident had a brief interview of mental status (BIMS) score of 15, indicating he was cognitively intact. The care plan for nutrition status, dated 1/19/21, indicated the resident was underweight with a history of significant weight loss. The resident desired weight gain, with a goal weight of 155-160 pounds. The interventions included offering meal substitute as needed. An interview was conducted with Employee C, a dietary technician, on 3/19/24 at 2:07 PM. She stated the resident was at risk for nutritional issues and weight loss. She stated that if he does not eat a meal, the staff should offer him something else. She stated they have an always available menu, but the staff have to let the kitchen know by 10:30 AM what the resident would like for lunch. She stated the kitchen staff could have made the resident a hot dog after the tray line was completed. A review of the facility policy Exercise of Rights (4.15 reviewed January 2023) revealed, Residents have freedom of choice, as much as possible, about how they wish to live their everyday lives and receive care, subject to our facility's rules and regulations affecting resident conduct and those regulations governing protection of resident health and safety.

Based on record review, staff interviews, and policy review, the facility failed to provide adequate supervision of a vulnerable resident identified to be at risk for elopement due to exit seeking, by allowing the resident to exit the facility unescorted by staff, and subsequently leave the facility grounds with a visitor unknown to the resident. This affected Resident #90 who was 1 of 2 sampled residents reviewed for accidents and supervision. The facility staff failed to intervene or report to nursing staff when the visitor reported to the receptionist that he was going to escort the resident across the street to the emergency room per the resident's request on 1/1/23 at approximately 5:50 PM. Facility nursing staff did not become aware the resident was not in the facility until approximately 7:45 PM on 1/1/23 when the resident's son called the facility to inform them she was at the emergency room receiving treatment for shoulder pain. This failure allowed the resident who had a documented diagnosis of dementia and moderate cognitive impairment to leave the facility premises with a visitor unknown to the resident, placing the resident at risk for serious injury, harm, abduction, elopement, or death. The situation resulted in a finding of Immediate Jeopardy. The facility's Administrator and the Director of Nursing were notified of the findings of Immediate Jeopardy on 1/13/23 at approximately 11:44 AM. The Immediate Jeopardy was ongoing as of the survey exit on 1/13/23. The findings include: Review of resident #90's electronic medical record revealed the resident was admitted to the facility on [DATE] and had a current diagnosis of dementia. The admission MDS (Minimum Data Set) with an assessment reference date of 11/15/22 indicated the resident had a BIMS (Brief Interview for Mental Status) score of 8, indicating moderate cognitive impairment. An elopement risk observation, documented on 11/30/22, indicated the resident was at risk for elopement with a score of 3, and proceed with safety interventions. The record revealed a current plan of care dated 12/10/22 stating the resident was at risk for elopement due to noted exit seeking and she exhibited fluctuations in level of cognition and understanding. The care plan goal included the resident's risk for elopement will be minimized through the next review date with a target date of 3/10/23. The care plan interventions dated 12/10/22 included inform staff and the resident's visitors about risk for elopement and exit seeking, monitor for verbalizations of wanting to leave, picture in elopement book, redirect and provide support when wandering or requesting to exit the facility, and report observations and concerns to physician/nurse practitioner as needed. A psychiatric progress note dated 12/28/22 revealed resident #90 had a history of dementia and presented as pleasantly confused. Progress notes reviewed over the previous 30 days noted intermittent confusion, wandering, restlessness, and placing herself on the floor. Resident limitations listed cognitively impaired and hearing impaired, alert to person and partial to date. The resident progress notes dated December 1, 2022 through January 1, 2023 revealed 14 documented observations of the resident wandering in the facility and being redirected by staff on 12/1/22, 12/2/22, 12/3/22, 12/4/22, 12/5/22, 12/10/22, 12/11/22,12/12/22, 12/22/22, 12/24/22, 12/30/22, and 1/1/23. The resident progress notes dated 1/1/23 recorded as a late entry on 1/11/23 indicated the facility was notified by the resident's son that she had left the facility and gone to the emergency room . The resident did not sign out of the facility upon leaving the facility and did not have a staff member escort her. She returned to the facility with her sons via personal vehicle. The resident was placed on one-to-one supervision due to risk for elopement. Review of the facility investigation revealed on 1/1/23 at approximately 5:45 PM employee B (former receptionist) observed resident #90 to enter the front lobby, exit the facility, and sit on a bench outside the front of the facility. She then observed the resident speaking with a visitor of another resident. The visitor then walked into the facility and stated the resident had asked to be assisted to the hospital across the street to get assistance for her arm. He stated he was going to walk her across the street, and they left the facility property on 1/1/23 at approximately 5:50 PM. The registered nurse house supervisor reported he was notified by the resident's son on 1/1/23 at approximately 7:45 PM that she had left the facility and gone to the emergency room . Review of the facility investigation and staff statements of the event revealed prior to the event the resident had asked a staff member to go home while she was ambulating the halls on 1/1/23, and the resident was observed going to the doors looking for a way to get outside on 1/1/23. An interview was conducted with the Director of Nursing (DON) on 1/12/23 at 2:43 PM. She stated the visitor was at the facility to visit another resident. She called that resident's sister, and she did not have any contact information for the visitor. A telephone interview was conducted with employee B (former receptionist) on 1/12/23 at 3:16 PM. Employee B stated resident #90's picture was not in the elopement book at the time of the event on 1/1/23 and refused to answer further questions regarding the event. A telephone interview was conducted with the resident's son on 1/12/23 at 3:25 PM. He stated the resident was in the hospital, had just had surgery, and was being placed on hospice for terminal care. An interview was conducted with the DON on 1/13/23 at 9:56 AM. The DON stated the resident tailgated with a group of visitors out the front lobby door when the receptionist unlocked the front lobby door for the visitors to exit. The DON clarified the resident exited both sets of doors at the lobby, the door that enters the lobby and the door that exits the building. The resident exited via the front door with the group of visitors and the receptionist had to unlock both doors for the resident and group to exit, then the resident sat on the bench outside the front door. Further interview was conducted with the DON on 1/13/23 at 10:04 AM. The DON stated the facility determined the root cause of the event was staff did not follow process and should have redirected the resident back into the facility. The facility had no evidence to support the resident knew the visitor that escorted her to the emergency room (ER). The visitor came in and asked the receptionist if he could take resident #90 across the street to the ER and the receptionist said yes. She stated the resident's photo was in the elopement book at the time of the event and the receptionist acknowledged she was aware of the resident's picture being in the elopement book. The DON stated the only policy the facility had that covers the resident sign out procedure is the transfer or discharge policy stating they would provide verbal or written notice of intent to leave and there is not a specific policy of who can sign the resident out of the facility. Review of the facility policy Transfer and Discharge (effective date 11/1/18) revealed therapeutic leave is a type of Resident-initiated transfer. A Resident-initiated transfer or discharge is one in which the Resident has provided written or verbal notice of their intent to leave the facility, which is documented in the Resident's record. A Resident's expression of a general desire to return home or to the community or elopement of a Resident who is cognitively impaired will not be taken as a notice of intent to leave. Review of the facility policy for Resident Elopement Risk Management Guidelines (revised 1/12/2020) revealed the facility will strive to provide a safe environment for residents and implement measures to identify residents at risk for elopement, as well as preventative measures to minimize elopement occurrences. The policy defines elopement as: An elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Page 2 number 6 of the policy indicates when a a resident is observed to be wandering to an unsafe situation or exiting the facility, the nearest staff should intervene or summon help if unable to safely manage the event. If wandering behavior escalates, safety checks should be implemented, and the resident should be evaluated for possible cause and new interventions implemented as needed.

Based on record review, staff interviews, and Administrator job description review, the facility failed to utilize its resources effectively to develop and implement policies to ensure resident safety is maintained when residents leave the facility with other individuals and to ensure the appropriate staff are aware of the resident's departure from the facility. This has the potential to affect all residents in the facility who exit the facility for leave of absence. (Cross reference F689). The findings include: On 1/1/23, a cognitively impaired resident, identified at risk for elopement (resident #90), was allowed to exit the facility and leave the facility grounds with a visitor unknown to the resident. Review of the facility investigation revealed the nursing staff were not aware the resident had left the facility for approximately 1 hour and 55 minutes. An interview was conducted with the Director of Nursing (DON) on 1/12/23 at 2:43 PM. She stated the visitor was at the facility to visit another resident. She called that resident's sister, and she did not have any contact information for the visitor. A follow-up interview was conducted with the DON on 1/13/23 at 10:04 AM, who stated that the visitor came in and asked the receptionist if he could take resident # 90 across the street to the emergency room and the receptionist said yes. She stated the resident's photograph was in the elopement book at the time of the event and the receptionist acknowledged she was aware of the resident's picture being in the elopement book. The DON stated the only policy the facility had that covers the resident sign out procedure is the transfer or discharge policy stating they would provide verbal or written notice of intent to leave and there is not a specific policy of whom can sign the resident out of the facility. An interview was conducted with the Administrator on 1/13/23 at 10:12 AM. He stated he works with the DON in every aspect and trusts the DON with everything to keep the residents safe and ensure the staff are properly educated. He assisted to ensure the facility staff were educated, post tests were completed, and staff understood the risk and how they have to keep the residents safe and healthy. During the survey, the facility was not able to provide evidence of a process to educate visitors to ensure only authorized persons are allowed to escort a cognitively impaired resident from the facility or a policy regarding the process for signing a resident out of the facility and ensuring the appropriate staff are aware of the resident's departure from the facility. Review of the Administrator job description (dated 3/2018) revealed the purpose of the position is to manage all business-related activity to achieve the facility's vision and supporting strategies and assures that the company image as an ethical and high quality provider of health services is developed and maintained. Duties and responsibilities include: intervenes as appropriate in potentially threatening situations and follows-up with staff after crisis has been resolved; manages safety according to facility procedures/guidelines; ensures that potential safety/health hazards are eliminated or controlled through regular reviews of work activities, materials, and facilities; provides employees with training and instructions on safe work practices in all aspects of their employment; ensures that potential safety/health hazards are eliminated or controlled through regular reviews of work activities, materials, and facilities; provides employees with unsurpassed training and instructions on safe work practices with every aspect of their employment; and ensures that employees are adequately oriented and trained to perform their duties.

Based on record review, staff interviews, and Administrator job description review, the facility failed to utilize its resources effectively to develop and implement policies to ensure resident safety is maintained when residents leave the facility with other individuals and to ensure the appropriate staff are aware of the resident's departure from the facility. This has the potential to affect all residents in the facility who exit the facility for leave of absence. (Cross reference F689). The findings include: On 1/1/23, a cognitively impaired resident, identified at risk for elopement (resident #90), was allowed to exit the facility and leave the facility grounds with a visitor unknown to the resident. Review of the facility investigation revealed the nursing staff were not aware the resident had left the facility for approximately 1 hour and 55 minutes. An interview was conducted with the Director of Nursing (DON) on 1/12/23 at 2:43 PM. She stated the visitor was at the facility to visit another resident. She called that resident's sister, and she did not have any contact information for the visitor. A follow-up interview was conducted with the DON on 1/13/23 at 10:04 AM, who stated that the visitor came in and asked the receptionist if he could take resident # 90 across the street to the emergency room and the receptionist said yes. She stated the resident's photograph was in the elopement book at the time of the event and the receptionist acknowledged she was aware of the resident's picture being in the elopement book. The DON stated the only policy the facility had that covers the resident sign out procedure is the transfer or discharge policy stating they would provide verbal or written notice of intent to leave and there is not a specific policy of whom can sign the resident out of the facility. An interview was conducted with the Administrator on 1/13/23 at 10:12 AM. He stated he works with the DON in every aspect and trusts the DON with everything to keep the residents safe and ensure the staff are properly educated. He assisted to ensure the facility staff were educated, post tests were completed, and staff understood the risk and how they have to keep the residents safe and healthy. During the survey, the facility was not able to provide evidence of a process to educate visitors to ensure only authorized persons are allowed to escort a cognitively impaired resident from the facility or a policy regarding the process for signing a resident out of the facility and ensuring the appropriate staff are aware of the resident's departure from the facility. Review of the Administrator job description (dated 3/2018) revealed the purpose of the position is to manage all business-related activity to achieve the facility's vision and supporting strategies and assures that the company image as an ethical and high quality provider of health services is developed and maintained. Duties and responsibilities include: intervenes as appropriate in potentially threatening situations and follows-up with staff after crisis has been resolved; manages safety according to facility procedures/guidelines; ensures that potential safety/health hazards are eliminated or controlled through regular reviews of work activities, materials, and facilities; provides employees with training and instructions on safe work practices in all aspects of their employment; ensures that potential safety/health hazards are eliminated or controlled through regular reviews of work activities, materials, and facilities; provides employees with unsurpassed training and instructions on safe work practices with every aspect of their employment; and ensures that employees are adequately oriented and trained to perform their duties.

Based on record review, staff interviews, quality assurance performance improvement plan review, and policy review, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to supervision of residents with cognitive impairment, a process to ensure resident safety when leaving the facility with visitors and educating staff and visitors of such process for 1 of 2 residents sampled for accidents and supervision. (Resident # 90) Cross reference F689 The findings include: On 1/1/23, a cognitively impaired resident, identified at risk for elopement (resident # 90) was allowed to exit the facility and leave the facility grounds with a visitor unknown to the resident. Review of the facility investigation revealed the nursing staff were not aware the resident had left the facility for approximately 1 hour and 55 minutes. Review of the facility Performance Improvement Plan Worksheet dated 1/1/23 indicated the event to be investigated: Resident #90 left facility property without staff escort. The resident went to the hospital with a visitor escort, staff was not notified of resident leaving the property and the resident did not sign out LOA (Leave of Absence). Resident independently ambulatory with cognitive deficits, worked as nurse prior to retirement, voiced an intent and request to go to the hospital for medication and sling for her arm. Upon investigation, it was determined the resident tailgated someone exiting the facility. She was observed by the staff in the front lobby to walk out the front doors and sit under the entrance awning. The resident was observed by staff members to speak with a visitor and the resident requested this visitor walk her to the hospital. The visitor notified the staff members of this request, and the resident was assisted to the hospital by the visitor. Root cause analysis- the staff members voiced being aware of the elopement book at the front desk and voiced understanding of the elopement process. For unknown reason neither staff member intervened and did not notify other staff of resident leaving the facility. Design and implement changes: All exit doors were observed, and appropriate signage was observed to be in place. All elopement observations were reviewed, and all were observed to be up to date and appropriate. Elopement books were reviewed, and all observed to be up to date with appropriate pictures and information available. Care plans have all been reviewed and observed to be appropriate. Resident placed on on to one (staff supervision). Observation of awareness of staff and others when exiting to ensure not followed by resident. Both staff members who observed the resident exit the facility have been suspended with termination pending due to failure to follow established facility protocols. Adult protective services notification completed via online reporting portal. Immediate Federal report completed. Measurements: Decrease risk of resident's ability to exit building without assistance through the following interventions- elopement observation completed on all residents, elopement drills completed on each shift for one week then weekly for one week, door alarms checked daily for appropriate function by maintenance/nursing on weekends-start date 1/2/23, all door codes were changed to exit doors in the facility completed 1/2/23, Administrator or designee to audit door checks at least weekly for 4 weeks start date 1/1/23, staff observations related to elopement prevention completed daily to monitor staff comprehension and compliance start date 1/1/23. The facility action plan failed to identify the need for education to staff and visitors regarding whom may escort a cognitively impaired resident from the facility, ensuring adequate supervision for resident's voicing a request to leave the facility, and policies to address the process of resident's signing out of the facility. An interview was conducted with the Director of Nursing (DON) on 1/12/23 at 2:43 PM. She stated the visitor was at the facility to visit another resident. She called that resident's sister, and she did not have any contact information for the visitor. A follow-up interview was conducted with the DON on 1/13/23 at 9:56 AM. The DON stated the resident tailgated with a group of visitors out the front lobby door when the receptionist unlocked the front lobby door for the visitors to exit. The DON clarified the resident exited both sets of doors at the lobby, the door that enters the lobby and the door that exits the building, with a group of visitors and the receptionist had to unlock both doors for the resident and group to exit, then the resident sat on the bench outside the front door. Further interview was conducted with the DON on 1/13/23 at 10:04 AM. The DON stated the facility determined the root cause of the event was staff did not follow process and should have redirected the resident back into the facility. The facility had no evidence to support the resident knew the visitor that escorted her to the emergency room (ER). The visitor came in and asked the receptionist if he could take resident # 90 across the street to the ER and the receptionist said yes. She stated the resident's photo was in the elopement book at the time of the event and the receptionist acknowledged she was aware of the resident's picture being in the elopement book. The DON stated the only policy the facility had that covers the resident sign out procedure is the transfer or discharge policy stating they would provide verbal or written notice of intent to leave and there is not a specific policy of who can sign the resident out of the facility. Review of the undated facility policy for Quality Assurance and Performance Improvement (QAPI) Program revealed it is the policy of the facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life for our residents. The QAPI program is ongoing, comprehensive, and addresses the full range of care and services provided by the facility. Established and implemented written policies and procedures include processes for feedback, data collection systems, and monitoring, including adverse event monitoring. The procedure includes maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of 483.75 Code of Federal Regulations. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities.

Based on record review, staff interviews, quality assurance performance improvement plan review, and policy review, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to supervision of residents with cognitive impairment, a process to ensure resident safety when leaving the facility with visitors and educating staff and visitors of such process for 1 of 2 residents sampled for accidents and supervision. (Resident # 90) Cross reference F689 The findings include: On 1/1/23, a cognitively impaired resident, identified at risk for elopement (resident # 90) was allowed to exit the facility and leave the facility grounds with a visitor unknown to the resident. Review of the facility investigation revealed the nursing staff were not aware the resident had left the facility for approximately 1 hour and 55 minutes. Review of the facility Performance Improvement Plan Worksheet dated 1/1/23 indicated the event to be investigated: Resident #90 left facility property without staff escort. The resident went to the hospital with a visitor escort, staff was not notified of resident leaving the property and the resident did not sign out LOA (Leave of Absence). Resident independently ambulatory with cognitive deficits, worked as nurse prior to retirement, voiced an intent and request to go to the hospital for medication and sling for her arm. Upon investigation, it was determined the resident tailgated someone exiting the facility. She was observed by the staff in the front lobby to walk out the front doors and sit under the entrance awning. The resident was observed by staff members to speak with a visitor and the resident requested this visitor walk her to the hospital. The visitor notified the staff members of this request, and the resident was assisted to the hospital by the visitor. Root cause analysis- the staff members voiced being aware of the elopement book at the front desk and voiced understanding of the elopement process. For unknown reason neither staff member intervened and did not notify other staff of resident leaving the facility. Design and implement changes: All exit doors were observed, and appropriate signage was observed to be in place. All elopement observations were reviewed, and all were observed to be up to date and appropriate. Elopement books were reviewed, and all observed to be up to date with appropriate pictures and information available. Care plans have all been reviewed and observed to be appropriate. Resident placed on on to one (staff supervision). Observation of awareness of staff and others when exiting to ensure not followed by resident. Both staff members who observed the resident exit the facility have been suspended with termination pending due to failure to follow established facility protocols. Adult protective services notification completed via online reporting portal. Immediate Federal report completed. Measurements: Decrease risk of resident's ability to exit building without assistance through the following interventions- elopement observation completed on all residents, elopement drills completed on each shift for one week then weekly for one week, door alarms checked daily for appropriate function by maintenance/nursing on weekends-start date 1/2/23, all door codes were changed to exit doors in the facility completed 1/2/23, Administrator or designee to audit door checks at least weekly for 4 weeks start date 1/1/23, staff observations related to elopement prevention completed daily to monitor staff comprehension and compliance start date 1/1/23. The facility action plan failed to identify the need for education to staff and visitors regarding whom may escort a cognitively impaired resident from the facility, ensuring adequate supervision for resident's voicing a request to leave the facility, and policies to address the process of resident's signing out of the facility. An interview was conducted with the Director of Nursing (DON) on 1/12/23 at 2:43 PM. She stated the visitor was at the facility to visit another resident. She called that resident's sister, and she did not have any contact information for the visitor. A follow-up interview was conducted with the DON on 1/13/23 at 9:56 AM. The DON stated the resident tailgated with a group of visitors out the front lobby door when the receptionist unlocked the front lobby door for the visitors to exit. The DON clarified the resident exited both sets of doors at the lobby, the door that enters the lobby and the door that exits the building, with a group of visitors and the receptionist had to unlock both doors for the resident and group to exit, then the resident sat on the bench outside the front door. Further interview was conducted with the DON on 1/13/23 at 10:04 AM. The DON stated the facility determined the root cause of the event was staff did not follow process and should have redirected the resident back into the facility. The facility had no evidence to support the resident knew the visitor that escorted her to the emergency room (ER). The visitor came in and asked the receptionist if he could take resident # 90 across the street to the ER and the receptionist said yes. She stated the resident's photo was in the elopement book at the time of the event and the receptionist acknowledged she was aware of the resident's picture being in the elopement book. The DON stated the only policy the facility had that covers the resident sign out procedure is the transfer or discharge policy stating they would provide verbal or written notice of intent to leave and there is not a specific policy of who can sign the resident out of the facility. Review of the undated facility policy for Quality Assurance and Performance Improvement (QAPI) Program revealed it is the policy of the facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life for our residents. The QAPI program is ongoing, comprehensive, and addresses the full range of care and services provided by the facility. Established and implemented written policies and procedures include processes for feedback, data collection systems, and monitoring, including adverse event monitoring. The procedure includes maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of 483.75 Code of Federal Regulations. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities.

Based on record review, staff interviews, and policy review, the facility failed to implement the plan of care for 1 of 2 residents reviewed for accidents and supervision. (Resident #90) The findings include: Review of resident #90's electronic medical record revealed the resident was admitted to the facility on [DATE] and had a current diagnosis of dementia. The care plan goal included the resident's risk for elopement will be minimized through the next review date with a target date of 3/10/23. The care plan interventions dated 12/10/22 included inform staff and the resident's visitors about risk for elopement and exit seeking, monitor for verbalizations of wanting to leave, picture in elopement book, redirect and provide support when wandering or requesting to exit the facility, and report observations and concerns to physician/nurse practitioner as needed. The admission MDS (Minimum Data Set) with an assessment reference date of 11/15/22 indicated the resident had a BIMS (Brief Interview of Mental Status) score of 8, indicating moderate cognitive impairment. The record revealed a current plan of care dated 12/10/22 stating the resident was at risk for elopement due to noted exit seeking and she exhibited fluctuations in level of cognition and understanding. An elopement risk observation, documented on 11/30/22, indicated the resident was at risk for elopement with a score of 3, and proceed with safety interventions. Further review of the record revealed that on 1/1/23, the resident was allowed to exit the facility and leave the facility grounds with a visitor unknown to the resident. Review of the facility investigation revealed the nursing staff were not aware the resident had left the facility for approximately 1 hour and 55 minutes. (Cross reference F689) An interview was conducted with the Director of Nursing (DON) on 1/13/23 at 9:56 AM. The DON stated that resident #90 exited both sets of doors at the lobby, the door that enters the lobby and the door that exits the building. The resident exited via the front door with the group of visitors and the receptionist had to unlock both doors for the resident and group to exit, then the resident sat on the bench outside the front door. Further interview was conducted with the DON on 1/13/23 at 10:04 AM. The DON stated the facility determined the root cause of the event was staff did not follow process and should have redirected the resident back into the facility. The visitor came in and asked the receptionist if he could take resident #90 across the street to the ER (emergency room ) and the receptionist said yes. The DON stated the resident's photo was in the elopement book at the time of the event and the DON indicated that the receptionist acknowledged she was aware of the resident's picture being in the elopement book. A telephone interview was conducted with employee B (former receptionist) on 1/12/23 at 3:16 PM. Employee B stated resident #90's picture was not in the elopement book at the time of the event on 1/1/23 and refused to answer further questions regarding the event. The facility was not able to provide any documentation or evidence to support the facility implemented the plan of care for resident #90, who was identified at risk for elopement. The facility did not educate the visitor regarding the resident's exit seeking, did not redirect and intervene when the resident exited the facility, and did not report the verbalization of the resident wanting to go home prior to the resident exiting the facility. Review of the facility policy for Comprehensive Care Plans (revised 1/7/2020) revealed an individual comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Each resident's comprehensive care plan is designed to incorporate identified problem areas and risk factors associated with identified problems, build on the resident's strengths, reflect the resident's expressed wishes regarding care and treatment goals, reflect treatment goals, timetables, and objectives in measurable outcomes, identify professional services that are responsible for each element of care, aid in preventing or reducing declines in the resident's functional status and/or functional levels, enhance the optimal functioning of the resident by focusing on a rehabilitative program, and reflect currently recognized standards of practice for problem areas and conditions.

Based on record review, staff interviews, and policy review, the facility failed to implement the plan of care for 1 of 2 residents reviewed for accidents and supervision. (Resident #90) The findings include: Review of resident #90's electronic medical record revealed the resident was admitted to the facility on [DATE] and had a current diagnosis of dementia. The care plan goal included the resident's risk for elopement will be minimized through the next review date with a target date of 3/10/23. The care plan interventions dated 12/10/22 included inform staff and the resident's visitors about risk for elopement and exit seeking, monitor for verbalizations of wanting to leave, picture in elopement book, redirect and provide support when wandering or requesting to exit the facility, and report observations and concerns to physician/nurse practitioner as needed. The admission MDS (Minimum Data Set) with an assessment reference date of 11/15/22 indicated the resident had a BIMS (Brief Interview of Mental Status) score of 8, indicating moderate cognitive impairment. The record revealed a current plan of care dated 12/10/22 stating the resident was at risk for elopement due to noted exit seeking and she exhibited fluctuations in level of cognition and understanding. An elopement risk observation, documented on 11/30/22, indicated the resident was at risk for elopement with a score of 3, and proceed with safety interventions. Further review of the record revealed that on 1/1/23, the resident was allowed to exit the facility and leave the facility grounds with a visitor unknown to the resident. Review of the facility investigation revealed the nursing staff were not aware the resident had left the facility for approximately 1 hour and 55 minutes. (Cross reference F689) An interview was conducted with the Director of Nursing (DON) on 1/13/23 at 9:56 AM. The DON stated that resident #90 exited both sets of doors at the lobby, the door that enters the lobby and the door that exits the building. The resident exited via the front door with the group of visitors and the receptionist had to unlock both doors for the resident and group to exit, then the resident sat on the bench outside the front door. Further interview was conducted with the DON on 1/13/23 at 10:04 AM. The DON stated the facility determined the root cause of the event was staff did not follow process and should have redirected the resident back into the facility. The visitor came in and asked the receptionist if he could take resident #90 across the street to the ER (emergency room) and the receptionist said yes. The DON stated the resident's photo was in the elopement book at the time of the event and the DON indicated that the receptionist acknowledged she was aware of the resident's picture being in the elopement book. A telephone interview was conducted with employee B (former receptionist) on 1/12/23 at 3:16 PM. Employee B stated resident #90's picture was not in the elopement book at the time of the event on 1/1/23 and refused to answer further questions regarding the event. The facility was not able to provide any documentation or evidence to support the facility implemented the plan of care for resident #90, who was identified at risk for elopement. The facility did not educate the visitor regarding the resident's exit seeking, did not redirect and intervene when the resident exited the facility, and did not report the verbalization of the resident wanting to go home prior to the resident exiting the facility. Review of the facility policy for Comprehensive Care Plans (revised 1/7/2020) revealed an individual comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Each resident's comprehensive care plan is designed to incorporate identified problem areas and risk factors associated with identified problems, build on the resident's strengths, reflect the resident's expressed wishes regarding care and treatment goals, reflect treatment goals, timetables, and objectives in measurable outcomes, identify professional services that are responsible for each element of care, aid in preventing or reducing declines in the resident's functional status and/or functional levels, enhance the optimal functioning of the resident by focusing on a rehabilitative program, and reflect currently recognized standards of practice for problem areas and conditions.

Based on observation, staff interviews, record review, and policy review, the facility failed to ensure staff followed appropriate isolation precautions during the provision of housekeeping services for 1 of 1 sampled resident on transmission-based precautions. (Resident #209) The findings include: An observation of resident #209 was conducted on 1/10/23 at approximately 9:30 AM. The resident was in his room and there was a sign beside the door stating special enteric precautions (related to the intestines) in addition to standard precautions. The sign indicated visitors and staff should cleanse hands upon entering with sanitizer or soap and water and cleanse out of the room using only soap and water. Gown and gloves are required prior to entering the room. (Photographic evidence obtained.) Employee A (housekeeper) was observed in the room at this time, mopping the floor with only gloves on and no gown. She then exited the room and placed the used mop on her housekeeping cart. She then walked to another room across the hall and entered the room. She began dusting with the same gloves on she used to mop in resident # 209's room and did not wash her hands. An interview was conducted with employee A on 1/10/23 at 9:37 AM. She stated the gloves she had on to clean the room across the hall from resident #209's room were the same gloves she had on to clean resident #209's room. She stated she should have changed her gloves. Employee A stated she was told if she was not having contact with the resident in the special enteric precautions room, she did not have to wear a gown. She confirmed she did not wear a gown. Review of resident #209's medical record revealed a current physician order dated 1/6/23 for contact isolation until 2/5/23 for C-diff (Clostridioides difficile). According to the Centers for Disease Control and Prevention website accessed on 1/17/23 at 2:37 PM, C. diff (also known as Clostridioides difficile or C. difficile) is a multi-drug resistant germ (bacterium) that causes diarrhea and colitis (an inflammation of the colon) and it is contagious. An interview was conducted with the Director of Nursing (DON) on 1/12/23 at 9:51 AM. The DON stated staff should don a gown and gloves to enter an enteric precautions room and should not clean another room with the same gloves. The DON verified resident # 209 was on contact isolation for C-diff. Review of the undated facility policy for Enteric Contact Precautions revealed examples of infections requiring Enteric Contact Precautions include but are not limited to bacterial diarrhea associated with Clostridium Difficile. In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The decision on whether precautions are necessary will be evaluated on a case-by-case basis. In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, non-sterile) when entering the room. Remove gloves before leaving the room and perform hand hygiene. After removing gloves and washing hands, do not touch potentially contaminated environmental surfaces or items in the resident's room. Wear a disposable gown upon entering the isolation room or cubicle. After removing the gown, do not allow clothing to contact potentially contaminated environmental surfaces or items in the resident's room.

Based on observation, staff interviews, record review, and policy review, the facility failed to ensure staff followed appropriate isolation precautions during the provision of housekeeping services for 1 of 1 sampled residents on transmission-based precautions. (Resident # 209) The findings include: An observation of resident #209 was conducted on 1/10/23 at approximately 9:30 AM. The resident was in his room and there was a sign beside the door stating special enteric precautions (related to the intestines) in addition to standard precautions. The sign indicated visitors and staff should cleanse hands upon entering with sanitizer or soap and water and cleanse out of the room using only soap and water. Gown and gloves are required prior to entering the room. (Photographic evidence obtained.) Employee A (housekeeper) was observed in the room at this time, mopping the floor with only gloves on and no gown. She then exited the room and placed the used mop on her housekeeping cart. She then walked to another room across the hall and entered the room. She began dusting with the same gloves on she used to mop in resident # 209's room and did not wash her hands. An interview was conducted with employee A on 1/10/23 at 9:37 AM. She stated the gloves she had on to clean the room across the hall from resident #209's room were the same gloves she had on to clean resident #209's room. She stated she should have changed her gloves. Employee A stated she was told if she was not having contact with the resident in the special enteric precautions room, she did not have to wear a gown. She confirmed she did not wear a gown. Review of resident #209's medical record revealed a current physician order dated 1/6/23 for contact isolation until 2/5/23 for C-diff (Clostridioides difficile). According to the Centers for Disease Control and Prevention website accessed on 1/17/23 at 2:37 PM, C. diff (also known as Clostridioides difficile or C. difficile) is a multi-drug resistant germ (bacterium) that causes diarrhea and colitis (an inflammation of the colon) and it is contagious. An interview was conducted with the Director of Nursing (DON) on 1/12/23 at 9:51 AM. The DON stated staff should don a gown and gloves to enter an enteric precautions room and should not clean another room with the same gloves. The DON verified resident # 209 was on contact isolation for C-diff. Review of the undated facility policy for Enteric Contact Precautions revealed examples of infections requiring Enteric Contact Precautions include but are not limited to bacterial diarrhea associated with Clostridium Difficile. In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The decision on whether precautions are necessary will be evaluated on a case-by-case basis. In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, non-sterile) when entering the room. Remove gloves before leaving the room and perform hand hygiene. After removing gloves and washing hands, do not touch potentially contaminated environmental surfaces or items in the resident's room. Wear a disposable gown upon entering the isolation room or cubicle. After removing the gown, do not allow clothing to contact potentially contaminated environmental surfaces or items in the resident's room.

Based on observation, record review and interview, the facility's staff failed to treat 1 of 15 sampled residents with respect and dignity regarding incontinent care, Resident #13. The facility failed to provide incontinent care and allowed Resident #14 to lay on soiled linen while the staff members went to lunch. The findings include: On 10/25/2022 at approximately 11:15 AM, an observation with interview was conducted on Resident #13. Upon entering the resident's room, the resident stated she was very upset. The resident stated that she pressed her call light approximately 10 minutes ago. She stated two CNAs (Certified Nursing Assistants) had been helping her roommate. She stated she asked the CNA's there to help get her changed and cleaned up because she had a bowel movement while laying in the bed. She informed the surveyor that she was told by the CNA's that they would return at 11:30 AM to get her cleaned up, because they had to go to lunch. During this time, the Unit Manager (UM) entered the room. The resident reported to the Unit Manager what had been said by the staff. The UM left the room and returned with another CNA, CNA BB, to assist the resident with her perineal care and linen change. A review of the Annual MDS assessment dated [DATE] revealed a BIMS of 13. She had no identified behaviors and participated in care plan meetings. Resident #14 requires 2+ person extensive assist with bed mobility, transfers, and toileting. The resident MDS assessment revealed she is always incontinent of bowel and bladder. An interview dated 10/25/2022 at approximately 11:20 AM with the UM revealed the names of the two CNA's who refused care to Resident #13 were CNA D and CNA C. An interview on 10/25/2022 at approximately 11:54 AM was conducted with the DON. The DON stated that if a resident calls out for care It depends on the situation. But it should be delivered as promptly as possible. An interview was conducted on 10/25/22 at approximately 1:00 PM with CNA D. The CNA reported the normal process for resident requests to have their bed changed and/or perineal care is to change them and clean them up. The CNA did admit to going to lunch before providing care to Resident #13. She stated, Yes. I did make the resident wait today. I know I am supposed to do it right away. But we have assigned lunches. And the girl that was with me told me we had to go to lunch because we can't be on lunch when trays come out. I am still new here and trying to learn the ways here. I did tell Resident #14 that we would be back to clean her up after lunch. An interview conducted on 10/25/22 at approximately 1:45 PM was conducted with CNA C. The CNA reported the normal process for resident requests to have their bed changed and/or perineal care is to change them right then. The CNA did admit to going to lunch before providing care to Resident #13. I did make Resident #13 wait today. I have low blood sugar and I have to eat my lunch. I told the other girl that she could do it. But I had to eat. I was going to come back and help her after. I had just helped her with the lady in the room with her. I know I am supposed to change the residents when they are soiled. A follow-up interview was conducted on 10/26/22 at approximately 10:49 AM with the DON. The DON stated that staff are supposed to let the other CNA's know that they are going to lunch. The staff are supposed to also tell the nurse before leaving the floor. The DON reported that the staff were given a verbal warning yesterday, after being advised that Resident #13 did not receive a linen change and incontinent care. The DON stated, There wasn't a negative outcome to the resident. She just needed to wait a little bit for care to be rendered.

Based on observations, staff and physician interviews, and record review, the facility failed to ensure the environment remains as free of accident hazards as is possible by failing to ensure unattended beds remained the lowest position for 2 of 15 sampled residents reviewed for accidents, Resident #14 and #15. The facility failed to ensure bed position (height) was included in investigations post falls and reported to attending clinicians for 1 of 15 sampled residents, (Residents #2). Resident #2 sustained a fall with injury from her bed during care and died later the same day. The fall was investigated, but there was no evidence showing the bed height was reviewed during the investigation, or that the height of the bed at the time of the fall was reported to the evaluating clinician. The findings include: An interview was conducted on [DATE] at approximately 3:45 PM with Certified Nurse Aide (CNA) A. The CNA stated that she was changing Resident #2. CNA A stated she had asked the resident to roll to one side of the bed so she could be cleaned. She just rolled out of the bed. CNA A stated that she went around the side of the bed to check on the resident and called out for help. I asked her if she was okay. She was more worried about me than herself. She asked me if I was okay. The CNA reported that the staff got her up and put her back to bed. A review of a progress note dated [DATE] at approximately 7:55 AM by Registered Nurse (RN) #U revealed Resident #2 to be alert with some confusion. She was able to make her needs known. The progress note stated that at approximately 6:00 AM the resident was being cleaned and having a brief changed by CNA A. The note stated the resident rolled out of bed and landed on her stomach. The note stated a skin tear to the left elbow, a bruise to the left knee, and pain to the right shoulder (no mention of the injury to the eye area). Unit Manager O (UM O) was notified, as well as the APRN P. The resident was given Tylenol for pain and a stat x-ray 2-view was ordered for bilateral shoulders. The note did not indicate bed height at the time of the incident. An interview was conducted on [DATE] at approximately 2:00 PM with the UM. He stated that Resident #2 fell early Monday morning. The UM did not witness the fall of Resident # 2 nor did he speak to CNA A who was caring for Resident #2 at the time of the fall. The UM stated he was concerned about the residents Range of Motion (ROM). He stated the resident was complaining that she could not move her arm. The APRN was called to come and evaluate her. An interview was conducted on [DATE] at approximately 3:00 PM with APRN P. The APRN stated she received a call from the UM that Resident #2 had a fall on her right side. The APRN stated she was told Resident #2 was a witnessed fall and that she turned herself over and fell out of bed. The APRN stated the UM was concerned about her. I told him not to send the resident out and that I would be there soon. I assessed her at 8:20 AM and he called me at 8:00 AM. She was at her baseline neurologically. There were no obvious deformities. I did order x-rays on her. She had some bruising to her knees. She had discoloration to her right eyebrow. The APRN stated that she was in her office when a Code was called later to the resident's room. The APRN did attend the Code. The APRN stated that Resident #2 had minimal response. She had emesis in her mouth, but was breathing and maintaining her airway. She was on oxygen via a nasal cannula, which was changed to a non-rebreather mask. The APRN stated the staff called EMS and Resident #2 was sent to the hospital. A review of a progress note dated [DATE] by Licensed Practical Nurse (LPN) T, revealed at approximately 10:30 AM LPN T went to Resident #2's room after being alerted that Resident #2 was unresponsive. The LPN was unable to establish a blood pressure. Emergency Medical Services (EMS) was contacted for emergent pick up. The progress note documented by the LPN revealed the resident's pupils were dilated and fixed at this time. The progress noted further stated the resident was given her Eliquis and Aspirin following a fall from the bed per orders from the APRN. The LPN notified a family friend to advise that the resident was being sent to the hospital. A record review dated [DATE] revealed neuro checks were performed following the fall of Resident #2. Documentation on the neuro check form revealed the resident's strength to be weak in all extremities, her speech was clear, and she was responsive to stimuli. Her level of consciousness (LOC) was noted to be oriented and confused. A Record review of Resident #2's Annual and Quarterly minimum data set (MDS) assessment dated for [DATE] and [DATE], respectively, revealed Resident #2 required two+ person physical staff assistance with bed mobility and transfers. She required a one-person physical assistance with dressing, bathing, and personal hygiene. The resident was incontinent of bowel and bladder. On the morning of [DATE], an investigation was performed by the ADON. She was informed that Resident #2 had sustained a fall at approximately 8:15 AM and went to assess her. Per the report, the ADON completed an interview with CNA A. The CNA A was questioned about the fall from the bed. The CNA reported that she was providing perineal care to the resident. She had asked her to roll over. She stated, She just plopped and fell to the floor. The ADON questioned CNA A, of why she did not have 2-person assist in the care of the resident. The report stated that, She always rolls herself over without any problem and doesn't need any help to roll over. The investigation did not mention the bed height at the time of the fall. An interview was conducted on [DATE] at approximately 10:49 AM with the DON. The DON was asked if she was aware of the height of the bed when Resident #2 rolled out of the bed and fell . She stated she is aware of the height of CNA A. CNA A was about six feet tall. She stated the height of the bed would likely have been at working level of her hips and waist when providing care for the resident. An interview was conducted on [DATE] at approximately 1:10 PM with the Medical Director who reported that he was made aware of a fall with Resident #2 by text message. The Medical director stated he was not informed of the bed height at the time of the fall. The Medical Director indicated that bed height could be a factor when determining whether to send a resident out to a hospital post fall. An interview was conducted on [DATE] at approximately 11:54 AM with the Director of Nursing (DON). The DON reported that the Assistant Director of Nursing (ADON) had been trending the falls for the month of September and a Quality Assurance meeting was held regarding the falls for September. The DON was asked if she had a Performance Improvement Process (PIP) in place. She stated that the facility had gone through and audited everything. She stated education was provided to all staff. She stated that she had a Performance Improvement Plan started, but it was not a formally completed plan. The DON stated that all falls are discussed in their Interdisciplinary Team Meetings (IDT). An observation on [DATE] at approximately 10:00 AM revealed Resident #14's bed was observed in a raised position, high off the ground. A Licensed Practical Nurse (LPN) # AA was called over due to concerns of the height of the bed. The LPN stated that the resident raised the bed by himself. The LPN reported that the resident had been reminded not to raise the bed up so high but continues to do so. An observation on [DATE] at approximately 10:15 AM revealed Resident #15's bed was observed at a high level from the ground and unattended. The resident was lying in bed with no sheet or blanket covering her, and not bed rails were raised. The surveyor went to the resident's doorway and waited to get the attention of someone to assist the resident. Certified Nursing Assistant M (CNA M) then walked into the room with linens in order to change the residents bed linen.

Based on record review and interview, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (Form CMS -SNF ABN) and/or the Notice of Medicare Non-coverage (Form CMS -NOMNC) to two (#156, #308) of three sampled residents reviewed for beneficiary protection notification following discontinuation of Medicare Part A skilled services. The findings include: A review of the facility's form titled Beneficiary Notice- Residents discharged Within the Last Six-Months revealed Resident #156 was discharged from Medicare Part A skilled services on 5/28/2021 and remained in the facility. The SNF Beneficiary Protection Notification Review form indicated that the facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Per this form, the SNF ABN Form CMS was not provided to the resident as required. Further review of the form titled Beneficiary Notice- Residents discharged Within the Last Six-Months revealed that Resident #308 was discharged from Medicare Part A skilled services on 2/13/2021 and also remained in the facility. The SNF Beneficiary Protection Notification Review form indicated that the facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Per this form, the SNF ABN Form CMS was not provided to the resident. On 8/25/2021 at 12:30 PM, an interview was conducted with the Director of Nursing (DON). When asked about Resident #156 she stated, We did not complete a 'Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage,' we just issued a 'Notice of Medicare Non-coverage.' I have looked all over and that is all we have. The same thing happened with Resident #308. For whatever reason it was not completed. There are definitely some things in the building that need correcting and we are working on it. We do not have a policy specific to the notification forms.

Based on observation, staff interview, and clinical record review the facility failed to implement the care plan for 1 of 3 (#3) residents reviewed for falls. The findings include: Requested list of residents with recent falls on entry. A review of the provided list showed that resident #3 was listed twice for February 2021. She had a fall on 2/7/21 at 2:56 PM, resulting in a hematoma to the back of the head. She also had a fall on 2/19/21 without injury. The record review revealed Minimum Data Set (MDS) quarterly dated 11/28/2020. Brief Interview Mental Status indicated she was cognitively intact with a score of 15 and independent in most activities of daily living and or supervision. Resident #3 had a care plan for falls implemented on 10/25/18 related to weakness and [DIAGNOSES REDACTED]. The interventions included observe for unsteady gait, bed lowest position, and call light in reach. On 3/9/21 at approximately 9:25 AM, resident observation was made of resident sitting on the side of her bed with feet on the floor. At this time the resident was asked about her call light. She looked around her bed and then pointed to the floor. Observation was made of the call light lying on the floor at the head of the bed. Employee A, a Registered Nurse (RN) Unit Manager (UM), was taken to Resident #3's room on 3/9/21 at approximately 10:33 AM. The resident was observed sitting in her chair by the window. The call light was still on the floor at the head of the bed. Employee A, RN UM, was asked if the resident would be able to reach her call light. He stated, No. He then reached down picked up the call light and stretched it as far as possible, but it was still not in reach while she sat in the chair. He then stated, I will have to get a longer cord for that.

Based on observations and interviews, the facility failed to provide a clean and sanitary living environment by failing to ensure oxygen concentrator filters were free of dust for 2 of 3 residents observed (#217 & #221). The findings include: On 3/2/20 and 3/3/20 observations were made of the oxygen concentrators for residents #217 & 221. The concentrators were noted to have dusty filters during both observations. On 3/3/20 at approximately 2:13 PM, the Director of Nursing (DON) was interviewed after she observed the concentrator filters. She stated Yes, they need to be changed. She then said the Respiratory Therapist (RT) was just in this week. She was asked to provide a policy and procedure for the cleaning of the oxygen concentrators. She said she was not sure there was a policy. (Photographic evidence obtained) On 3/5/20 at approximately 7:11 AM, a follow up interview was conducted with the DON in which she stated she would have one of her staff ensure all oxygen filters were cleaned weekly. She then said she wanted the RT to concentrate on assessing the resident and changing the tubing for residents on oxygen.

Based on staff interview and clinical record review the facility failed to impliment care plan interventions for 1 of 1 resident (#281) sampled for elopement. The findings include: A record review was conducted for resident #281 which revealed that on 2/24/20 at 5:22 PM, the resident was discovered sitting in her wheelchair unattended, outside the facility next to the C wing door. Review of the resident's record revealed a care plan initiated on 2/24/2020 for elopement with a goal target date of 5/24/2020. Interventions included having the resident's picture posted at all the nursing stations, to make staff aware the resident was an elopement risk. On 2/24/20 at 10:18 AM, an interview was conducted with the registered nurse (RN) employee H, who was working at the nursing station closest to where the resident eloped on 2/24/2020. He was asked to show the pictures of residents at risk of elopement. He stated there were no pictures of residents at the desk to his knowledge. On 3/4/20 at 10:25 AM, an interview was conducted with the unit manager for the area where resident #281 resided during which she was asked about elopement risks and report that resident #281 had eloped recently. She reported that the resident was put on every 15 minute checks for 3 days. She was asked to read the care plan interventions and confirmed the intervention stating that a picture will be posted at all nursing stations, however further stated No, there is not a picture posted of her at this station. On 3/4/20 at 10:39 AM, an interview was conducted with the Risk Manager. During which she stated that resident #281's picture was taken down after 3 days. She was asked if the care plan still had the intervention for the picture at nursing station and she said, Yes.

Based on observations, policy review and interviews, the facility failed to ensure 1 of 4 medication carts were free of expired medications. The findings include: On 3/4/20 at approximately 10:53 AM, an observation of the medication cart 1 for C wing was conducted with staff A, a licensed practical nurse (LPN). There were 4 packages of 3 milliliter (ml) vials of [MEDICATION NAME] and [MEDICATION NAME] for residents #75 and #80, observed to be expired as of 1/20. (photographic evidence obtained) On 3/4/20 at approximately 11:05 AM, an interview was conducted with staff A. Staff A stated the nurses are responsible for checking their carts when coming on shift. They are supposed to check the carts for expired and/or discontinued medications and remove them from the cart. Staff A stated she did not check the cart when she took the cart this morning. On 3/04/20 at approximately 9:40 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the nurses are supposed to go through the carts each shift and look for expired medications, remove them from the carts and reorder medications. A review of the policy Medication Storage in the Facility, 2006, page 3 section G stated all expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining.