Every finding on record at Spring Meadows Health and Rehabilitation

Based on policy review, medical record review, observation, and interview, the facility failed to ensure proper infection control practices for 1 of 2 (Resident #20) residents reviewed for isolation precaution. The facility had a census of 107. The findings include: 1. Review of the facility's policy titled, Transmission Based (Isolation) Precautions, dated 6/4/2024, revealed, Signage that includes instructions for use of specific PPE [personal protective equipment] will be placed in a conspicuous location outside of the resident's- room .either the CDC [Centers for Disease Control] category of transmission-based precautions .contact, droplet, or airborne .or instructions to see the nurse before entering will be included in the signage .Contact Precautions .Intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment . Review of the facility's undated policy titled, Recommendations for Personal Protective Equipment (PPE), revealed, .Infection/Conditions .Multidrug-resident organisms (MDROs) infection or colonization .ESBL [Extended-spectrum beta lactamases] .Contact-Precautions recommended in settings with evidence of ongoing transmission or in settings with increased risk for transmission . Review of the CDC Long Term Care Facility Frequent Asked Questions, dated 6/28/2024, revealed .What are the differences between Enhanced Barrier Precautions and Contact Precautions .Contact Precautions require the use of gown and gloves on every entry into a resident's room, regardless of the level of care being provided to the resident. The resident is given dedicated equipment ( .stethoscope and blood pressure cuff) and is placed in a private room. When private rooms are not available, some residents ( .residents with the same pathogen) may be roomed together. Residents on Contact Precautions are recommended to be restricted to their rooms except for medically necessary care, including restriction from participation in group activities. Contact Precautions are generally intended to be time limited and, when implemented, should include a plan for discontinuation or de-escalation . 2. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Hypertension, Cognitive Communication Deficit, and Overactive Bladder. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #20 had a Brief Interview for Mental Status score of 13, indicating the resident was cognitively intact, and dependent on staff for Activity of Daily living (ADLS). Review of the [named laboratory] report dated 7/3/2024 revealed, .Escherichia coli [bacteria normally live in the intestines] . Review of a Physician's Order dated 7/4/2024 revealed, .Contact isolation (ESBL in urine) .every shift until 07/11/2024 .Active .7/4/2024 Review of the Care Plan updated 7/8/2024 revealed, .Actual infection r/t [related to] ESBL [Extended-Spectrum Beta-Lactamase] urine .7/8/2024 .Encourage fluids unless contraindicated .Follow contact precautions . Observation in the resident's room on 7/9/2024 at 3:35 PM and on 7/10/2024 at 8:36 AM, revealed Resident #20 was in Enhanced Barrier Precaution with a signage posted on wall outside of door. Resident #20 had no biohazard barrels in the room for infectious waste and linen. Resident #20 was out of her room in the dining room. There was no evidence Resident #20 was in contact isolation. Review of the facility's Order Summary Report, dated 7/10/2024 revealed, .Contact Isolation (ESBL in urine) . During an interview in the North Hall at the medication cart on 7/10/24 8:43 AM, Licensed Practical Nurse (LPN R), confirmed that Resident #20 was not in Contact Isolation, but her roommate was the resident in Enhanced Barrier Precaution for a wound. During an interview on 7/10/24 at 1:48 PM, the Director of Nursing (DON) confirmed that Resident #20 has orders for Contact Isolation for ESBL in her urine, requires incontinent care and wears a brief. The DON confirmed that Contact Isolation and Enhanced Barrier are not the same precautions. The DON confirmed that the nursing staff should follow physician orders for contact isolation. During a continued interview and observation on 7/10/24 at 1:57 PM, outside of Resident #20's room, the DON confirmed that the Enhanced Barrier sign on the wall is the incorrect sign and that the sign should be for Contact Isolation. During a continued interview on 7/10/24 at 2:19 PM, the DON was asked how a brief should be disposed of if a resident is in Contact Isolation. The DON confirmed the disposable briefs should be disposed of in biohazardous waste containers within the resident's room. The DON confirmed that any resident in Transmission-Based Precautions should have barrels in their rooms for the disposal of both hazardous waste and trash.

Based on policy review, observation, and interview, the facility failed to provide effective maintenance services to ensure a safe, functional, and comfortable environment as evidenced by the disrepair of the bathroom flooring for 1 out of 104 occupied resident's rooms. The findings include: 1. Review of the facility's policy, titled, Preventive Maintenance, with a date of 3/1/2023, revealed, .A Preventive Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environmental for residents, staff, and the public .The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a sage and operable manner . 2. Observations and interview in the resident's room on 7/08/2024 at 11:20 AM, 7/09/2024 at 8:00 AM, and on 7/09/2024 at 3:33 PM, revealed in Resident #17's bathroom was a large area of missing pieces of linoleum in multiple places around the resident's toilet. Resident #17 confirmed the bathroom floor has been that way for the past 3 years. 3. During an interview on 7/10/2024 at 12:57 PM, Certified Nursing Assistant (CNA M) was asked if she had noticed any issues in Resident #17's bathroom. CNA M stated, .the flooring had been like that since she was hired over a year ago . During an interview on 7/10/2024 at 1:48 PM, Licensed Practical Nurse (LPN N) was taken into Resident #17's bathroom and asked if she noticed anything about the bathroom that would warrant concerns. LPN N stated, .Yes, the floor needs to be fixed [repaired] . LPN N was asked if the missing linoleum was a fall risk for the resident. LPN N confirmed that it was a fall risk and that she would notify maintenance. During an interview on 07/10/2204 at 2:38 PM, the Maintenance Director and the Maintenance Assistant were asked if they were aware of any concerns or issues with Resident #17's bathroom flooring. The Maintenance Director confirmed that he was initially made aware of Resident #17's bathroom flooring over a year ago but could not recall the exact date. The Maintenance Director was asked should it have been repaired. The Maintenance Director stated that he needs to check to make sure that linoleum can be used to replace the flooring in the facility. The Maintenance Director was asked what the next step would be once he finds out what flooring can be used. The Maintenance Director confirmed that he would find the flooring on (named online retail). During an interview on 7/11/2024 at 6:09 PM, The Administrator was asked the process of reporting repairs in the facility. The Administrator stated that staff would immediately enter a ticket for repair in computerized repair system for maintenance. The Administrator was asked how long it should take for maintenance to address those repairs. The Administrator confirmed that it depends on the repair, but most should be addressed immediately. The Administrator was asked if it should take a year to complete a repair on a bathroom floor. The Administrator stated, .No, that should have been addressed prior to 1 year .

Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete resident assessments, using the Centers for Medicare & Medicaid Services-specific RAI (Resident Assessment Instrument) process, within the regulatory time frames for 7 of 28 sampled residents (Resident #5, #17, #22, #48, #76, #86, and #93) reviewed for completion of the MDS resident assessments. The findings include: 1. Review of the MDS 3.0 RAI Manual v (version) 1.17.1 October 2019, page 2-37 revealed .using the Centers for Medicare & Medicaid Services-specific RAI process within the regulatory time frames. 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Diabetes, Coronary Artery Disease, Hypertension, Depression, and Polyneuropathy. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/7/2022, revealed Item Z0500B with a completion date of 11/23/2022. The quarterly assessment should have been completed by 11/21/2022. 3. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE], with diagnoses including Stroke, Coronary Artery Disease, Hypertension, Diabetes, Dementia, Hemiplegia, Anxiety, and Depression. Review of the quarterly Minimum Data Set (MDS) with an ARD of 1/18/2023, revealed Item Z0500B with a completion date of 12/7/2023. The quarterly assessment should have been completed by 12/2/2023. 4. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Cerebral Infarction, Dysphagia, Depression, and Anxiety. Review of the quarterly MDS with an ARD of 7/14/2023, revealed Item Z0500B with a completion date of 8/1/2023. The quarterly assessment should have been completed by 7/28/2023. 5. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE], with diagnoses including Dementia, Hypertension, Acute Kidney Failure, Depression, and Anxiety. Review of the admission MDS with an ARD of 2/3/2023, revealed Item Z0500B with a completion date of 2/22/2023. The admission assessment should have been completed by 2/10/2023. 6. Review of the medical record revealed Resident #76 was admitted to the facility on [DATE], with diagnoses including Diabetes, Coronary Artery Disease, Hypertension, Depression, and Anxiety. Review of the admission MDS with an ARD of 4/14/2023, revealed Item Z0400I with sections A0050 and A0700X completed on 8/28/2023. The admission assessment should have been completed by 4/21/2023. 7. Review of the medical record revealed Resident #86 was admitted to the facility on [DATE], with diagnoses including Dementia, Hypertension, Depression, Anxiety, and Spinal Stenosis. Review of the Admission MDS with an ARD 1/16/2023, revealed Item Z0500B with a completion date 2/2/2023. The admission MDS should have been completed by 1/30/2023. 8. Review of the medical record revealed Resident #93 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Diabetes, Quadriplegia, Dementia, and Hypertension. Review of the admission MDS with an ARD 7/15/2023, revealed Item Z0500B with a completion date of 7/26/2023. The admission MDS should have been completed by 7/22/2023. During an interview on 7/11/2024 at 3:50 PM, the MDS Coordinator was asked about the timeliness of completion of the MDS resident assessments. The MDS Coordinator confirmed that the assessments were completed and transmitted late. The MDS Coordinator confirmed that the Director of Nursing (DON) is responsible for ensuring that MDS resident assessments are completed in a timely manner. During an interview on 7/11/2024 at 6:09 PM, the Administrator was asked who is responsible for ensuring that MDS resident assessments are completed in a timely manner. The Administrator confirmed that the MDS Coordinators are responsible for completing all resident assessments in a timely manner and the Administrator is ultimately responsible with ensuring that the assessments are done timely.

Based on policy review, medical record review and interview, the facility failed to ensure a care plan meeting was scheduled for 2 of 2 (Resident #8 and #23) reviewed for care plan meeting. The findings include: 1. Review of the facility's undated policy titled CARE PLANNING - RESIDENT PARTICIPATION, revealed .The facility supports the resident's right to inform of, and participate in, his or her care planning and treatment .The facility will notify the resident and/or resident representative, in advance, of the care to be furnished and the type of caregiver or professional that will furnish care, as well as changes to the plan of care . 2. Medical record review revealed Resident #8 was admitted [DATE], with diagnoses including Dementia, Depression, Diabetes, Anxiety, and Bipolar Disorder. Review of quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #8 was cognitively intact. During an interview on 7/9/2024 11:20 AM, Resident #8 was asked if she attended the care plan meetings. Resident #8 stated, .No, I don't think so .that would be good to have . During an interview on 7/11/2024 at 8:34 AM, with Licensed Practical Nurse (LPN) Minimum Data Set (MDS) Coordinator was asked about the process for conducting a care plan meeting. The LPN MDS Coordinator stated, .We send an invitation out quarterly .Residents are supposed to be part of that meeting especially if they are alert and oriented . The LPN MDS Coordinator confirmed Resident #8 should have had an interdisciplinary team (IDT) care plan meeting on 11/17/2023, 3/1/2024, and on 5/17/2024, and confirmed there was no documentation the care plan conference meetings were conducted. 3. Medical record review revealed Resident #23 was admitted on [DATE], with diagnoses including Cerebral Infarction, Hemiplegia, Diabetes, Fibromyalgia and Degenerative Bone Disease. Review of quarterly assessment dated [DATE], revealed Resident #23 was cognitively intact. During an Interview on 7/11/2024 at 9:36 AM, the MDS Coordinator was asked if the facility documented the IDT care plan meetings. The MDS Coordinator stated, .the invitations are provided to families .but there's no documentation of care plan meetings, not that I see in the medical record . The MDS Coordinator confirmed Resident #23 should have had an IDT care plan meeting on 12/27/2023 and 3/22/2024, and if it's not documented it was not completed. The facility failed to provide documentation of care plan meetings for Resident #8 and Resident #23. During an interview on 7/11/2024 at 2:35 PM, with the Director of Nursing (DON) was asked how often the IDT care plan meetings should be carried out with the residents. The DON stated.Social Services and admission do this quarterly .we send out requests to the families .I personally am not involved in this [care plan meetings] .the staff involved .MDS .Social Services .Activity Director .Dietary . and at times the [Named] Unit Manager .Therapy . The DON was asked should the IDT care plan conference meetings be documented. The DON stated, Yes .we don't have the documentation of the interdisciplinary team [IDT] meetings .the residents should be involved in the meetings .

Based on medical record review, observation, and interview, the facility failed to ensure followed practitioner orders for a Percutaneous Gastrostomy (PEG) tube feeding and failed to date and label PEG tube feedings for 1 of 2 (Resident #63) sampled residents reviewed for enteral feedings. The findings include: Review of the medical record revealed Resident #63 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Depression, Anxiety, and PEG tube (Percutaneous Endoscopic Gastrostomy tube, a tube inserted into the stomach to deliver food). Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #63 was severely cognitively impaired, total dependence on staff for Activities of Daily Living, and coded for a PEG tube. Review of the facility's Order Review History Report. dated 6/11/2024 - 7/11/2024 revealed, .Enteral Feed Order six times a day Free water flushes 150 ml [milliliters] Q [every] 4H [hours], provides 900 total fluid .Enteral Feed Order every shift PEG. Jevity 1.5 .@ [at] 60ml [milliliters] x [times] 22hrs [hours] .Enteral Feed Order every shift Flush with 15cc [cubic centimeters] of water before and after each medication .Enteral Feed Order .every shift Check tube placement by gastric aspiration of contents, return contents, if residual > [greater than] 100 cc hold feed x 1 hour, recheck contents, if remains >100cc notify provider .Change tube feed administration set/bag ( .with Flush Bag) every 24hrs every night shift . Observation in the resident's room on 7/8/2024 at 11:10 AM, 7/9/2024 at 3:30 PM, and on 7/9/2024 at 4:42 PM, revealed Resident #63 had an undated and untimed enteral feeding bag via pump at 60 ml/hr. Observation during medication administration on the New Wing medication cart on 7/9/2024 at 4:42 PM, revealed LPN O gathered medication and supplies and entered Resident #63's room. LPN O filled a plastic cup with water from the resident's bathroom, removed the syringe from the plastic sleeve, flushed the resident's Peg tube with 15 ml of water, administered the medications, flushed the Peg tube with 15 ml of water, and placed the syringe back into the plastic sleeve. LPN Q failed to check placement and check the PEG tube residual before administering medication, ad failed to clean, rinse and dry the syringe before storage. Observation during medication administration on the New Wing medication cart on 7/10/24 at 4:25 PM, revealed LPN Q gathered her medication and supplies and entered Resident #63's room, checked the PEG tube residual, checked the PEG tube placement, and attempted to administer the first cup of medication per gravity. LPN Q replaced the plunger and gently pushed the medications through the Peg tube with the plunger. LPN Q administered the second medication and the third medication and failed to flush with 15 ml of water between each medication. During an interview on 7/11/24 at 2:17 PM, the Director of Nursing (DON) confirmed that nursing staff should put a date and time on the enteral feeding bottle/bag and the automatic water flush bag set when it is hung and started. The DON was asked when should nursing staff flush the PEG tube when administering medications. The DON confirmed that the nursing staff should follow physician orders for flush when administering medications to residents with PEG tubes before and after medications. The DON was asked what should nursing staff do prior to administering medications via PEG tube. The DON confirmed that nursing staff should check residual and placement prior to administering medications via PEG tube.

Based on review of staff in-services and interview the facility failed to ensure the mandatory annual 12 hours of in-services were provided for the Certified Nursing Assistant (CNA) for 12 of 61 staff members (CNA A, B, C, D, E, F, G, H, I, J, K, and L reviewed for in-servicing training. The findings include: 1. Review of the facility's policy titled, CNA REQUIRED TRAINING, dated 3/1/2023, revealed It is the policy of this facility to comply with State and Federal requirements as they pertain to the training, certification, and continuing education if its nurse aides .The facility will provide at least 12 hours of in-service training annually, based on the employment date, not calendar year .Documentation of the in-services will be forwarded to the HR [Human Resource] Director . 2. Review of a list of CNA staff provided by the facility revealed the following: CNA A was hired on 11/30/2022. CNA B was hired on 1/12/2022. CNA C was hired on 9/4/2013. CNA D was hired on 7/22/2020. CNA E was hired on 2/14/2018. CNA F was hired on 6/30/2020. CNA G was hired on 2/3/2021. CNA H was hired on 3/9/2022. CNA I was hired on 8/5/2020. CNA J was hired on 6/4/2008. CNA K was hired on 2/15/2017. CNA L was hired on 7/1/2011. The facility was unable to provide documentation of 12 hours of required in-service training for CNA's A, B, C, D, E, F, G, H, I, J, K, L for the past 12 months. During an interview on the Human Resources Director confirmed CNA A, B, C, D, E, F, G, H, I, J, K, and L did not have the annual 12 hours of CNA in-services. During an interview on 7/11/2024 at 3:40 PM, the Administrator was asked about the required CNA in-services for CNAs employed over one year. The Administrator stated, .They should have 12 hours of in-services each year from hire date anniversary to hire date .

Based on policy review, medical record review, observations and interviews, the facility failed to revise and update the Care Plan to include fall interventions and communicate to staff the residents with a fall risk for 7 of 8 sampled residents (Resident #1, #2, #3, #5, #6, #7 and #8) reviewed with falls. The findings include: 1. Review of the facility's policy titled, Fall Risk Assessment, revised October 2022, revealed .It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents .An At Risk for Falls care plan will be completed for each resident to address each item identified on the risk assessment and will be updated accordingly. The At Risk for Falls care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident. Monitor the effectiveness of the care plan interventions, and modify the interventions as necessary, in accordance with current standards of practice . Review of the facility's policy titled, Fall Prevention, dated 10/2022, revealed .Each resident will be assessed for fall risk and will receive care and services in accordance with their risk to minimize the likelihood of falls .Protocols and intervention will be implemented on fall risk .When any resident experiences a fall, the facility will: Review the resident's care plan and update as indicated . Review of the facility's policy titled, Incidents and Accidents, dated 11/2022, revealed .The purpose of the incident reporting can include: Assuring that appropriate and immediate interventions are implemented, and corrective actions are taken to prevent recurrences and improve the management of resident care . 2. Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE], with diagnoses of Vascular Dementia, Psychotic Disturbance, Hypertension, Transient Ischemic Attacks, Mood Disturbance, History of Falls and Agitation. Review of the Fall Risk assessment dated [DATE], documented Resident #1 scored a 14 which indicated at risk for falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 was assessed to have a Brief Interview of Mental Status (BIMS) score of 10, which indicated Resident #1 was moderately impaired cognitively for daily decision making. Review of the medical record revealed Resident #1 fell on [DATE] at 10:00 PM. Review of Resident #1's undated Care Plan on 4/18/2023, revealed no documentation of the 3/7/2023, fall or interventions for the fall. Review of the Nurse Practitioner (NP) note dated 3/9/2023 at 1:04 PM, revealed .patient complained some pain right leg .no indication for imaging at this time after physical assessment . Review of the NP note dated 3/13/2023 at 1:44 PM, revealed .Patient seen for follow-up on left ankle pain, swelling and bruising. Patient has had a couple falls in the last week, but bruising and swelling to left foot/ankle reported over the weekend, significant swelling and bruising to left heel and toes noted, patient reports painful-ordered STAT x-ray foot and ankle. Tylenol for pain. Ice topically for pain . Review of Nurse's note dated 3/13/2023 at 10:47 PM, revealed .Late note, res [resident] xray of left ankle per [named NP] shows fx [fracture], .transfer to ER [emergency room ] for eval and tx [treat], res [resident] left at 5:20 PM . Review of Resident #1's hospital History & Physical dated 3/13/2023, revealed .Called to [named Long-Term Care (LTC) facility] to speak with the nurse. Spoke with nurse [named person] who reports [Resident #1] fell twice last week. First time was Tuesday [3/7/2023] and the resident complained of ankle pain once and then started eating a sandwich, so they [staff] forgot about it .[Resident #1] fell again on Thursday [3/9/2023]. Over the weekend, the left ankle started to swell and for this reason, they [the facility staff] brought her to the ER [emergency room ] for a checkup. He [RN #1] reports she [Resident #1] is normally non ambulatory, using a wheelchair, he [RN #1] reports she [Resident #1] can try and walk and will take 2 steps before falling. She [Resident #1] will intermittently try and get out of her chair without assistance in the setting of dementia .diagnostic radiology results fracture of the lateral malleolus with minimal displacement. Fracture of the medial malleolus [small bone on the inner side of the ankle at the end of the leg bone] without significant displacement. The area associated soft tissue swelling around the ankle. Suggestion of small avulsion along the anterior margin of the distal tibia [leg bone] .I had an extensive discussion with the patient and present family members about their current situation and clinical status .After a mutual discussion, we agreed upon intervention in the form of left ankle closed treatment without manipulation, wbat [weight bearing as tolerated] with boot, FU [follow up] clinic 2-3 weeks repeat evaluation . Review of the hospital Final Report dated 3/14/2023, revealed .Place her [Resident #1] in a orthopedic boot .OK for stand to transfer in boot .elected for nonoperative treatment . Review of NP note dated 3/16/2023 at 4:23 PM, revealed .Late entry reason for appointment readmission .discussion .family and ortho felt non-operative approach was best-walking boot placed . Review of Resident #1's undated Care Plan on 4/18/2023, revealed no revision to reflect the 3/13/2023 ER visit with the diagnoses of fracture of the lateral malleolus with minimal displacement. Fracture of the medial malleolus without significant displacement and small avulsion along the anterior margin of the distal tibia. Placement of boot for left ankle and activity of weight bearing as tolerated. Observations on 4/18/2023 at 4:00 PM, revealed Resident #1 sitting in a wheelchair in the common area eating a sandwich. The boot was not on the resident's foot/leg. Registered Nurse (RN) #1 walked over to Resident #1 and stated I need to put your boot on. Nurse #1 then proceeded to place the boot on Resident #1's left foot/leg incorrectly. The resident started yelling no, it's wrong, no, no. RN #1 stated it is right. Observation revealed the boot was placed incorrectly. Resident #1 continued to yell that is not right. RN #1 removed the boot and placed the boot on again. Resident #1 began yelling no, no it's wrong, no, no, no and shaking her head. When RN #1 was asked if the boot was on correctly, he stated yes. Observation revealed the boot was not on correctly and the surveyor went and got the Chief Nursing Officer (CNO). The CNO removed the incorrectly placed boot and placed it on the resident correctly. The resident stated, that is right, that feels much better. During an interview on 4/18/2023 at 4:00 PM, the CNO confirmed Resident #1's boot was incorrectly placed by the nurse. During an interview on 4/18/2023 at 5:15 PM, Licensed Practical Nurse (LPN) Unit Manager #1 stated .I have seen that splint [boot] on like that. I just thought she [Resident #1] had loosened it but really it was put on wrong by [named RN]. We all need an in-service on how to apply splints, they all are so different . During an interview on 4/19/2023 at 12:40 PM, when asked how was she aware of which residents were a Fall Risk Resident, Certified Nursing Assistant (CNA) #1 stated, .We don't have anything written down like a list or anything .We look at the tablet for our medical record .We don't have anything for Ms. [Resident #1] about at risk for falls or for her to wear a boot on her left foot .There is nothing on any ADL [activities of daily living] tabs first or second screen .the last tab is the care plan and we would have to look through the entire care plan to find anything .No, we don't look at the care plan . During an interview on 4/24/20223 at 5:15 PM, Unit Manager LPN #2 confirmed there was no documentation on Resident #1's care plan for the fall 3/7/2023, interventions for the fall, and the 3/13/2023 new diagnoses of a fractured ankle bone. 3. Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of Cerebral Infarction with Flaccid Hemiplegia Left Side, Heart Failure, Diabetes Mellitus Type 2, Chronic Obstructive Pulmonary Disease and Osteoarthritis. Review of the Fall Risk assessment dated [DATE], documented Resident #2 scored a 13 which indicated at risk for falls. Review of the quarterly MDS assessment dated [DATE], revealed Resident #2 was assessed to have a BIMS score of 6, which indicated Resident #2 was severely impaired cognitively for daily decision making. Review of Nurse's note dated 4/11/2023 at 2:35 PM, revealed at 12:30 PM patient complained of pain in left shoulder, Nurse Practitioner notified ordered x-ray left humerus. Review of Resident #2's x-ray report dated 4/11/2023, revealed .acute proximal left humerus fracture with minimal displacement . Review of the Physician's order dated 4/11/2023, revealed ensure that sling is in place left arm every shift for left humerus fracture. Review of Resident #2's undated Care Plan on 4/18/2023, revealed no documentation of sling to be applied to left arm every shift for left humerus fracture. Review of Resident #2's orthopedic physician visit dated 4/14/2023, revealed .upon review of imaging from over a month ago in the hospital I do see on chest x-ray and CT scan [computerized tomography - detailed xray] a 4-part displaced head split proximal humerus [arm] fracture of the left side. This was not seen on the radiologist read but is apparent .device dispensed [sling] and fitted at this visit, shown how to properly apply wear and care this medically necessary for treatment . Review of electronic medical record the CNA accesses dated 4/19/2023, revealed no documentation or communication to the staff of Resident #2's at risk for falls or application of left arm sling to be in place every shift. During an interview on 4/19/2023 at 12:40 PM, CNA #1 and #2 stated, .We don't have anything for Ms. [Resident #2] about at risk for falls or for her to wear the sling on all shifts .There is nothing on any ADL [activities of daily living] tabs first or second screen . During an interview on 4/24/20223 at 5:15 PM, Unit Manager LPN #2 confirmed no documentation on Resident #2's care plan sling to be applied to left arm every shift for humerus fracture. 4. Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Dementia without Behaviors, Repeated Falls, Hypertension and Anxiety. Review of the Fall Risk assessment dated [DATE], documented Resident #3 scored a 15 which indicated at risk for falls. Review of the medical record revealed Resident #3 fell on [DATE] at 5:39 PM. Review of Resident #3's undated Care Plan on 4/18/2023, revealed no documentation of the 2/17/2023 fall or interventions for the fall. Review of the Fall Risk assessment dated [DATE], documented Resident #3 scored a 13 which indicated at risk for falls. Review of the quarterly MDS assessment dated [DATE], revealed Resident #3 was assessed to have a BIMS score of 3, which indicated Resident #3 was severely impaired cognitively for daily decision making. Review of Nurse's note dated 4/2/2023 at 12:00 PM, revealed Resident #3 complained of pain in right hand to her daughter, and there was minor swelling on the top of the resident's right hand. No bruising was noted. An x-ray was ordered. Review of radiology (xray) results dated 4/2/2023, revealed there was no fracture noted with the conclusion the resident has moderate degenerative joint disease. Review of the undated Care Plan on 4/18/2023, revealed no documentation of diagnoses moderate degenerative joint disease or hand pain. During an interview on 4/19/2023 at 12:45 PM, when CNA #2 was asked how they were aware of which Residents were at a Fall Risk, CNA #2 stated, .nothing is written down .sometimes we may be told in report I guess .nothing officially .hit and miss . During an interview on 4/24/20223 at 5:15 PM, Unit Manager LPN #2 confirmed there was no documentation on Resident #3's care plan for the 2/17/2023 fall and interventions for the fall. She also confirmed no documentation of the 4/2/2023 diagnoses moderate degenerative joint disease or hand pain. 5. Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Dementia without Behaviors, Cerebral Infarction, Aphasia, Diabetes Mellitus Type 2, and Hypertension. Review of the Fall Risk assessment dated [DATE], documented Resident #5 scored a 13 which indicated at risk for falls. The medical record revealed Resident #5 fell on [DATE] at 5:53 PM, and 3/28/2023 at 8:05 PM. Review of Resident #5's undated Care Plan on 4/18/2023, revealed no documentation of the 3/25/2023, or 3/28/2023, falls or interventions for falls. Review of the admission MDS assessment dated [DATE], revealed Resident #5 was assessed to have a BIMS score of 15, which indicated Resident #5 was cognitively intact for daily decision making. During an interview on 4/24/20223 at 5:15 PM, Unit Manager LPN #2 confirmed no documentation on Resident #5's care plan for falls 3/25/2023 and 3/28/2023 and interventions for the falls. 6. Review of the medical record, revealed Resident #6 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses Asthma, Intracranial Abscess and Granuloma, Hydrocephalus, Macular Degeneration, Hypertension and Atrial Fibrillation. Review of the admission MDS assessment dated [DATE], revealed Resident #6 was assessed to have a BIMS score of 13, which indicated Resident #6 was cognitively intact for daily decision making. Review of the Fall Risk assessment dated [DATE], documented Resident #6 scored a 14 which indicated at risk for falls. Review of the medical record revealed Resident #6 fell on the following dates: 3/28/2023 at 2:50 PM, 4/4/2023 at 10:15 AM, 4/4/2023 at 2:50 PM, 4/7/2023 at 2:45 PM, and 4/14/2023 at 4:22 PM. Review of Resident #6's undated Care Plan on 4/18/2023, revealed no documentation of the 3/28/2023 at 2:50 PM, 4/4/2023 at 10:15 AM, 4/4/2023 at 2:50 PM, 4/7/2023 at 2:45 PM, and 4/14/2023 at 4:22 PM falls or interventions for the falls. During an interview on 4/19/2023 at 1:13 PM, RN #2 was asked how he was aware of which residents were at high risk for falls. RN #2 stated, .I think there is a list . RN #2 went to the nurse's desk and looked and stated, .there is no list .Oh, I can pull up on PCC [Point Click Care electronic medical record] and see it .[Resident #6] I know she had a recent fall . RN #2 pulled up Resident #6's information and stated, .no, nothing documented about fall risk .I don't know . During an interview on 4/24/20223 at 5:15 PM, Unit Manager LPN #2 confirmed there was no documentation on Resident #6's care plan for the falls on 3/28/2023, 4/4/2023 at 10:15 AM, 4/4/2023 at 2:50 PM, 4/7/2023, and 4/14/2023 and interventions for the falls. 7. Review of the medical record, revealed Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses Dementia with Behaviors, Diabetes Mellitus Type 2, Asthma, Repeated Falls and Hypertension. Review of the Fall Risk assessment dated [DATE], documented Resident #7 scored a 16 which indicated at risk for falls. The medical record revealed Resident #7 fell on [DATE] at 6:06 PM. Review of Resident #7's undated Care Plan on 4/18/2023, revealed no documentation of the 2/17/2023, fall or interventions for the fall and no documentation of resident getting stuck backing out of areas in her wheelchair and no interventions. Review of the quarterly MDS assessment dated [DATE], revealed Resident #7 was assessed to have a BIMS score of 8, which indicated Resident #7 was moderately cognitive impaired for daily decision making. Review of the Nurse's note dated 4/5/2023 at 10:20 PM, revealed Resident #7 .resident getting stuck backing out of areas in her wheelchair . During an interview on 4/24/20223 at 5:15 PM, Unit Manager LPN #2 confirmed there was no documentation on Resident #7's care plan for the fall on 2/17/2023, interventions for the fall and no documentation of safety interventions for the wheelchair. Unit Manager LPN #2 stated, .She [Resident #7] would get stuck backing her wheelchair up for example into the bed rail, under the over bed table, things that had a ledge .we would assist her to get unstuck . 8. Review of the medical record, revealed Resident #8 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses of Parkinson's Disease, Cerebral Infarction, Seizures, History of Falls and Major Depressive Disorder. Review of the Fall Risk assessment dated [DATE] documented Resident #8 scored an 18 which indicated at risk for falls. The medical record revealed Resident #8 fell on [DATE] at 6:33 AM and 2/24/2023 at 8:31 PM. Review of Resident #8's undated Care Plan on 4/18/2023, revealed no documentation of the 2/18/2023, or 2/24/2023, fall or interventions for the falls. Review of the quarterly MDS assessment dated [DATE], revealed Resident #8 was assessed to have a BIMS score of 8, which indicated Resident #8 was moderately cognitive impaired for daily decision making. During an interview on 4/24/20223 at 5:15 PM, Unit Manager LPN #2 confirmed thee was no documentation on Resident #8's care plan for the falls on 2/18/2023, and 2/24/2023, and interventions for the falls. During an interview on 4/24/2023 at 5:15 PM, Unit Manager LPN #1 and #2 was asked how is it communicated to staff if a resident is at risk for falls, Unit Manager LPN #1 stated, .Yeah, how do we do this . During an interview on 4/24/2023 at 5:30 PM, the Administrator was asked when is the resident's care plan revised and updated and how is it communicated to the staff which residents are at risk for falls. The Administrator stated, .We have run into a lot of different issues and were not aware of until your visit .

Based on policy review, facility investigation review, weather website review, medical record review, and interview, the facility failed to ensure a safe environment with adequate supervision to prevent elopement for 1 of 6 (Resident #5) sampled residents reviewed for elopement/wandering behaviors. The facility's failure to ensure residents were adequately supervised resulted in Immediate Jeopardy when Resident #5, who had severe cognitive impairment, exited the facility unsupervised, when a visitor entered the building through the front door of the facility and Resident #5 walked out of the door before it had closed, and was found by staff sitting on the front porch of the facility. The resident was unsupervised and out of the facility for approximately 58 minutes. The facility's failure to ensure residents that were severely cognitive impaired were adequately supervised resulted in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Chief Operation Officer, Chief Nursing Officer, Regional Director of Operation and the Administrator, were notified of the Immediate Jeopardy (IJ) for F-689 on 4/24/2023, at 6:48 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited at F-689 at a scope and a severity of J, which is Substandard Quality of Care. The IJ existed from 2/13/2023 through 2/20/2023. The Immediate Jeopardy was removed onsite when the facility implemented a corrective action plan. The Immediate Jeopardy was removed onsite when the facility implemented a corrective action plan. The corrective actions and monitoring plan were validated onsite by the surveyor on 4/25/2023 - 4/26/2023 through review of sign in sheets, interviews with staff and families, interview with the Administrator, review of audits, observations of plan interventions, and review of the facility QAPI meeting for 3/23/2023. The facility was cited for past noncompliance for F-689 and is not required to submit a Plan of Correction. The findings include: 1. Review of the facility's undated policy titled, ELOPEMENT AND WANDERING RESIDENTS, revealed .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .The facility is equipped with door locks/alarms to help avoid elopements .Adequate supervision will be provided to help prevent accidents or elopements . 2. Review of the medical records revealed Resident #5 was admitted to the facility on [DATE], with diagnoses of Diabetes Mellitus, Osteoarthritis, Dementia, Glaucoma, and Anxiety. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 had severe cognitive impairment, required supervision with one person assist for walking, and was not a risk for elopement. Review of the nurses' note dated 2/13/2023 at 12:45 [PM], written by Licensed Practical Nurse (LPN) #1 revealed, .Resident noted by staff member sitting in chair on front porch. Resident stated a man carrying boxes in the building-opened the door for me .I just wanted to sit on the porch like I do at home. I like fresh air sometimes-I wasn't going anywhere else. Resident escorted into building . Resident was immediately assessed per nurse-0 [no] s/s [signs/symptoms] injury noted. 0 [no] complaints voiced. resident will be placed in elopement risk book . Review of Timeanddate.com website revealed the outside temperature on 2/13/2023 at 12:00 PM, was 66 degrees Fahrenheit. During a telephone interview on 4/17/2023 at 11:38 AM, Visitor #1 stated, .arrived at [the facility] .she was standing right outside the entry door .I thought she was a visitor .and I walked in and she walked out .I held the door for her .I went into the lobby and she was already outside .staff was in the office busy working .didn't look like a patient .had her normal street clothes on .I remembered letting that lady out .I didn't even think about dementia patient having to be watched closely .now that I know it .I can see that's important . During a telephone interview on 4/17/2023 at 11:51 AM, Former Business Office Manager (BOM) stated, .it was the day before my last day .she was sitting outside on the patio furniture .had cards in her hands .when you talk to her long enough you will see she isn't with it .she was sitting there by herself .it was lunch hour .there were a lot going on that day .transportation van .I think they were dropping someone off .I thought they might be dropping her off . Former BOM confirmed she went on to lunch and stated, .she had on jeans and t-shirt .don't remember seeing a jacket . During an interview on 4/18/2023 at 1:27 PM, Patient Care Liaison #1 stated, .it was 12:45 PM, .I was leaving the building .saw her through the glass .asleep in the chair .had her eyes closed .I said are you ok .she was sitting in the sun .it was one of those unseasonable warm day .she wanted to stay there . During an interview on 4/19/2023 at 12:50 PM, Nurse Practitioner (NP) #2 confirmed Resident #5 was severely cognitive impaired. NP #2 was asked was it safe for her to be outside unsupervised. NP #2 stated, No. During an interview on 4/25/2023 at 3:45 PM, the Administrator was asked is it safe for a severely cognitively impaired resident to be outside of the facility and unsupervised. The Administrator stated, No. The facility's corrective actions were validated onsite by the surveyor on 4/25/2023 and 4/26/2023 through policy review, observation, review of education, review of elopement books, sign in sheets and staff and visitor interviews conducted on all shifts. 1. On 2/13/2023 Resident #5 was assisted back into the facility. Resident #1 was present at the facility during the investigation. 2. On 2/13/2023 Resident #5 was assessed by NP #2 with no injuries. This was verified by the surveyor by interview with NP #2. 3. Beginning on 2/13/2023, staff sat at the front door, until the door code could be changed, and education provided to visitors and families. This was verified by the surveyor through medical record review and interviews with staff and family. 4. On 2/13/2023 the Responsible Party, Physician Extender and Medical Director was notified of event. This was verified by the surveyor though medical record review and interviews. 5. Beginning on 2/13/2023 all staff, including ancillary staff, received in-service training related to Elopement, and Tips For Prevention of Elopements with a complete date of 2/20/2023. The training was verified by the surveyor through review of all active staff sign-in sheets for in-services and staff interviews on all shifts. 6. On 2/13/2023, the front door that Resident #5 eloped from is locked from 7:30 PM to 6:30 AM, 7 days a week. This was verified by the surveyor through office and Administration staff interviews. 7. On 2/13/2023 Resident #5's elopement risk assessment was reassessed and revised to at risk for elopement and was placed in the elopement book. This was verified by the surveyor through review of the elopement risk assessment and elopement book. 8. On 2/13/2023 Resident #5's Care Plan was initiated to include at risk for elopement with interventions. This was verified by the surveyor through review of the Care Plan. 9. On 2/13/2023 Resident #5's Care Plan was initiated to include 1:1 activities outside. This was verified by the surveyor through review of the Care Plan and interview with the Activity Director. 10. On 2/13/2023 Resident #5 was placed in 1:1 for 24 hours, then 15 minute checks for 72 hours. This was verified by the surveyor through review of medical records and staff interviews. 11. On 2/13/2023 education was provided to the staff member that had left Resident #5 sitting on the porch unsupervised. This was verified by the surveyor through review of the education and interview with that staff member. 12. On 2/13/2023 to have the front office receptionist (assigned to monitor the front door) to ensure someone remains at the desk when stepping away from the desk, so they have a clear view of the front door. This was verified through random observations and interviews of the front office staff. 13. On 2/15/2023, the door code was changed and will be changed every 3 months. This was verified by the surveyor through interview with the Administrator. 14. New admission families were educated on not allowing anyone out the front door that was not with them and to tell other family members that would be visiting. This was verified by the surveyor through family interviews. 15. On 2/13/2023 an additional bright colored signage was added to the front door, saying not to let anyone out that is not with your family/group. This was verified by the surveyor through observations of the front door. 16. On 2/13/2023 visitors and families that came to the facility were educated and this was ongoing for everyone that entered the facility and had to be let in by staff because they didn't know the code and the code had been changed, this continued for all new visitors and families. This was verified by the surveyor through interview with the Administrator and interviews with families. 17. On 2/13/2023 all new hires were educated on elopement upon hire. This was verified by the surveyor by review of the new employee's education in-service. 18. On 2/13/20223 an elopement policy review was conducted with no necessary changes. This was verified by the surveyor through interview with the Administrator. 19. On 2/13/2023 new admissions are assessed for elopement and care plans are put in place. This was verified by the surveyor through review of the elopement assessments and Care Plans. 20. On 2/13/2023 all residents identified at risk for elopements are in the elopement book and care planned at risk. This was verified by the surveyor through review of the elopement binders, Care Plans and staff interviews. 21. Beginning on 2/13/2023 elopement drills were conducted. This was verified by the surveyor through review of the completed elopement drill sign in sheets, interviews with the Maintenance Supervisor and staff on all three shifts. 22. On 2/13/2023 the Interdisciplinary Team (IDT) spoke with the Medical Director and conducted a Adhoc, Quality Assurance and Performance Improvement (QAPI) review to discuss incident and interventions put in place and preventative measures. On 3/23/2023 the IDT met with the Medial Director for their monthly meeting of QAPI and continued to discuss the elopement risk. This was verified by the surveyor through review of the QAPI meeting minutes, sign in sheet and interview with the Medical Director and Administrator. On 2/20/2023 a monitoring plan was implemented. The corrective actions and monitoring plan were validated onsite by the surveyor on 4/25/2023 - 4/26/2023 through review of sign in sheets, interviews with staff from nursing, housekeeping, maintenance and front desk, interview with families, interviews with the Administrator, review of audits, observations of plan interventions, and review of minutes for the 3/23/2023 QAPI meeting. 23. The facility implemented the following interventions and monitoring, the Administrator or Director of Nursing will audit new hire orientation/training and current staff quarterly training education on elopement policy and procedures to include location of elopement book. Audits will be conducted monthly and reported to the QAPI committee during meeting. Any deficient practice identified will be reported to the Administrator and that employee will receive re-education or counseling regarding policy and procedure as needed. Audits will be conducted until QAPI committee determines substantial compliance. 24. The facility implemented the following interventions and monitoring, the Social Services Director or Nursing Unit Manager will audit monthly the Elopement Book daily and report any deficient practice to the QAPI committee during monthly of any deficient practice. Any deficient practice identified will be reported to the Administrator and that employee will receive re-education or counseling regarding policy and procedures as need. Audits will be conducted until QAPI committee determines substantial compliance. 25. The facility implemented the following interventions and monitoring, the MDS employee or Director of Nursing will audit the Elopement Risk Assessments and Care Plan for completion on admission and quarterly. Any deficient practice identified will be reported to the Administrator and that employee will receive re-education or counseling regarding policy and procedures as need. Audits will be conducted until QAPI committee determines substantial compliance. 26. The facility implemented the following interventions and monitoring, Administrator or Patient Care Liaison will audit signage, kiosk, front office and weekend coverage, automatic evening door locking schedule, monthly PCC robo [automated] call to contact list, new resident admission education for elopement risk needs monthly and report to the QAPI committee of any deficient practice. Any deficient practice identified will be reported to the Administrator and that employee will receive re-education or counseling regarding policy and procedures as need. Audits will be conducted until QAPI committee determines substantial compliance. 27. The facility implemented the following interventions and monitoring, Administrator or Maintenance Director will audit elopement drills and doors, to include coded doors, and report to QAPI committee of any deficient practice during monthly. Any deficient practice identified will be reported to the Administrator and that employee will receive re-education or counseling regarding policy and procedures as need. Audits will be conducted until QAPI committee determines substantial compliance.

Based on weather website review, policy review, medical record review, observation, and interview, the facility failed to report incidents of elopement for 2 of 7 sampled residents (Resident #45 and #87) reviewed for wandering and elopement. The facility's failure to report incidents of elopement to the State Survey Agency resulted in Immediate Jeopardy when Resident #45, a vulnerable, severely cognitively impaired resident, exited the facility without staff knowledge or supervision and was found approximately 94.6 feet from the New Wing North exit door, standing in the parking lot on a cold January day, out of sight of the staff for approximately five to ten minutes and when Resident #87 a vulnerable, moderately cognitively impaired resident exited the facility without staff knowledge or supervision and was found leaning against the building, outside the New Wing South exit door, at approximately Midnight, out of sight of the staff for an undetermined amount of time. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Manager #1, and the Staff Development Coordinator were notified of the Immediate Jeopardy for F-609 on 7/21/2022 at 7:18 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-609. The facility was cited at F-609 at a scope and a severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 1/22/2022 to 7/24/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy was received on 7/24/2022 at 7:06 PM. The corrective actions were validated onsite by the surveyors on 7/24/2022 and 7/25/2022 through medical record review, review of education records, auditing tools, observations, and staff interviews conducted on all shifts. The findings include: Review of the facility's undated policy titled, Elopements and Wandering Residents, revealed .This facility ensures that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents .'Elopement' occurs when a resident leaves the premises or a safe area without authorization .and/or any necessary supervision to do so .Appropriate reporting requirements to the State Survey agency shall be conducted . Review of the facility's undated policy titled, Incidents and Accidents, revealed .It is the policy of this facility for staff .to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident .The purpose of incident reporting can include .Meeting regulatory requirements for analysis and reporting of incidents and accidents .the following incidents/accidents require an incident/accident report .Elopement . Review of the medical record, revealed Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Incident Report dated 1/22/2022, revealed .CNA [Certified Nursing Assistant] [#1] alerted nurse that while she was putting another resident to bed she saw resident [resident] [#45] ambulating down sidewalk and standing at the corner of the parking lot where the white lines are .Staff exited the building and assisted resident back in building .Resident was placed into a wheelchair and wheeled back into the building without difficulty. 15 minuee [minute] checks iknitiated [initiated] .No Injuries observed at time of incident .oriented to person .Oriented to Place .No Injuries observed Post Incident . Review of an Alert Note dated 1/22/2022 at 1:36 PM, revealed Res [resident] [#45] was found walking at corner of parking lot nearest back door of new wing. Was re-directed back into building and 15 minute checks initiated .CNA that saw res [resident] filled out statement. Family, DON, and MD [Medical Doctor] notified .Her primary nurse witnessed her at the desk 11:50am [11:50 AM]. The panel on the wall alarm was in place and working. It takes approximately 3-4 min [minutes] for the resident to walk to the door based on poor gait. The team responded and the resident was escorted back in the facility 1200 1201 [12:00 PM 12:01 PM] . Review of Time and Date.com/weather revealed the high temperature for 1/22/2022 was 36 degrees Fahrenheit (F) and the recorded low temperature was 34 degrees F at 12:00 PM. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severely impaired cognition and exhibited wandering behaviors on 1 to 3 days of the assessment period. Observation of the New Hall North exit door on 7/20/2022 at 3:13 PM, revealed a Loud Mate Safety Alarm secured to the upper frame of the door with Velcro, with a string coming from the alarm box and secured to the upper part of the blind with a clip. The door was opened, and the alarm was activated. LPN #9 identified the location where Resident #45 was found. The Maintenance Director used a walking wheel to measure the distance from the door to the area where LPN #9 indicated Resident #45 was found. The distance measured approximately 94.6 feet. During a telephone interview on 7/20/2022 at 4:12 PM, CNA #1 was asked to describe the incident of Resident #45's elopement. CNA #1 stated, .I was walking with [Named Resident #1] to put her to bed, and I got to the room .I look up out the window and saw [Named Resident #45] standing on the sidewalk. CNA #1 was asked how far down the sidewalk she Resident #45 was. CNA #1 stated, An inch from the parking lot, I think she was by the white lines. CNA #1 was asked if the resident's exit from the building was witnessed by staff. CNA #1 stated, No ma'am, I only saw her out the window. CNA #1 was asked if the alarm sounded. CNA #1 stated, .I heard the alarm going off as I was approaching the door. CNA #1 was asked how long the resident was out of the building. CNA #1 stated, About 5 or 10 minutes . During a telephone interview on 7/22/2022 at 10:32 AM, the Social Services Director confirmed Resident #45's elopement was not reported to the State Survey agency. The Social Services Director stated, .it wasn't reportable because the tech [CNA] was with her, she was in no danger .we realize now this wasn't the case . Review of the medical record, revealed Resident #87 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Behavior Charting dated 5/9/2022 at 4:28 AM, revealed .recently woke up from his sleep. res [resident] [#87] is slightly confused when found .res was in bed (passed by staff who was answering another res' call light) about 15 min [minutes] before he triggered door alarm. res found standing right outside new wind [wing] south exit . Review of the Nurse Practitioner Note dated 5/9/2022 at 4:39 PM, revealed .5/9 [2022] seeing pt [patient] [Resident #87] today per [by] nursing request .pt attempted to elope facility over the weekend. pt unsure why he did it. staff states pt experiencing increased confusion . Review of the quarterly MDS dated [DATE], revealed Resident #87 had a BIMS of 9, indicating he was moderately cognitively impaired, and had no wandering behaviors. During a telephone interview on 7/21/2022 at 11:30 AM, LPN #6 was asked about the incident when Resident #87 exited the building. LPN #6 stated, .it was around late-night midnight .passed his room and noticed he wasn't there and then he was found by the techs [CNAs], just right outside the back door. I believe the alarm went off, and when we opened the door he was standing out to the side of the door. When we opened the door, the door swings out to the left, he was leaning against the right side of the building with a blanket over him . LPN #6 was asked if she saw him exit the door. LPN #6 stated, No. LPN #6 was asked if the CNA saw him exit the door. LPN #6 stated, I don't think so . During an interview on 7/21/2022 at 6:11 PM, the Administrator, DON, ADON, Unit Manager #1 and the Staff Development Coordinator were asked what the definition of elopement was. The Administrator stated, When a resident leaves the premises, from safe area to unsafe area . The Administrator was asked what defines a safe area. The Administrator stated, Inside the building. The Administrator was asked what defines an unsafe area. The Administrator stated, .if they [residents] are not accompanied with a staff member. The Administrator was asked when an elopement should be reported. The Administrator stated, When a resident leaves the premises. The Administrator was asked to define premises. The Administrator stated, The property . The Administrator confirmed the incidents of elopements for Resident #45 and #87 were not reported to the State Survey agency. Observation outside the New Hall South exit door on 7/24/2022 at 8:00 PM, revealed the Maintenance Director used a walking wheel to measure the distance from the area outside the New Hall South exit door where Resident #87 was found, to the parking lot. The distance measured approximately 61.2 feet. During an interview on 7/24/2022 at 8:14 PM, CNA #2 confirmed she had observed Resident #87 in his room approximately 10-15 minutes before hearing the exit door alarm. CNA #2 stated, I [had] just got done with rounds and throwing the trash away, when I come [came] out we heard the door [alarm] go off. I go down, seen [saw] the door close, I go and open the door and I seen [saw] him right by the bushes .he was already out the door when we went down the hallway . During an interview on 7/24/2022 at 8:40 PM, LPN #6 confirmed she had notified the DON of the elopement the morning it occurred. During an interview on 7/24/2022 at 5:31 PM, the Regional Director of Clinical Operations confirmed he was not working with this facility at the time of Resident #45's elopement and that he was not made aware of the elopement of Resident #87 at the time it occurred. Refer to F-610, F-689, F-835, and F-867. The surveyors verified the removal plan by: 1. The elopements were reported to the state agency on 7/21/2022 by the Administrator. The surveyors verified by email with the State agency. 2. Staff education was initiated on 7/21/2022 on the following: a. Policies and procedures for Elopement, Incidents/Accidents b. 15-minute (min) safety checks, 24 hours (hrs.) a day, 7 days a week c. Reporting to State Agencies no later than 2 hrs. after any reportable event. d. Safety checks every (q) 15 min for 24 hrs. times 7 days a week until new door alarms are installed. c. This plan was updated 7/24/2022 to reflect an Adhoc (impromptu) Quality Assurance Performance Improvement (QAPI) committee met on 7/24/2022 at 10:00 AM to discuss the effectiveness of the safety check plan. The team concluded continual presence with 15-minute documented checks 24 hrs. a day, 7 days a week until door alarm/mag (magnetic) locking system is installed and working properly to ensure resident safety. The surveyors reviewed the training, QAPI minutes, in-service sign-in sheets, and interviewed staff from all departments on all shifts. 3. The DON and the Administrator were educated on the reporting requirements to the State agencies regarding unusual incidents of abuse, neglect, or elopement by the Chief Nursing Officer (CNO) on 7/23/2022. The surveyors reviewed the training and interviewed the CNO, Administrator, and DON. 4. A Quality Assurance auditing tool will be implemented by 7/27/2022 to ensure compliance with this plan and will be completed daily by the Unit Manager or designee. Any changes to the schedule will be reported immediately to a Unit Manager by the scheduler or department manager to ensure no staff member works without this in-service education. Audits will be double checked by the ADON daily. The Quality Auditing Tool will be utilized until agency staff is no longer working in our building and 100 percent (%) of facility employed staff have been in-serviced. All in-service education mentioned in this plan will immediately be included in facility new hire employee orientation to ensure continued compliance. The surveyors reviewed the audits and interviewed nursing management staff and the Administrator. 5. After an unusual event of Elopement, Incident & Accident or Abuse, a thorough and complete investigation will be initiated by the Charge Nurse to include assessments of any resident involved, notification of the Physician or Nurse Practitioner, DON, ADON, or Administrator and the resident involved Responsible Party. The DON or ADON will review investigations daily for completion and compliance. The surveyors reviewed the training, in-service sign in sheets, and interviewed nursing staff on all shifts, the ADON, and the DON. 6. A written statement will be obtained from all staff working the current shift, the shift prior and the shift after an incident of elopement or allegation of abuse. Statements from all staff will be dated and signed by the employee on the day of the event. The surveyors reviewed the training, in-service sign in sheets, and interviewed staff. 7. Statements from families, visitors, and other residents will be obtained if deemed necessary and appropriate. The surveyors reviewed the training, in-service sign in sheets, and interviewed staff on all shifts, the DON, and the Administrator. 8. Statements will be turned in to the DON or Designee by the end of the shift. The surveyors reviewed the training, in-service sign in sheets, and interviewed staff, the DON, and the Administrator. 9. After an elopement or allegation of Abuse, interventions will be implemented based on a Root Cause Analysis (RCA) and will then be Care Planned by the Resident Assessment Coordinator or the DON. The surveyors reviewed the training, in-service sign in sheets, and interviewed nursing staff on all shifts, the DON, and the Administrator. 10. The Physician or Nurse Practitioner will be notified immediately after an incident of abuse or elopement and will complete a follow up assessment. The surveyors reviewed the training, in-service sign in sheets, and interviewed nursing staff on all shifts, the DON, and the Administrator. 11. Follow up discussion about any new elopement, new elopement risk incident or accident or allegation of abuse will take place in the daily morning clinical meeting, daily morning stand-up meeting, and daily afternoon stand-down meeting which will be ongoing. The surveyors reviewed the training, in-service sign in sheets, and interviewed members of the Interdisciplinary Team, the DON, and the Administrator. 12. All auditing will continue 2 times a week for 4 weeks, if substantial compliance is reached, auditing will continue weekly for 1 month and then it will be 1 time per month thereafter. This will be reviewed in QAPI monthly or PRN (as needed) if concerns are identified to re-evaluate the need to reinstate frequent monitoring. The surveyors interviewed nursing management staff, members of the QAPI team, the DON, and the Administrator. The facility's noncompliance at F-609 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, job description review, facility investigation review, medical record review, observation, and interview, the facility failed to ensure incidents of elopement, staff-to-resident abuse, and drug diversions were thoroughly investigated for 5 of 10 sampled residents (Resident #45, #87, #19, #68, and #90) reviewed for wandering/elopement behaviors and at risk for abuse. The facility's failure to thoroughly investigate incidents of elopement resulted in Immediate Jeopardy when Resident #45, a cognitively impaired resident at risk for wandering/elopement, exited the facility without staff knowledge, walked approximately 94.6 feet from the facility, and was found standing in the parking lot in the back of the facility and when Resident #87 a vulnerable, moderately cognitively impaired resident exited the facility without staff knowledge or supervision and was found leaning against the building, outside the New Wing South exit door, at approximately Midnight, out of sight of the staff for an undetermined amount of time. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Manager #1, and Staff Development Coordinator were notified of the Immediate Jeopardy (IJ) for F-610 on 7/21/2022 at 7:18 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-610 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 1/22/2022 through 7/24/2022. An acceptable Removal Plan for F-610, which removed the immediacy of the Jeopardy, was received on 7/25/2022 at 11:43 AM. The corrective actions were validated onsite by the surveyors on 7/25/2022 through observations, review of education records, and staff interviews conducted on all shifts. The findings include: Review of the facility's policy titled, ABUSE/NEGLECT/EXPLOITATION, dated 11/2017, revealed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect occur .Written procedures for investigation include .Identifying staff responsible for the investigation .Investigating different types of alleged violations .Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation .focusing the investigation on determining if abuse, neglect, exploitation, and /or mistreatment has occurred, the extent, and cause .Providing complete and thorough documentation of the investigation . Review of the facility's undated policy titled, Quality Assurance and Performance Improvement (QAPI), revealed .Systems and reports demonstrating systematic identification, reporting, investigating, analysis, and prevention of adverse events . Review of the facility's undated DON Job Description, revealed .The Director of Nursing ('DON') is responsible for .She/he also monitors the outcomes of nursing services activity by evaluating the performance of nursing staff, ensuring compliance with all facility and regulatory agency standards, policies and procedures, coordinating facility committees . Review of the medical record, revealed Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Elopement Evaluation dated 7/21/2021, revealed Resident #45 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Elopement Evaluation dated 8/13/2021, revealed Resident #45 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment, had wandering behavior, and required supervision when walking in her room or in the hallway. Review of the Incident Report dated 1/22/2022, revealed .CNA [Certified Nursing Assistant] [#1] alerted nurse that while she was putting another resident to bed she saw resident [Resident #45] ambulating down sidewalk and standing at the corner of the parking lot where the white lines are .Staff exited the building and assisted resident back in building .Predisposing Physiological Factors .Dementia .Predisposing Situation Factors .Wandering . The Incident Report did not specify what time Resident #45 was located and returned to the facility. Review of the medical record, revealed there were no Social Service Progress Notes related to Resident #45's behavior or psychological status after the 1/22/2022 elopement. Review of the facility's investigation revealed no written statements or interviews with the staff from the shift prior to the elopement. Elopement drills and education were not provided to all staff on all shifts. Observation in the resident's room on 7/20/2022 at 9:48 AM, revealed Resident #45 was seated in her wheelchair, neatly dressed, her head bowed, and her eyes closed. During a telephone interview on 7/20/2022 at 4:12 PM, CNA #1 was asked to describe the incident of Resident #45's elopement. CNA #1 stated, .I was walking with [Named Resident #1] to put her to bed and I got to the room .I looked out the window and saw [Named Resident #45] standing on the sidewalk . CNA #1 was asked how far down the sidewalk she Resident #45 was. CNA #1 stated, An inch from the parking lot, I think she was by the white lines. CNA #1 was asked if the resident's exit from the building was witnessed by staff. CNA #1 stated, No ma'am, I only saw her out the window. CNA #1 was asked if the alarm sounded. CNA #1 stated, .I heard the alarm going off as I was approaching the door. CNA #1 was asked how long the resident was out of the building. CNA #1 stated, About 5 or 10 minutes . Review of the medical record, revealed Resident #87 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Behavior Charting dated 5/9/2022 at 4:28 AM, revealed .recently woke up from his sleep. res [resident] [#87] is slightly confused when found .res was in bed (passed by staff who was answering another res' call light) about 15min [15 minutes] before he triggered door alarm. res found standing right outside new wind [wing] south exit . Review of the facility's investigation revealed no written statements or interviews with the staff related to Resident #87's elopement. There was no documentation staff received education related to the elopement, and there were no Social Services Progress Notes related to Resident #87's behavior or psychological status after the elopement on 5/9/2022. Review of the quarterly MDS dated [DATE], revealed Resident #87 had a BIMS of 9, indicating he had moderate cognitive impairment. During a telephone interview on 7/21/2022 at 11:30 AM, Licensed Practical Nurse (LPN) #6 was asked about Resident #87's elopement. She stated, .he [Resident #87] was found by the techs [CNAs] .outside the back door .leaning against the right side of the building . She was asked how he was dressed. She stated, I'm not sure . She was asked if she saw him exit the facility. She stated, No. She was asked if the technician saw him exit the facility. She stated, I don't think so. She was asked if the black box door alarm was on the door frame. She stated, I'm not sure. She was asked if she had the staff write statements regarding this event. She stated, I don't remember writing a statement. She was asked if the facility provided education to staff about elopement after this occurrence. She stated, I'm not sure. Review of the medical record, revealed Resident #19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #19 had moderately impaired cognition, had behaviors directed toward herself and others, rejected care, had wandering behaviors, and required extensive assistance from staff for her activities of daily living (ADLs). Review of an Incident Report dated 5/20/2022, revealed .An allegation of physical and verbal abuse was reported .by the floor technician .This even [event] happened 5/10/2022 or 5/11/2022 per the reporter .He [Technician] saw the aide [CNA #9] .in the common area on the unit .as [Resident #19] attempted to get up out of a common chair in the common area, the aide .stood in front of her in the hair [chair] placed both his hands on her shoulder from the front. He told her per the reporter, 'Sit your ass down' . and pushed her down in the chair with both hands. He witnessed him take her rollator from her as she attempted to stand again and stated, 'I said sit your ass down' . Review of the facility investigation revealed statements were not obtained from all staff on the unit, on the shift before the allegation of abuse or the shift after the allegation of abuse, and all staff were not educated about abuse after the alleged abuse incident. Review of the medical record, revealed Resident #68 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Incident Report dated 5/20/2022 revealed, An allegation of abuse was reported by the floor technician on 5/20/2022 .event occurred approximately on 5/10 [5/10/2022] .or 5/11/2022 in the evening hours .It was reported that the specific male aide [CNA #9] .was at the residents [resident's] door. The resident was also standing at the door from the inside of her room .the aide place [placed] his arm up in a fast abrupt manner and the physical gesture noted with the aide doing a push back at the door with his arm and closing the door abruptly with the resident at the inside of the door .he was unable to say if physical contact was made with this resident .The employee [accused] has voiced to the DON that he denies the allegations. He feels attacked because he is a male and the only male aide . Review of the quarterly MDS dated [DATE] revealed Resident #68 had severely impaired cognition, had behaviors directed toward herself and others, rejected care, had wandering behavior, and required extensive assistance from staff for her ADLs. During a telephone interview on 7/21/2022 at 9:51 AM, Floor Technician #1 was asked about his statement alleging CNA #9 was verbally and physically abusive to Resident #68 and Resident #19. He stated, .that day I was buffing the floor, and I stayed over to let it dry .[CNA #9] and I had words .[Resident #68] was trying to come out of the room and he stood in the door, he was closing the door while she was trying to open the door. He said something like, 'keep your [a**] in there,' I didn't say anything .another day, it was [Resident #19] was sitting in the day area. She tried to get up. He pushed her down and said, 'sit your [a**] down' . Review of the facility investigation revealed statements were not obtained from all staff on the unit on the shift before the allegation of abuse or the shift after the allegation of abuse, and all staff were not educated about abuse after the alleged abuse incident. During an interview on 7/20/2022 at 3:38 PM, the Administrator stated, We are .in-servicing staff beginning today . Review of the medical record, revealed Resident #90 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Tablet 5 MG [milligrams] Give 1 tablet by mouth .every 6 hours as needed for pain . Review of the annual MDS assessment dated [DATE], revealed Resident #90 had a BIMS of 15, indicating she was cognitively intact for decision making. Review of the facility's investigation, revealed on 7/8/2022, two 30 count medication cards of Resident #90's [MEDICATION(S)] 5 milligram (mg) and the corresponding narcotic sheets had been removed from the medication cart. This was discovered during the 3:00 PM-11:00 PM narcotic count. The facility failed to obtain witness statements on 7/8/2022, the day of the incident. The facility did not obtain staff member statements until 7/19/2022. During an interview on 7/19/2022 at 4:02 PM, the DON confirmed she did not obtain witness statements from the staff members on each shift after the drug diversion incident was identified. During an interview on 7/20/2022 at 7:43 AM, LPN #11 confirmed she did not write a statement on the day of the drug diversion incident. During an interview on 7/20/2022 at 11:11 AM, LPN #7 confirmed she did not write a witness statement until 7/20/2022 for the drug diversion incident. During an interview on 7/21/2022 at 7:22 PM, the Administrator was asked what constitutes a thorough investigation. She stated, Interviews, statements from involved parties to include staff, residents, family members, vendors . The Administrator was asked when an incident investigation should begin. She stated, Immediately. She was asked if the facility did a thorough investigation for the incidents of elopement, abuse, and drug diversion. She stated, .through the process of providing information to the survey team, we identified a more thorough investigation would be helpful in situations like these in providing education or additional training to the staff . During an interview on 7/22/2022 at 9:31 AM, the DON was asked if the facility completed a thorough investigation for the drug diversion. The DON stated, .we can improve . During an interview on 7/22/2022 at 3:53 PM, Agency CNA #9 was asked what training she had received in the facility related to abuse allegations or elopement. She stated, .I don't remember any training at all . During an interview on 7/22/2022 at 5:07 PM, Unit Manager #1 confirmed she did not get statements from other staff members. She only obtained a statement from agency Registered Nurse (RN) #1 related to the drug diversion incident. During a telephone interview on 7/24/2022 at 6:59 PM, CNA #11 confirmed she had worked with CNA #9. She confirmed she had not written a statement after the abuse allegation related to CNA #9. She was asked if she had received education about elopements after Resident #45's elopement in January. She stated, .no Ma'am .it's a sundowner situation or full moon. They are going to be off the map. Everybody [has] got to have their thinking caps on because something [is] going to happen. They can push those doors so quick. They will shove that door, and that door will pop open, and they get out quick. If you [are] way at the bottom of the hall and you [are] in with a patient you might not hear that alarm .they can move quicker than you think, certain ones you [have] got to watch .[Named Resident #45] [in January] she was walking with her walker and going to the bathroom on her own and push [pushed] that door open .Sometimes she would park the walker and walk without it . During a telephone interview on 7/24/2022 at 7:02 PM, LPN #8 confirmed she worked with CNA #9. She confirmed she had not been asked to write a statement after the abuse allegation related to CNA #9. During a telephone interview on 7/24/2022 at 7:17 PM, CNA #10 confirmed she worked the same shift with CNA #9. She was asked if she had written a statement after the abuse allegation related to CNA #9. She stated, No, Ma'am. During a telephone interview on 7/24/2022 at 7:32 PM, CNA #8 confirmed she was not asked to write a statement related to CNA #9's abuse allegation and did not receive any education related to abuse or elopement in January, May, or June. During a telephone interview on 7/24/2022 at 7:41 PM, LPN #10 confirmed she had worked with CNA #9 on numerous occasions. She was asked if she was asked to write a statement after the abuse allegation related to CNA #9. She stated, .no, not about that . During a telephone interview on 7/25/2022 at 10:29 AM, agency CNA #8 was asked if she had received abuse education after the abuse allegation related to CNA #9. She stated, I did not . She was asked if she had received education on elopement in May or June. She stated, .not that I recall. During a telephone interview on 7/25/2022 at 1:47 PM, CNA #6 was asked if she wrote a statement or had any education on abuse after the abuse allegation related to CNA #9. CNA #6 confirmed she didn't remember getting abuse education or writing a statement. The facility failed to provide documentation of witness statements, an investigation of the events and behaviors prior to the incidents, and failed to provide staff education based on the findings of the investigation. Refer to F-609, F-689, F-835, and F-867. The surveyors verified the removal plan by: 1. The facility will complete a risk management investigation prior to the end of the shift when any new elopement, incident & accident or allegation of abuse has been reported. This was confirmed through record review and interviews with staff and administration. 2. A written statement will be obtained from all staff working the current shift, the shift prior and the shift after an incident of elopement or allegation of abuse. Statements from all staff will be dated and signed by the employee on the day of the event. This was confirmed through interviews with staff on all shifts. 3. A root cause analysis will be documented on the risk assessment for any new elopement, incident & accident, or allegation of abuse to prevent recurrences. This was confirmed through observations, record review, and interviews with staff and administration. 4. The DON and Administrator were educated on the reporting requirements to State agencies regarding unusual incidents of abuse, neglect, or elopement by the Chief Nursing Officer (CNO) on 7/23/2022. This was confirmed through interviews with the DON, Administrator and CNO. 5. Staff education was initiated on 7/22/2022 on the policies and procedures for Elopement, Incidents & Accidents, Allegations of Abuse, and reporting to State Agencies no later than 2 hours after any reportable event. This was confirmed through record review and interviews. 6. Auditing of each new event will be reviewed by the clinical interdisciplinary team during the daily clinical start up meeting by members of the Interdisciplinary Team (IDT) team to ensure investigations are completed in a thorough and timely manner. This will be ongoing. This was confirmed through interviews with the DON, Administrator and the IDT. 7. All investigations of elopement, incidents, accidents, and allegations of abuse and suggestions will also be reviewed at the monthly Quality Assurance Performance Improvement (QAPI) meeting. This will be ongoing. This was confirmed through interviews. 8. All auditing will continue 2 times a week for 4 weeks, if substantial compliance is reached, auditing will continue weekly for 1 month and then it will be 1 time per month thereafter. This will be reviewed in QAPI monthly or as needed. If concerns are identified, the need to reinstate frequent monitoring will be re-evaluated. The surveyors reviewed the audits. 9. Education related to what is considered/defined as a full investigation was initiated on 7/24/2022 at 10:00 AM for all staff and will continue until ALL staff confirm by signing training their understanding of their responsibility in participating in a thorough investigation. The training included: a. What type of investigation is it? Elopement, abuse, other? b. Elopement/Abuse must be reported immediately to the Administrator/DON and charted. c. Notify Administrator/DON immediately and chart/complete assessment of the resident. d. Administrator/DON must report this to the State/ appropriate reporting agency within 2 hours of the occurrence. e. Assessment of the resident and document the Medical Doctor/Nurse Practitioner were notified in the medical record. Notify Responsible party and document. f. Obtain written statement from ALL staff in facility which must include the date/time of the incident. Statements will be obtained from the shift before the incident and after the incident occurred. g. Any staff not present for this initial in-service will not work until they have been in serviced and confirm understanding by signature. This was confirmed by review of the education and interviews with staff on all shifts. The facility's noncompliance at F-610 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on weather website review, policy review, facility investigation review, medical record review, observation, and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent elopement for 2 of 7 sampled residents (Resident #45 and #87) reviewed for elopement/wandering behaviors. Resident #45, who had severely impaired cognition, was at risk for wandering, and was a fall risk, exited the facility without staff knowledge through the New Wing North exit door on a cold January day, walked approximately 94.6 feet and was found by staff standing in the parking lot for an undetermined amount of time. Resident #87, who had severely impaired cognition, was at risk for wandering, and was a fall risk, exited the facility without staff knowledge through the New Wing South exit door and was found leaning against the building outside the door, out of view of the staff. The facility's failure to ensure residents at risk for wandering/elopement behaviors were adequately supervised resulted in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Director of Nursing (DON), the Assistant Director of Nursing (ADON), Unit Manager #1, and the Staff Development Coordinator were notified of the Immediate Jeopardy (IJ) for F-689 on 7/21/2022 at 7:18 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited at F-689 at a scope and a severity of J, which is Substandard Quality of Care. The IJ existed from 1/22/2022 through 7/24/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 7/24/2022 at 7:06 PM. The corrective actions were validated onsite by the surveyors on 7/24/2022 and 7/25/2022 through policy review, observation, review of education and audit tools, and staff interviews conducted on all shifts. The findings include: Review of the facility's undated policy titled, Incidents and Accidents, revealed .An 'incident' is defined as an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization .The following incidents/accidents require an incident/accident report but are not limited to .Elopement . Review of the facility's undated policy titled, Elopements and Wandering Residents, revealed .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .The facility is equipped with door locks/alarms to help avoid elopements .Staff are to be vigilant in responding to alarms in a timely manner .Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team .in order to develop a person-centered care plan .Adequate supervision will be provided to help prevent accidents or elopements .A social service designee will re-assess the resident and make any referrals for counseling or psychological/psychiatric consults .Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior .Documentation in the medical record will include findings from nursing and social service assessments, physician/family notification, care plan discussions, and consultant notes . Review of the medical record, revealed Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of [CONDITION(S)], Dementia, Anxiety, Depression, [CONDITION(S)], Hypertension, and Spinal Stenosis. Review of an Elopement Evaluation dated 7/21/2021, revealed .History of or attempted leaving the facility without informing staff: Yes .Verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door: Yes . Review of an Elopement Evaluation dated 8/13/2021, revealed .Does the resident have a history of or attempted leaving the facility without informing staff .Yes . Review of a Nurses' Progress Note dated 12/19/2021, revealed .Resident observed kicking and banging on closed doors with hands .not able to be re-oriented by staff members . Review of a Social Services Note dated 1/20/2022, revealed .Annual .Reviewed .behavior .frequent crying, repeat movement, and wandering . Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #45 had a Brief Interview of Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment, had wandering behavior, and required supervision when walking in her room or in the hallway. Review of an Alert Note, written by Licensed Practical Nurse (LPN) #2, on 1/22/2022 at 1:36 PM, revealed .Res [resident] [#45] was found walking at corner of parking lot nearest back door of new wing. Was re-directed back into building . The Alert Note did not specify what time Resident #45 was found. Review of the Incident Report dated 1/22/2022, revealed .CNA [Certified Nursing Assistant] [#1] alerted nurse that while she was putting another resident to bed she saw resident [Resident #45] ambulating down sidewalk and standing at the corner of the parking lot where the white lines are .Staff exited the building and assisted resident back in building .Predisposing Physiological Factors .Dementia .Predisposing Situation Factors .Wandering . The Incident Report did not specify what time Resident #45 was found. Review of the facility investigation file dated 1/22/2022, revealed a written statement from CNA #1 who saw Resident #45 outside. The statement revealed, .In the process of putting [Named Resident] to bed I [named herself] looked up and saw [Named Resident #45] out the window she was standing in the back parking lot the last time I saw her was [at] 12:00 [12:00 PM] in her room . Review of the facility investigation file dated 1/22/2022, revealed a written statement from LPN #9 who was providing care for Resident #45 the day of the elopement. The statement revealed, .I saw res [Resident #45] outside on pavement painted lined in area just past the sidewalk. Res had coat draped over her shoulders and was using walker .walking towards the cars in parking lot .last saw patient approx. [approximately] 1145 [11:45 AM]/1150 [11:50 AM] in front of nurses [nurses'] station facing activity room door .Had coat on at that time . Review of Time and Date.com/weather revealed on 1/22/2022, the high temperature for the day was 36 degrees Fahrenheit (F) and the recorded low temperature was 34 degrees F at 12:00 PM. Review of the medical record, revealed there were no Social Service Progress Notes related to Resident #45's behavior or psychological status after the 1/22/2022 elopement. Observation in the resident's room on 7/20/2022 at 9:48 AM, revealed Resident #45 was seated in her wheelchair, neatly dressed, her head was bowed, and her eyes were closed. During an interview on 7/20/2022 at 2:45 PM, LPN #9 was asked about Resident #45's elopement. She stated, I was working on New Wing, was the only nurse on that side . She confirmed she was at the Nurses' Station and did not see Resident #45 walk by the Nurses' Station. She confirmed the resident would have had to walk by the Nurses' Station to get to the New Wing North exit door. She stated, .I saw her when she was outside .she was in that back parking lot .she was on the pavement of the parking lot. She confirmed she did not see Resident #45 exit the facility. LPN #9 was asked if she heard the alarm go off. She stated, .I did not hear the alarm on the door, that wasn't going off. I was still learning the alarm system . Observation in the New Wing North Hall exit door on 7/20/2022 at 3:13 PM, with the Maintenance Director, revealed a small black Safety Alarm box attached to the frame of the New Wing North exit door with Velcro. The Alarm Box had a string attached to a pin that fit inside the box. The string was clipped on the upper part of the blind on the window of the door. The Maintenance Director demonstrated that when the door was opened, the string was stretched to the point it would pop the pin out of the alarm box, and the alarm would sound. The door also alarmed at the Nurses' Station when the door was opened. The door alarm at the Nurses' Station was not audible near the North end of New Wing. The Maintenance Director confirmed the small black Safety Alarm box could easily be removed by anyone in the facility, it was not a good alarm system, and the facility had discussed replacing it with a Magnetic Lock. The Maintenance Director used a walking wheel, beginning at the new Wing North exit door and walked down the sidewalk where LPN #9 indicated she found Resident #45 after the resident eloped. The Maintenance Director confirmed the distance measured was approximately 94.6 feet from the threshold of the New Wing North exit door to the point where Resident #45 was found. During a telephone interview on 7/20/2022 at 4:12 PM, CNA #1 was asked about Resident #45's elopement. CNA #1 stated, .I was walking with [Named Resident #1] to put her to bed, and I got to the room before she did .was pulling back her bed .look up out the window and saw [Named Resident #45] standing on the sidewalk .I think she was by the white lines . She confirmed she did not see Resident #45 exit the facility and stated, .I only saw her out the window . She was asked when she had last seen Resident #45 before she saw her outside. CNA #1 stated, .she was in her room, right after lunch . CNA #1 was asked if she heard the alarm sound in the room where she was. She stated, .No, I just saw her out the window .ran out of the room and yelled [Named Resident #45] is out the door . She was asked how long the resident was outside. She stated, .5 or 10 minutes . Review of the medical record, revealed Resident #87 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of [CONDITION(S)], Heart Failure, [CONDITION(S)], and Altered Mental Status. Review of the admission MDS dated [DATE], revealed Resident #87 had a BIMS of 3, which indicated severe cognitive impairment and required staff assistance for activities of daily living. Review of the Care Plan dated 10/31/2021 revealed .At risk for elopement related to .Wandering .10/13/2021 .The resident speaks of leaving the facility .10/19/2021 .talking about leaving the facility wanting a beer/placing hat/shoes on to walk to the store/walker . Review of the Behavior Charting dated 5/9/2022 at 4:28 AM, revealed .recently woke up from his sleep. res [resident] [#87] is slightly confused when found .res was in bed (passed by staff who was answering another res' call light) about 15min [15 minutes] before he triggered door alarm. res found standing right outside new wind [wing] south exit . Review of the Nurse Practitioner Note dated 5/9/2022 at 4:39 PM, revealed .5/9 [2022] seeing pt [patient] today per [by] nursing request .pt attempted to elope facility over the weekend. pt unsure why he did it. staff states pt experiencing increased confusion . Review of the medical record, revealed there were no Social Service Progress Notes related to Resident #87's behavior or psychological status after the elopement on 5/9/2022. During an interview on 7/20/2022 at 1:57 PM, the DON and the Administrator confirmed they did not think the elopement incidents on 1/22/2022 and 5/9/2022 were elopements because the residents did not leave the premises. During a telephone interview on 7/21/2022 at 11:30 AM, LPN #6 was asked about the incident when Resident #87 got outside the building. LPN #6 stated, .passed his room and noticed he wasn't there and then he was found by the techs [CNAs], just right outside the back door .I believe the alarm went off, and when we opened the door he was standing out to the side of the door. When we opened the door, the door swings out to the left, he was leaning against the right side of the building with a blanket over him . LPN #6 was asked if she saw him exit the door. LPN #6 stated, No. LPN #6 was asked if the tech saw him exit the door. LPN #6 stated, I don't think so .When we were looking for him we found him .then the alarm went off. We knew what door, we thought maybe its [Named Resident #87]. During an interview on 7/21/2022 at 6:11 PM, the Administrator confirmed an elopement is when a resident leaves the premises, or from a safe area to an unsafe area. The Administrator was asked if the premises outside the facility was safe. She stated, No, it's not. The Administrator was asked to define an unsafe area. She stated, If they are not accompanied by a staff member. The Administrator was asked if the alarm system was effective. The Administrator confirmed that, with the current alarm system, the door still opens immediately, and there is no delay in the door opening. She stated, .we feel the 15 second delay would enhance the ability to prevent actual elopement .it was determined in January that we would look into purchasing a system such as the Magnetic Locking System .it was discussed with Corporate who agreed this would be a helpful device . During a telephone interview on 7/22/2022 at 10:32 AM, the Social Services Director was asked to describe her role when a resident elopes. The Social Services Director stated, .If I feel like they are an elopement [risk], do a risk assessment, with a face sheet put all that information in the green book, let the nurses and staff know they are in the book for elopement risk .I document at least twice after an elopement . She was asked if she documented psychological or behavioral notes after Resident #45's elopement. The Social Services Director stated, I don't know if I wrote a note or not. The Social Services Director confirmed she had not documented psychological or behavioral notes after Resident #45's and Resident #87's elopement. During an interview on 7/22/2022 at 2:36 PM, the Administrator was asked if the facility should know where the residents are, when they exit the facility, and where they go. She stated, Yes. The Administrator was asked who was ultimately responsible for the safety and welfare of the residents. She stated, Everybody, all departments and every employee. Observation outside the New Hall South Exit Door on 7/24/2022 at 8:00 PM, revealed the Maintenance Director measured the distance from the area where Resident #87 was found to the parking lot. The distance measured using a walking wheel was approximately 61.2 feet from the parking lot. During an interview on 7/24/2022 at 8:14 PM, CNA #2 confirmed she had observed Resident #87 in his room approximately 10-15 minutes before hearing the exit door alarm. CNA #2 confirmed she was in the biohazard room with the door closed and did not hear the alarm until she exited the biohazard room and stated, I [had] just got done with rounds and throwing the trash away, when I come [came] out, we heard the door [alarm] go off. I go down .I go and open the door, and I seen [saw] him [Resident #87] right by the bushes .he was already out the door when we went down the hallway . During an interview on 7/25/2022 at 3:20 PM, the Maintenance Director was asked if he inspected the exit doors after each elopement. The Maintenance Director stated, .Not every door . The surveyors verified the removal plan by: 1. Staff education was initiated on 7/22/2022 on the following: a. Policies and procedures for Elopement, Incidents and Accidents, Allegations of Abuse, every 15-minute safety checks (24 hours/day, 7 days/week), b. Reporting to State Agencies no later than 2 hours after any reportable event. c. Safety checks every 15 minutes, 24 hours/day, 7 days/week, until new door alarms are installed and working properly. This was confirmed through review of the in-service sheets, in-service sign-in sheets, observation of the safety checks of the exit doors and residents, and interviews with staff on all shifts. 2. On 7/21/2022, a new Elopement Risk Assessment was completed on 100 percent (%) of the residents for risk and any resident found to score 4 or higher on Elopement Assessments had interventions implemented to prevent elopement from occurring. This was confirmed through review of the resident Elopement Risk Assessments and interviews. 3. On 7/22/2022, the facility initiated staff education on conducting risk assessments, recognizing if resident exhibits intention to leave, e.g. exit seeking, wandering, packing belongings, verbalizing the want to leave, reporting, and intervening to prevent elopement. This was confirmed through review of in-services and in-service sign-In sheets, and interviews with staff on all shifts. 4. Education was initiated for all staff on 7/22/2022, regarding the elopement book, Elopement Policy Procedures, Incidents & accidents. This was confirmed through review of the elopement book, review of in-services and in-service sign-In sheets, and interviews with staff on all shifts. 5. All previously mentioned education will be provided for any staff returning to work after being off or on leave prior to working their first shift back to work. This was confirmed through interview with the Staffing Development Coordinator and DON. 6. Staff education was initiated on 7/22/2022, on the following: a. Policies and procedures for Elopement, Incidents & Accidents, Allegations of Abuse 15-minute safety checks, 24 hours/day, 7 days/week b. Reporting to State Agencies no later than 2 hours after any reportable event. c. Safety checks every 15 minutes, 24 hours/day, 7 days/week, until new door alarms are installed and working properly. d. An Adhoc (Impromptu) Quality Assurance Performance Improvement (QAPI) committee met on 7/24/2022 at 10:00 AM to discuss the effectiveness of the safety check plan. The Team concluded continual presence with 15-minute documented checks, 24 hours/day, 7 days/week, until door alarm/magnetic locking system is installed and working properly will be most effective to ensure resident safety. This was confirmed through observation of the 15-minute safety checks and staff interviews. 7. All new admissions, readmission, residents exhibiting exit seeking behavior or expressing a desire to leave will have a Risk Assessment completed and needed interventions will be implemented and care planned. This was confirmed through medical record review and interview with the DON and Staff Development Coordinator. 8. DON or designee will audit records of all new admissions, readmissions, and residents exhibiting exit seeking behavior to verify all needed assessments have been completed and appropriate interventions implemented. This was confirmed through interview with the DON and the Administrator. 9. A Quality Assurance (QA) auditing tool will be implemented by 7/27/2022, to ensure compliance with this plan and will be completed daily by the Unit Manager or designee. Any changes to the schedule will be reported immediately to a Unit Manager by the scheduler or department manager to ensure no staff member works without receiving this in-service education. Audits will be double checked by the ADON daily. The Quality Auditing Tool will be utilized until agency staff is no longer working in the facility and 100% of facility employed staff have been in-serviced. All in-service education mentioned in this plan will immediately be included in facility new hire employee orientation to ensure continued compliance. This was confirmed through interviews with the DON, ADON, Staff Development Coordinator, and Administrator. 10. All investigations of elopement, incidents & accidents, allegations of abuse, and suggestions will be reported, reviewed, and discussed at the monthly QAPI meeting. This was confirmed through interview with the DON and Administrator. 11. Auditing tools will be implemented by 7/27/2022, to ensure compliance with this plan and will be monitored daily by the nursing Unit Managers and double checked for compliance by the ADON. This was confirmed through interviews with the ADON and the DON. 12. The DON and Administrator will audit daily for overall compliance of this plan. This was confirmed through interview with the DON and the Administrator. 13. All auditing will continue 2 times a week for 4 weeks. If substantial compliance is reached, auditing will continue weekly for 1 month, and then it will be 1 time a month thereafter. This will be reviewed in QAPI monthly or as needed. If concerns are identified, will re-evaluate the need to reinstate frequent monitoring. This was confirmed through interviews with the Administrator and the DON. The facility's noncompliance at F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, Board of Examiners for Nursing Home Administrators (BENHA) review, job description review, and interview, the facility Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable well-being of cognitively impaired residents with wandering behaviors. Administration failed to provide oversight to monitor and provide a safe resident environment for cognitively impaired residents with wandering behaviors, to report, and investigate incidents of elopement. These failures resulted in Immediate Jeopardy when Resident #45, a severely cognitively impaired resident with exit-seeking behaviors, exited the building without staff knowledge or supervision and was found approximately 94.6 feet from an exit door, standing in the parking lot on a cold January day, out of staff sight for five to ten minutes and when Resident #87, a moderately cognitively impaired resident exited the facility without staff knowledge or supervision and was found leaning against the building, outside an exit door at approximately midnight, out of sight of the staff for an undetermined amount of time. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Manager #1, and Staff Development Coordinator, were notified of the Immediate Jeopardy at F-609, F-610, and F-689 on 7/21/2022 at 7:18 PM, in the Conference Room. The Administrator and DON, were notified of the Immediate Jeopardy for F-835 and F-867 on 7/22/2022 at 6:20 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-609, F-610, F-689, F-835, and F-867. The facility was cited at F-609, F-610, and F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 1/22/2022 through 7/24/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 7/25/2022 at 1:20 PM. The corrective actions were validated onsite by the surveyors on 7/25/2022 through observations, review of education records, and staff interviews conducted on all shifts. The findings include: Review of the facility's undated Chief Executive Officer (CEO) (Administrator) Job Description, revealed .The CEO is responsible for the day to day operations and direction of the facility, and ensures that the facility complies with all policies and procedures set forth by the company, as well as those required by regulatory agencies. Also ensures that expectations of the corporation and our customers are met or exceeded on a continual basis .Ensures that the facility complies with all policies and procedures set forth by THE COMPANY, regulatory agencies, and other appropriate bodies .Ensures the provision of quality of services through the design and implementation of facility wide quality assurance and program evaluation plans .Ensures quality care .Demonstrates effective management/leadership skills .Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures .that are necessary for providing quality care and maintaining a sound operation .Must be able to communicate .regulations .to personnel .Makes decisions in a timely manner . Review of the BENHA form revealed the Administrator was hired 1/3/2020. Review of the facility's undated DON Job Description, revealed .The Director of Nursing ('DON') is responsible for effective overall management of the Nursing department and coordination with other disciplines to provide quality care to all patients/residents. She/he supports and practices the philosophy, objectives and standards of the Department of Nursing and participates in the revision of these as necessary to ensure quality care to all patients/residents. She/he also monitors the outcomes of nursing services activity by evaluating the performance of nursing staff, ensuring compliance with all facility and regulatory agency standards, policies and procedures, coordinating facility committees .Ensure that nursing interventions meet the personal, physical, and cognitive needs of each patient/resident .Assumes full responsibility for the operation and management of the facility in the temporary absence of the Facility Administrator or as directed by the Administrator .Participates in the selection of patients/residents to be admitted by evaluating the level and amount of care required by prospective patients/residents in relation to exiting nursing capabilities .Meets with committee members to evaluate activities within the facility and to identify opportunities for continuous improvement in nursing operations . Review of the facility's undated policy titled, Quality Assurance and Performance Improvement (QAPI), revealed .It is the policy of this 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 . Review of the facility's undated policy titled, Elopements and Wandering Residents, revealed .This facility ensures that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents .'Elopement' occurs when a resident leaves the premises or a safe area without authorization .and/or any necessary supervision to do so .The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risk, implementing interventions to reduce hazards and risks and monitoring for effectiveness and modifying interventions when necessary .The administrator or designee should also notify the company's corporate office .Appropriate reporting requirements to the State Survey agency shall be conducted .A social services designee will re-assess the resident and make any referrals for counseling .Staff may be educated on the reason for elopement and possible strategies for avoiding such behavior . Review of the facility's undated policy titled, Incidents and Accidents, revealed .It is the policy of this facility for staff .to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident .The purpose of incident reporting can include .Meeting regulatory requirements for analysis and reporting of incidents and accidents .the following incidents/accidents require an incident/accident report .Elopement . Observation of the New Hall North exit door on 7/20/2022 at 3:13 PM, revealed the Maintenance Director used a walking wheel to measure the distance from the door to the area where Resident #45 was found. The distance measured approximately 94.6 feet. During a telephone interview on 7/20/2022 at 4:12 PM, Certified Nursing Assistant (CNA) #1 was asked to describe Resident #45's elopement. CNA #1 stated, .I was walking with [Named Resident #1] to put her to bed and I got to the room .I looked out the window and saw [Named Resident #45] standing on the sidewalk . CNA #1 was asked how far down the sidewalk was Resident #45. CNA #1 stated, An inch from the parking lot, I think she was by the white lines. CNA #1 was asked if she saw her exit the building. CNA #1 stated, No ma'am, I only saw her out the window . CNA #1 was asked if she heard the alarm sound. CNA #1 stated, .I heard the alarm going off as I was approaching the door. CNA #1 was asked how long the resident was out of the building. CNA #1 stated, About 5 or 10 minutes . During a telephone interview on 7/21/2022 at 11:30 AM, Licensed Practical Nurse (LPN) #6 was asked about the incident when Resident #87 was found outside the building. LPN #6 stated, .passed his room and noticed he wasn't there and then he was found by the techs [CNAs], just right outside the back door .I believe the alarm went off, and when we opened the door he was standing out to the side of the door. When we opened the door, the door swings out to the left, he was leaning against the right side of the building with a blanket over him . LPN #6 was asked if she saw him exit the door. LPN #6 stated, No. LPN #6 was asked if the CNA saw him exit the door. LPN #6 stated, I don't think so . Observation outside the New Hall South Exit Door on 7/24/2022 at 8:00 PM, revealed the Maintenance Supervisor used a walking wheel to measure the distance from the New Hall South Exit Door where Resident #87 was found to the parking lot. The distance measured approximately 61.2 feet. During an interview on 7/21/2022 at 2:30 PM, the Administrator and the Maintenance Director confirmed elopement drills should be conducted yearly and after an incident of elopement. The Administrator confirmed the last elopement drill was conducted 1/31/2022 and no elopement drills were conducted after Resident #87 eloped. During an interview on 7/21/2022 at 2:47 PM, the Staff Development Coordinator confirmed no in-services related to elopement were provided after Resident #87 eloped. During an interview on 7/21/2022 at 6:11 PM, the Administrator, DON, ADON, Unit Manager #1 and Staff Development Coordinator were asked to define elopement. The Administrator stated, When a resident leaves the premises, from safe area to unsafe area . The Administrator was asked what was considered a safe area. The Administrator stated, Inside the building. The Administrator was asked what an unsafe area was. The Administrator stated, .if they [residents] are not accompanied with a staff member. The Administrator was asked when an elopement should be reported. The Administrator stated, When a resident leaves the premises. The Administrator was asked to define premises. The Administrator stated, The property . When asked to define a thorough investigation, the Administrator stated, Interviewing and receiving statements from involved parties meaning staff members, residents, family members or vendors when applicable. The Administrator was asked when the investigation should be started after an incident. The Administrator stated, Immediately. The Administrator was asked how many elopement drills had been conducted in the facility since January, and the DON responded, I count 3 .Inside .the elopements you see a QA [Quality Assurance] tool in the investigation. We treat it like a drill . The Administrator stated, The actual elopement drill was conducted January 31, 2022 .an in-service was completed 1/22/2022 . The Administrator and DON were asked when an elopement drill should be conducted. The DON stated, An elopement drill should be conducted when a resident elopes. The Administrator stated, Yearly and as needed . The DON stated, We did a head count which is part of an elopement drill . The Administrator was asked when it was determined the facility needed a magnetic locking system and why one was necessary. The Administrator stated, .we feel the 15 second delay would enhance the ability to prevent actual elopement .it was determined in January 2022 that we would look into purchasing a system .it was discussed with corporate office who agreed this would be a helpful device, and are in support of purchasing and placement . The Administrator and DON were asked how the staff were educated after each elopement occurrence. The DON stated, We have done education before. When an elopement happens, we huddle and discuss it . The DON and Administrator were asked what should be reported to the state agency. The DON stated, .Elopements that are not care planned .that are not witnessed . During a telephone interview on 7/22/2022 at 10:32 AM, the Social Services Director confirmed Resident #45's elopement was not reported to the State Survey agency. The Social Services Director stated the elopement was not a reportable incident because the aides were with Resident #45, and she was in no danger (the resident exited the facility unsupervised). The Social Services Director was asked what the Social Services role was following an elopement. The Social Services Director stated, .I document at least twice after an elopement. I'm still checking progress notes and stuff like that .go sit and talk with them [residents] .a couple of days later check on them again and document that. The Social Services Director confirmed she did not do follow up documentation on Resident #45 and #87's behaviors and mental status following the incidents of elopement. During a telephone interview on 7/22/2022 at 11:30 AM, the Chief Nursing Officer (CNO) confirmed she was not aware of Resident #87's elopement. The CNO was asked if she felt this was something that should be immediately discussed with her. The CNO stated, Absolutely. During a telephone interview on 7/22/2022 at 2:18 PM, the Medical Director confirmed he was not aware of Resident #87's elopements. Refer to F-609, F-610, F-689, and F-867. The surveyor verified the Removal Plan by: 1. As of 7/21/2022, Resident #45 and #87 have been placed on 15-minute safety checks, 24 hours (hrs.) a day, 7 days a week until the new door safety alarm has been installed and working properly. The surveyors reviewed the documentation of the 15-minute checks and the order for the safety alarm. 2. Staff education was initiated on 7/22/2022 on the following: a. Policies and procedures for Elopement, Incidents & Accidents, Allegations of Abuse, 15-minute safety checks, 24 hours a day, 7 days a week, reporting to State Agencies no later than 2 hours after any reportable event. b. Safety checks every 15 minutes, 24 hours a day, 7 days a week until new door alarms are installed and working properly. c. An Adhoc (Impromptu) QAPI meeting was held on 7/24/2022 at 10:00 AM to discuss the effectiveness of the safety check plan. The team concluded continual presence with 15-minute documented checks 24 hours a day, 7 days a week until door alarm/magnetic locking system is installed and working properly to ensure resident safety. The surveyors reviewed the training, QAPI minutes, in-service sign-in sheets, and interviewed staff from all departments, on all shifts. 3. A Quality Assurance (QA) auditing tool will be implemented by 7/27/2022 to ensure compliance with this plan and will be completed daily by the Unit Manager or designee. Any changes to the schedule will be reported immediately to a Unit Manager by the scheduler or department manager to ensure no staff member works without this in-service education. Audits will be double checked by the ADON daily. The Quality Auditing Tool will be utilized until agency staff is no longer working in the building and 100 percent (%) of facility employed staff have been in-serviced. All in-service education mentioned in this plan will immediately be included in facility new hire employee orientation to ensure continued compliance. The surveyors interviewed nursing management, staff, and the Administrator. 4. The DON and the Administrator were educated on reporting requirements to State agencies regarding unusual incidents of abuse, neglect, or elopement by the Chief Nursing Officer (CNO) on 7/23/2022. The surveyors reviewed the training and interviewed the CNO, Administrator, and DON. 5. Follow up discussion about any new elopement, new elopement risk incident or accident or allegation of abuse will take place in the morning clinical meeting, morning stand up meeting, and afternoon stand down meeting. The surveyors reviewed the training, in-service sign in sheets, and interviewed members of the Interdisciplinary Team, the DON, and the Administrator. 6. All investigations of elopement, incidents & accidents, allegations of abuse, and suggestions will be reported and reviewed at the QAPI meeting. The surveyors interviewed members of the QAPI team, the DON, and the Administrator. 7. The DON will report the findings to QAPI committee monthly for at least 3 months or until resolved. The surveyors interviewed the DON. 8. All auditing will continue 2 times a week for 4 weeks, if substantial compliance is reached, auditing will continue weekly for 1 month and then it will be 1 time a month thereafter. This will be reviewed in QAPI monthly or as needed if concerns are identified to re-evaluate the need to reinstate frequent monitoring. The surveyors interviewed nursing management staff, members of the QAPI team, the DON, and the Administrator. 9. The Administrator received QAPI education with the expectations from the Corporate CNO, on 7/23/2022 regarding overall requirements and expectations related to the rules, guidelines, timely reporting to the appropriate state agency, timely reporting of incidents such as abuse/elopement/misappropriation, and all others, and complete oversight of the facilities QAPI program. The surveyors reviewed the education and interviewed the Administrator and the CNO. 10. The Administrator is responsible for ensuring compliance with QAPI within the facility. The surveyors interviewed the Administrator. 11. Oversight will be provided by the corporate Management, reports will be sent weekly, and review on a telephone call each Friday. The surveyors interviewed the Administrator, DON, and CNO. 12. Corporate will participate in monthly QAPI meetings with an invitation sent for the call by the Administrator. The surveyors interviewed the Administrator, DON, and CNO. 13. The Administrator was provided in-service training on Administration/Duties on 7/23/2022 by the CNO. A member of the corporate team will be on-site and in the facility on a weekly basis for 6 weeks or until compliance is achieved, then bi-weekly for 2 months, then ongoing at least monthly. The surveyors reviewed the education, and interviewed the Administrator, DON, and CNO. The facility's noncompliance at F-835 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, job description review, Quality Assurance Performance Improvement (QAPI) reports, medical record review, observation, and interview, the QAPI committee failed to ensure systems and processes were in place that involved tracking/trending, evaluation/reevaluation of interventions, data, and trends to address quality concerns related to wandering and elopement behaviors. The QAPI committee failed to ensure a thorough investigation of a resident elopement, failed to identify quality deficiencies and effective interventions, failed to monitor the effectiveness of the interventions, and failed to assess staff knowledge of the care of residents with wandering/elopement behaviors in order to identify deviations and adverse events when residents exited the facility without staff knowledge. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #45, a cognitively impaired resident assessed as a risk for wandering/elopement left the facility unsupervised and was found in the back parking lot of the facility and when Resident #87, a cognitively impaired resident, exited the facility and was found outside the facility at approximately midnight. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Manager #1, and Staff Development Coordinator, were notified of the Immediate Jeopardy at F-609, F-610, and F-689 on 7/21/2022 at 7:18 PM, in the Conference Room. The Administrator and DON, were notified of the Immediate Jeopardy for F-835 and F-867 on 7/22/2022 at 6:20 PM, in the Conference Room. The facility was cited Immediate Jeopardy (IJ) at F-609, F-610, F-689, F-835, and F-867. The facility was cited at F-609, F-610, and F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 1/22/2022 through 7/24/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 7/25/2022 at 11:43 AM. The corrective actions were validated onsite by the surveyors on 7/25/2022 through observations, review of education records, and staff interviews conducted on all shifts. The findings include: Review of the facility's undated policy titled, Quality Assurance and Performance Improvement (QAPI), revealed .It is the policy of this 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 .The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan .Develop and implement appropriate plans of action to correct identified quality deficiencies .The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program .Systems and reports demonstrating systematic identification, reporting, investigating, analysis, and prevention of adverse events .The QAPI program will be ongoing, comprehensive, and will address the full range of care and services provided by the facility . Review of the facility's undated Chief Executive Officer (CEO) (Administrator) Job Description, revealed, .The CEO is responsible for the day to day operations and direction of the facility, and ensures that the facility complies with all policies and procedures set forth by the company, as well as those required by regulatory agencies. Also ensures that expectations of the corporation and our customers are met or exceeded on a continual basis .Ensures the provision of quality of services through the design and implementation of facility wide quality assurance and program evaluation plans .Ensures quality care .Demonstrates effective management/leadership skills .Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objective, policies and procedures .that are necessary for providing quality care and maintaining a sound operation .Must be able to communicate .regulations .to personnel .Makes decisions in a timely manner . Review of the facility's undated DON Job Description, revealed .The Director of Nursing ('DON') is responsible for effective overall management of the Nursing department and coordination with other disciplines to provide quality care to all patients/residents. She/he supports and practices the philosophy, objectives and standards of the Department of Nursing and participates in the revision of these as necessary to ensure quality care to all patients/residents. She/he also monitors the outcomes of nursing services activity by evaluating the performance of nursing staff, ensuring compliance with all facility and regulatory agency standards, policies and procedures, coordinating facility committees .Assumes full responsibility for the operation and management of the facility in the temporary absence of the Facility Administrator or as directed by the Administrator .Meets with committee members to evaluate activities within the facility and to identify opportunities for continuous improvement in nursing operations . Review of the medical record, revealed Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Incident Report dated 1/22/2022, revealed .CNA [Certified Nursing Assistant] [#1] alerted nurse that while she was putting another resident to bed she saw resident [resident] [#45] ambulating down sidewalk and standing at the corner of the parking lot where the white lines are. Staff exited the building and assisted resident back in building .Resident was placed into a wheelchair and wheeled back into the building without difficulty. 15 minuee [minute] checks iknitiated [initiated] .No Injuries observed at time of incident .oriented to person .Oriented to Place .No Injuries observed Post Incident . During an interview on 7/20/2022 at 2:45 PM, Licensed Practical Nurse (LPN) #9 was asked where she was when Resident #45 eloped. LPN #9 stated, .I think I was at the Nurses' Station .I did not see [Named Resident #45] walk past the Nurses' Station or exit the door .[Named CNA #1] came and said [Named Resident #45] is outside in the parking lot .she [Resident #45] had her walker with her walking on the pavement . LPN #9 was asked if the alarm sounded. LPN #9 stated, I did not hear the alarm on the door .was still learning the alarm system I don't remember hearing the alarm to be honest . LPN #9 confirmed the doors were not checked by anyone after Resident #45's elopement. Observation with the Maintenance Director on 7/20/2022 at 3:13 PM of the New Wing North Hall exit door, revealed a Loud Mate Safety Alarm secured to the upper frame of the door with Velcro, with a string coming from the alarm box and secured/clipped to the upper part of the blind. The door was opened, and the alarm was activated. LPN #9 identified the location where Resident #45 was found in the parking lot at the white lines. The Maintenance Director measured the distance from the door to the area where LPN #9 indicated Resident #45 was found using a walking wheel. The distance measured from the door to the white lines was approximately 94.6 feet. During a telephone interview on 7/20/2022 at 4:12 PM, CNA #1 was asked to describe the incident of Resident #45's elopement. CNA #1 stated, .I was walking with [Named Resident #1] to put her to bed .I got to the room .I look up out the window and saw [Named Resident #45] standing on the sidewalk . CNA #1 confirmed she did not see the resident exit the building. CNA #1 stated, I only saw her out the window. CNA #1 was asked if an alarm was sounded. CNA #1 stated, .I heard the alarm going off as I was approaching the door . CNA #1 was asked how long Resident #45 was out of the building. CNA #1 stated, .About 5 or 10 minutes . During a telephone interview on 7/22/2022 at 10:32 AM, the Social Services Director confirmed Resident #45's elopement was not reported to the State Survey agency. The Social Services Director stated the elopement was not a reportable incident because the aides were with her, and she was in no danger (the resident exited the facility unsupervised and without staff). Review of the medical record, revealed Resident #87 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Behavior Charting dated 5/9/2022 at 4:28 AM, revealed .recently woke up from his sleep. res [resident] [#87] is slightly confused when found .res was in bed (passed by staff who was answering another res' call light) about 15min [15 minutes] before he triggered door alarm. res found standing right outside new wind [wing] south exit . During a telephone interview on 7/21/2022 at 11:30 AM, LPN #6 was asked about the incident when Resident #87 got outside the building. LPN #6 stated, .it was around late-night midnight .passed his room and noticed he wasn't there and then he was found by the techs [CNAs], just right outside the back door. I believe the alarm went off, and when we opened the door, he was standing out to the side of the door .he was leaning against the right side of the building with a blanket over him . LPN #6 was asked if she saw him exit the door. LPN #6 stated, No. LPN #6 was asked if the CNA saw him exit the door. LPN #6 stated, I don't think so .When we were looking for him we found him .and then the alarm went off . Observation outside the New Hall South Exit Door on 7/24/2022 at 8:00 PM, revealed the Maintenance Director measured the distance from the area where Resident #87 was found to the parking lot. The distance measured using a walking wheel was approximately 61.2 feet from the parking lot. The facility had an elopement drill on 1/31/2022 with the first shift staff members only. The facility was unable to provide the monthly QAPI committee Agenda/Minutes for 1/2022, 2/2022, 4/2022, and 6/2022. During an interview on 7/20/2022 at 6:36 PM, the Administrator confirmed the facility had QAPI meetings monthly. The Administrator was unable to provide QAPI meeting minutes for meetings in January, February, April, and June. During an interview on 7/21/2022 at 6:11 PM the Administrator, DON, ADON, Unit Manager #1, and Staff Development Coordinator were asked to define elopement. The Administrator stated, .when a resident leaves the premises from safe area to unsafe area . The Administrator was asked what was considered a safe area. The Administrator stated, Inside the building. The Administrator was asked what an unsafe area was. The Administrator stated, .if they [residents] are not accompanied with a staff member . The Administrator was asked when an elopement should be reported. The Administrator stated, When a resident leaves the premises. The Administrator was asked to define premises. The Administrator stated, The property . The Administrator confirmed the incidents of elopement for Resident #45 and Resident #87 were not reported to the State Survey Agency. Continuing the interview on 7/21/2022 at 6:11 PM, the DON and Administrator were asked what the facility did to identify the root cause of repeated elopements in the facility in the last 6 months. The DON stated, Wanting to go home and having problems adjusting to new facility .not used to being in Long Term Care and not being able to leave when they [residents] want to . The Administrator was asked when an Adhoc (impromptu) QAPI meeting should be held. The Administrator stated, When the facility identifies an incident or concern has been identified where improvements can be made to policies and procedures, an Adhoc will be held to educate, develop a root cause analysis. The DON stated, And possible need for a safer environment for the resident. The Administrator was asked since Resident #45 eloped in January, why was the Adhoc meeting not held until yesterday. The Administrator stated, The Adhoc meeting was not only for her, it was to review the facility's needs .educate staff . The Administrator confirmed there was no Adhoc meeting held after Resident #45 and #87 eloped. The Administrator stated, Through the process of providing documentation to the survey team it was apparent that we identified a more thorough investigation would be helpful . During a telephone interview on 7/24/2022 at 5:31 PM, the Regional Director of Clinical Services confirmed he was not aware of the 2 elopements that occurred in the facility. The Regional Director of Clinical Services confirmed he was not made aware of the elopement until the survey. The Regional Director of Clinical Services confirmed that during the facility's weekly meeting, the elopements were not discussed. The Regional Director of Clinical Services confirmed he did not attend the Adhoc meeting. Refer to F-609, F-610, F-689, and F-835. The surveyors verified the removal plan by: 1. On 7/23/2022, the Adhoc QAPI Committee reviewed the elopement assessments for the following residents to determine the root cause. a. Resident #45: Root cause, resident enjoys being outdoors. b. Resident #87: Acute mental status, unable to express his needs. d. These residents were assessed and found to be an elopement risk prior to their elopement. e. These residents had Care Plans for behaviors prior to their elopement. f. As of 7/21/2022, these residents were placed on 15-minute safety checks, 24 hours a day, 7 days a week until the new door alarm system is in place and working properly. This was confirmed through observations, record review, and interviews. 2. Resident #45 goes outside with supervision of staff as warranted. Resident #87 is monitored for any acute mental status episodes that may increase his risk of elopement. The Interdisciplinary team identified the following root causes for the above elopements: a. The 15 second release after holding the door allows the resident to get out when the door releases. b. The tone loudness is not at the highest capacity for staff to hear if in resident room with residents. c. The black box door alarm could be removed easily by resident is not the best system to alert for an elopement. d. Lack of understanding of reporting requirements and the term on or off the premise deemed as an elopement. e. Lack of staff education regarding warning signs and triggers. f. The need for a new door alarm system to prevent elopements. g. Increase in agency staff requires the need for more education input from the team. h. Staff reporting changes in residents' behavior or medical condition that may place them at higher elopement risk. i. Identified the need for improved communication of residents at risk for elopement. j. Current Elopement Policy to be reviewed for any needed changes. This was confirmed through observations, record review, and interviews. 3. Staff education was initiated on 7/22/2022 on the following: a. Policies and procedures for Elopement, Incidents & Accidents, Allegations of Abuse, b. 15-minute safety checks, 24 hours a day, 7 days a week, c. Reporting to State Agencies no later than 2 hours after any reportable event. d. Safety checks every 15 minutes, 24 hours a day, 7 days a week until new door alarms are installed and working properly, e. An adhoc QAPI meeting was held on 7/24/2022 at 10:00 AM to discuss the effectiveness of the safety check plan. The team concluded continual presence with 15-minute documented checks 24 hours a day, 7 days a week until door alarm/magnetic locking system is installed and working properly to ensure resident safety. This was confirmed through observations, record review, review of QAPI minutes, review of education and in-service sign in sheets, and interviews with staff on all shifts. 4. The DON and Administrator were educated on reporting requirements to State agencies regarding unusual incidents of abuse, neglect, or elopement by the Chief Nursing Officer (CNO) on 7/23/2022. This was confirmed through interviews. 5. A new Magnetic Lock alarm system is scheduled to be installed by 8/8/2022. This was confirmed through record review and interviews. 6. Staff were educated on 7/23/2022 on monitoring the doors every 30 minutes, 24 hours per day, 7 days a week until the new alarming Magnetic Lock system is installed. 7. The QAPI committee will convene and review any new elopement or abuse allegation within 72 hours of occurrence to ensure a thorough investigation is conducted, root cause is correctly identified, and corrective action plan is implemented. This will be conducted weekly for 4 weeks, assessed for effectiveness, then monthly thereafter. This was confirmed through observations, record review, and interviews. 8. The Administrator and DON will monitor this plan daily for compliance. This was confirmed through interviews with the Administrator and DON. 9. All auditing will continue 2 times a week for 4 weeks. If substantial compliance is reached, auditing will continue weekly for 1 month and then it will be 1 time a month thereafter. This will be reviewed in QAPI monthly or as needed. If concerns are identified with the auditing, QAPI will re-evaluate the need to reinstate frequent monitoring. This was confirmed through observations, record review, and interviews. 10. Education was initiated by the Administrator on 7/24/2022 and again on 7/25/2022 for all QAPI members, the Department Managers, and the Interdisciplinary Team (IDT) members regarding the QAPI process with handouts provided. Any member not available on the above dates will be educated prior to working their next scheduled shift. This was confirmed through observations, record review, and interviews. 11. The Administrator is responsible for the overall QAPI program in the facility and will be monitored for compliance by Corporate Management weekly through report submission ensuring compliance and by a follow up call 1 time weekly on Friday. This was confirmed through interviews. The facility's noncompliance at F-867 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when the oven had build-up of a shiny, brown substance on the inside doors and all sides in the inside of the oven, the coffee machine had a build-up of black splashes and the spout of the coffee machine had a build-up of a dark gray substance, the toaster had a build-up of crumbs, the juice machine had a build-up of a thick, orange, red, and tan substance on the spout and on the sides of the machine, there was a pink, slimy substance on the water curtain of the ice machine in the Dining Room, the stove's grease trap was filled with a black liquid with thick black stringy material and a thermometer floating in it, the stove's drip pan had several particles of dried food and dark grime covering the pan, there was a build-up of a black substance inside the gas oven on all sides, there was thick, dark brown build-up on the can opener, there was a build-up of dark, brown crumbs on top of the deep fryer and inside the deep fryer, the vent-a-hood was covered with a build-up of thick gray dust, 1 of 7 dietary staff (Dietary Aide #1) stacked 12 wet plates onto a clean serving cart, 16 plate holders were wet-nested on a metal working table, 1 of 7 dietary staff (Dietary Aide #2) failed to remove their gloves and perform hand hygiene after leaving the dirty side of the dishmachine and before removing clean dishes from the clean side of the dishmachine. The facility had a census of 109 residents with all 109 residents receiving a tray from the Kitchen. The findings include: Review of the facility's undated policy titled, .Sanitation/Infection Control, revealed .The proper procedures for washing and sanitizing, pots, pans, and utensils are posted and followed by staff . Review of the facility's undated policy titled, .Cleaning and Sanitizing Dietary Areas and Equipment, revealed .All kitchen areas and equipment shall be maintained in a sanitary manner and be free of buildup of food, grease, or other soil .Procedure for Cleaning Ovens .5. Spray inside oven and door with oven cleaner and let stand .6. Wipe off loosened grease and carbon .7. If oven door still has any soil left. Repeat 5 and 6 .Procedure for washing pots and Pans .Remove .to designated storage area after drying .Allow to air dry .Procedure for Cleaning Coffee and Tea Dispensers .Scrub all parts with a solution .Be sure to dismantle and carefully clean the faucet; otherwise deposits will accumulate .Procedure for Cleaning Pop-Up Toaster for Conveyor .Immediately after Use: Conveyor .Brush Crumbs .Remove toast guide and tray and brush crumbs .Wipe off .with sanitizing solution .Wipe dry .Procedure for Cleaning Hood Filter Over Stove .Remove screen or vent from over stove .Run .through dishwasher .Wipe off hood completely with degreaser . Review of the facility's undated policy titled, .Deep Fryer Cleaning Policy and Procedure, revealed .Deep fryer will be cleaned on a regular basis .Clean the element whenever the oil is filtered or changed .Wipe down the exterior at the end of the day .Clean the fry basket at the end of the day . Review of the facility's undated policy titled, .Sanitation of Ice Machine, revealed .It is the policy of this facility that the ice machine shall be sanitized twice monthly . Review of the facility's undated policy titled, .Infection Control, revealed .The dietary department personnel are alert to the need for infection control .All dishes, pots, and pans, flatware, drinking glasses are properly cleaned, sanitized, and handled by method .compatible with long term care regulations . Observation in the Kitchen on 7/18/2022 at 10:45 AM, revealed the following: a. a shiny, brownish build-up inside the doors of the standing oven and on all sides of the oven inside b. the coffee machine had a dark gray build-up on the spout and the metal area on the coffee machine had a build-up of black splashes c. the toaster had a build-up of crumbs on the conveyor d. the juice machine spouts had a thick orange colored, thick red colored, and thick tan colored build-up on the spouts and sides of the juice machine e. the grease trap was filled with a black liquid with multiple black stringy materials and a thermometer floating in it f. the drip pan had a build-up of dried food particles and dark grime g. the standing oven had a build-up of a black substance on all sides of the inside of the oven h. the gas oven doors had a build-up of a brownish substance inside and outside the oven, and there was a black golf-ball sized ball of an unknown substance on the bottom of the left oven i. the vent-a-hood had a build-up of thick gray dust. Observation in the Dining Room on 7/18/2022 at 10:45 AM, 7/18/2022 at 2:40 PM, 7/19/2022 at 2:15 PM, and on 7/20/2022 at 10:50 AM, revealed the ice machine had a pink, slimy build-up along the bottom ledge of the water curtain. Observation in the Kitchen on 7/18/2022 at 2:40 PM, on 7/19/2022 at 2:15 PM, and 7/20/2022 at 10:50 AM, revealed the following: a. a shiny, brownish build-up inside the doors of the standing oven and on all sides of the inside of the oven b. the coffee machine had a dark gray build-up on the spout and the metal area of the coffee machine had a build-up of black splashes c. a toaster with a build-up of crumbs on the conveyor d. the juice machine spouts had a thick orange colored, thick red colored, and thick tan colored build-up on the spouts and sides of the juice machine e. the grease trap was filled with a black liquid with multiple black stringy materials and a thermometer floating in it f. the drip pan had a build-up of dried food particles and dark grime g. the standing oven had a build-up of a black substance on all sides of the inside of the oven h. the gas oven doors had a build-up of a brownish substance on the inside and outside, and there was a black golf-ball sized ball of an unknown substance on the bottom of the left oven i. the vent-a-hood had a build-up of thick gray dust j. the can opener had a build-up of a dark brown substance k. there was a build-up of crumbs on the top and sides of the deep fryer. Observation in the Kitchen on 7/19/2022 at 2:15 PM, revealed Dietary Aide #1 stacked several wet plates in the plate holder located on the food serving line and 16 wet-nested plate holder bottoms were stacked on a metal worktable in the clean area. Observation in the Dishwashing Area on 7/20/2022 at 10:50 AM, revealed Dietary Aide #2 failed to remove his gloves and perform hand hygiene, walked to the clean side of the dishmachine, and began removing the clean dishes, wearing the same soiled gloves. During an interview on 7/20/2022 at 6:38 PM, the Dietary Manager confirmed there should not be a build-up of a shiny, brown substance inside the standing oven, there should not be a build-up of black splashes on the coffee machine, there should not be a dark gray build-up on the spout of the coffee machine, there should not be a build-up of crumbs in the toaster, the juice machine should not have thick, orange, red, and tan build-up on the spout and on the sides of the machine, the ice machine should not have a pink, slimy substance on the water curtain, the stove's grease trap should not be filled with a black liquid with thick, black strands and a thermometer floating in it, the stove's drip pan should not be covered with a build-up of particles of dried food and dark grime, the inside of the oven should not have a build-up of a black substance, the can opener should not have a thick, dark brown build-up, the deep fryer should not have a build-up of dark, brown crumbs on the top and inside of the fryer, the vent-a-hood should not have a build-up of thick gray dust, plates and plate holders should not be wet nested, and staff should remove their gloves and perform hand hygiene after leaving the dirty side of the dishmachine to remove clean dishes from the clean side.

Based on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, review of Employee Screening logs, employee time sheets, agency invoices, and interview, the facility failed to ensure practices to prevent the spread of infection were maintained when 23 of 121 staff members (Dietary Aide #2, #3, and #4, Housekeeper #1, #2, #3, and #4, Licensed Practical Nurse (LPN) #4 and #8, Agency LPN #1, #2, and #3, Certified Nursing Assistant (CNA) #4, #5, #6, and #7, and Agency CNA #1, #2, #3, #4, #5, #6, and #7) failed to complete screening for the prevention and detection of COVID-19 prior to working on 1 of 1 days (7/15/2022) reviewed. This had the potential to affect the 109 residents residing in the facility. The findings include: Review of the facility's undated policy titled, Coronavirus Surveillance, revealed .This facility will implement heightened surveillance activities for coronavirus illness during periods of transmission in the community and/or during a declared public health emergency for the illness .Screening for visitors and staff .Signs or symptoms of a respiratory infection .In the last 14 days, has had contact with someone with a confirmed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .International travel within the last 14 days .Residing in a community where community based spread of COVID-19 is occurring .Staff who have signs and symptoms of a respiratory infection shall not work . Review of the CDC document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/2/2022, revealed .Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic .Establish a process to identify anyone entering the facility, regardless of their vaccination status .options could include (but are not limited to): individual screening on arrival at the facility . Review of the Employee Screening logs, employee time sheets, and agency invoices, revealed the following employees worked on 7/15/2022 and failed to screen for signs and symptoms of COVID-19: Dietary Aide #2, #3, and #4, Housekeeper #1, #2, #3, and #4, LPN #4, and #8, Agency LPN #1, #2 and #3, CNA #4, #5, #6, and #7, and Agency CNA #1, #2, #3, #4, #5, #6, and #7. During an interview on 7/21/2022 at 11:07 AM, the Environmental Services Supervisor reviewed the employee screenings and confirmed the employees listed above did not screen prior to working in the facility on 7/15/2022. During an interview on 7/21/2022 at 2:21 PM, the Staff Development Coordinator/Infection Control Nurse confirmed the county positivity rate was high. During an interview on 7/22/2022 at 3:19 PM, the Administrator confirmed staff should screen for signs and symptoms of COVID-19 prior to working.

Based on policy review, medical record review, and interview, the facility failed to provide information regarding a resident's right to formulate an Advance Directive to residents or the residents' responsible parties for 21 of 24 sampled residents (Resident #2, #3, #9, #12, #14, #15, #16, #19, #22, #28, #30, #34, #39, #45, #62, #67, #76, #82, #100, #153 and #255) reviewed for Advanced Directives. The findings include: Review of the facility's policy titled, Communication of Code Status dated 2017, revealed .It is the policy of this facility to adhere to residents' rights to formulate advance directives .The facility will follow facility policy regarding a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an Advance Directive . Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. Review of Resident #2's medical record, revealed there was no documentation the resident or their responsible party were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #3 had a BIMS score of 99, which indicated severe cognitive impairment. Review of Resident #3's medical record, revealed there was no documentation the resident or their responsible party were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #9 had a BIMS score of 8, which indicated moderate cognitive impairment. Review of Resident #9's medical record, revealed there was no documentation the resident or their responsible party were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #12 was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE], revealed Resident #12 had a BIMS score of 14, which indicated intact cognition. Review of Resident #12's medical record, revealed there was no documentation the resident or their responsible party were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #14 had a BIMS score of 99, which indicated severe cognitive impairment. Review of Resident #14's medical record, revealed there was no documentation the resident or their responsible party were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change MDS assessment dated [DATE], revealed Resident #15 had a BIMS score of 3, which indicated severe cognitive impairment. Review of Resident #15's medical record, revealed there was no documentation the resident or their responsible party were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the quarterly MDS assessment dated [DATE], revealed Resident #16 had a BIMS of 6, which indicated severe cognitive impairment. Review of Resident #16's medical record, revealed there was no documentation the resident or their responsible party were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #19 had severe cognitive impairment. Review of Resident #19's medical record, revealed there was no documentation the resident or their responsible party were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #22 had a BIMS score of 11, which indicated moderate cognitive impairment. Review of Resident #22's medical record, revealed there was no documentation the resident or their responsible party were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE], revealed Resident #28 had a BIMS score of 8, which indicated moderate cognitive impairment. Review of Resident #28's medical record, revealed there was no documentation the resident or their responsible party were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #30 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #30 had a BIMS score of 2, which indicated severe cognitive impairment. Review of Resident #30's medical record, revealed there was no documentation the resident or their responsible party were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #34 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS assessment dated [DATE], revealed Resident #34 had a BIMS score of 7, which indicated severe cognitive impairment. Review of Resident #34's medical record, revealed there was no documentation the resident or their responsible party were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #39 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #39 had a BIMS score of 15, indicating she was cognitively intact for decision making. Review of Resident #39's medical record, revealed there was no documentation the resident or their responsible party were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #45 had a BIMS score of 4, which indicated severe cognitive impairment. Review of Resident #45's medical record, revealed there was no documentation the resident or their responsible party were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #62 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS assessment dated [DATE], revealed Resident #62 had a BIMS score of 4, which indicated severe cognitive impairment. Review of Resident #62's medical record, revealed there was no documentation the resident or their responsible party were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #67 was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE], revealed Resident #67 had a BIMS score of 15, indicating he was cognitively intact. Review of Resident #67's medical record, revealed there was no documentation the resident or their responsible party were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #76 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE], revealed Resident #76 had a BIMS score of 9, which indicated moderate cognitive impairment. Review of Resident #76's medical record, revealed there was no documentation the resident or their responsible party were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #82 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change MDS assessment dated [DATE], revealed Resident #82 had a BIMS score of 14, indicating she was cognitively intact. Review of Resident #82's medical record, revealed there was no documentation the resident or their responsible party were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #100 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change MDS assessment dated [DATE], revealed resident #100 had a BIMS score of 14, indicating she was cognitively intact for decision making. Review of Resident #100's medical record, revealed there was no documentation the resident or their responsible party were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #153 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE], revealed Resident #153 had a BIMS score of 6, which indicated severe cognitive impairment. Review of Resident #153's medical record, revealed there was no documentation the resident or their responsible party were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #255 was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE], revealed Resident #255 had a BIMS score of 7, which indicated severe cognitive impairment. Review of Resident #255's medical record, revealed there was no documentation the resident or their responsible party were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. During an interview on 7/20/2022 at 6:01 PM, the Patient Care Liaison confirmed on admission the facility should offer and educate the family or the residents about the Advance Directives.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 4 sampled residents (Resident #37) were free of a significant medication error when 1 of 5 licensed nurses (Licensed Practical Nurse (LPN) #4) administered an incorrect dosage of an anticoagulant medication. The findings include: Review of the facility's undated policy titled, High Risk Medications-Anticoagulants, revealed .Anticoagulant refers to a class of medications that are used to prevent clot extension and formation .[MEDICATION(S)] .Anticoagulants shall be prescribed by a physician or other authorized practitioner with clear indications for use . Review of the facility's undated policy titled, Medication Administration, revealed .Medications are administered by licensed nurses .as ordered by the physician . Review of the facility's undated policy titled, Medication Errors, revealed .The facility shall ensure medications will be administered as follows .according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record, revealed Resident #37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .give 1 tablet by mouth two times a day .for 21 Days . Observation during medication administration at the South Hall Medication Cart on 7/20/2022 at 8:22 AM, revealed LPN #4 sanitized her hands and removed a [MEDICATION(S)] 20 mg tablet for Resident #37. LPN #4 knocked and entered the resident's room and administered the medication to Resident #37, then returned to the medication cart. During an interview on 7/20/2022 at 11:24 AM, LPN #4 was asked how much [MEDICATION(S)] was administered to Resident #4. LPN #4 confirmed she had administered a 20 mg tablet and that she should have administered a 15 mg tablet. During an interview on 7/22/2022 at 8:59 AM, the Director of Nursing (DON) was asked if the nursing staff were expected to follow Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated, Yes .

Based on facility policy review, Registered Dietician contract review, record review, observation, and interview, the facility failed to maintain proper kitchen sanitation when 2 of 6 Kitchen staff (Dietary Aide #2 and #3) had unrestrained facial hair, food was open to air in the freezer, and 2 of 3 Kitchen staff (Cook #1 and Dietary Aide #1) did not record the correct 3 compartment sink sanitizer results. This had a potential to affect 85 of the 89 residents receiving meals from the Kitchen. The findings include: Review of the facility's policy titled, (Named Nursing Home) Food Safety Requirements, dated 3/1/2019, showed, .Refrigerated storage .or placed in freezer .Keeping foods covered or in tight containers .Dietary staff must wear hair restraints .hairnet .beard restraint . Review of the facility's Registered Dietician contract showed, .The program manager will provide guidance and training to the Dietary Manager .in all areas of kitchen management .(Named Corporation) will oversee management .assure regulatory compliance in-service training . 1. Observation in the Kitchen on 3/9/2020 at 10:53 AM and 3/10/2020 at 3:06 PM, showed Dietary Aide #2 had unrestrained facial hair. Observation in the Kitchen on 3/10/2020 at 3:36 PM, showed Dietary Aide #3 had unrestrained facial hair. During an interview on 3/11/2020 at 7:48 AM, the Dietary Manager confirmed that facial hair should be covered with a hair restraint. 2. Observation in the Kitchen on 3/9/2020 at 10:53 AM, showed frozen fish and scrambled frozen egg patties open to the air in the walk-in freezer. Observation in the Kitchen on 3/10/2020 at 10:55 AM, showed frozen scrambled egg patties open to the air in the walk-in freezer. During an interview on 3/11/2020 at 7:48 AM, the Dietary Manager confirmed that food should not be open to the air in the freezer. 3. Observation in the Kitchen on 3/9/2020 at 10:53 AM, showed the facility used Quaternary Sanitizer in the 3 compartment sink. Review of the facility's sanitizer poster over the 3 compartment sink showed that the sanitizer test strips should read between 150-400 parts per million (ppm). The poster documented, Dip test paper for 10 seconds in test solution .Compare colors immediately with colors on the test paper package to determine ppm. ALWAYS COMPARE AGAINST PACKAGE SCALE .Testing solution should be between 150-400 ppm . The test strips used and the poster did not have a value of 120. The values were 0, 150, 200, or 400. Review of the facility's Sanitization Control Log for the Three-Compartment Sink showed, .record the ppm's of sanitizing solution in final rinse .if chemical sanitization used .Quaternary .150-200 . Review of the facility's Sanitizing Sink Temperature/Chemical Record, showed all sanitizer readings were performed daily between 2/1/2020 to 3/10/2020 and were documented as 120. Observation and interview in the Kitchen on 3/10/2020 at 10:42 AM, showed Cook #1 was washing pots and pans in the 3 compartment sink. Cook #1 was asked if she performed the check of the sanitizer in the third compartment. Cook #1 stated, yes, but we have been out of the strips for about a week (prior to the survey) . Cook #1 performed the test strip and the strip actually read 200 ppm. Cook #1 stated, I know it is suppose to be 120-150. Cook #1 was asked what she was going to chart as the result. Cook #1 stated, 120, but it is a little darker . Observation and interview on 3/10/2020 at 3:06 PM, Dietary Aide #1 performed a sanitizer test strip that read 150. Dietary Aide #1 was asked what the test strip for the sanitizer should read. She stated, 120. During an interview with the Dietary Manager on 3/10/2020 at 3:40 PM, the Dietary Manager was asked where the reading of 120 originated. The Dietary Manager stated, I always estimated 120. It has always been 120-130 . The Dietary Manager was asked how the 120 was calculated since there was no mark for 120 on the test strip. The Dietary Manager stated, I estimate when it isn't that dark . The Dietary Manager confirmed the sanitizer should read at least 150. During an interview with the Dietary Manager on 3/11/2020 at 7:48 AM, the Dietary Manager was asked if the 3 compartment sink sanitizer should be tested and recorded accurately. The Dietary Manager stated, Yes.

Based on policy review, record review, observation, and interview, the facility failed to employ sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition services for 3 of 3 (Cook #1, Dietary Aide #1, and Dietary Manager) Kitchen staff observed performing sanitizer testing. This had a potential to affect 85 of the 89 residents receiving meals from the kitchen. The findings include: Review of the facility's undated policy titled, Manual(NAME)Washing - 3 Compartment Sink, showed, .The facility utilizes a 3 compartment sink to wash, rinse, and sanitize pots, pans and other utensils to prevent the spread of bacteria that may cause food borne illness .Third step: Sanitizing with .chemical sanitizing solution used according to manufacturer's instructions . Observation and interview in the Kitchen on 3/9/2020 at 10:53 AM, the Dietary Manager stated that they had not had the correct strips to test the 3 compartment sink. The Dietary Manager performed a test for pH (acid base balance). The Dietary Manager confirmed the chemical supply company had provided her with the pH strips and they had not been testing for the sanitizer since they were out of the correct strips. The facility used Quaternary Sanitizer in the 3 compartment sink. Review of the facility's sanitizer poster over the 3 compartment sink showed that the sanitizer test strips should read between 150-400 parts per million (ppm). The poster documented, Dip test paper for 10 seconds in test solution .Compare colors immediately with colors on the test paper package to determine ppm. ALWAYS COMPARE AGAINST PACKAGE SCALE .Testing solution should be between 150-400 ppm . The test strips used and the poster did not have a value of 120. The values were 0, 150, 200, or 400. Review of the facility's Sanitization Control Log for the Three-Compartment Sink showed, .record the ppm's of sanitizing solution in final rinse .if chemical sanitization used .Quaternary .150-200 . Review of the facility's Sanitizing Sink Temperature/Chemical Record showed that all sanitizer readings were performed daily between 2/1/2020 to 3/10/2020 and were documented as 120. Observation in the Kitchen on 3/10/2020 at 10:42 AM, showed Cook #1 was washing pots and pans in the 3 compartment sink. Cook #1 was asked if she performed the check of the sanitizer in the third compartment. Cook #1 stated, yes, but we have been out of the strips for about a week (prior to the survey) . Cook #1 performed the test strip and the strip actually read 200 ppm. Cook #1 stated, I know it is suppose to be 120-150. Cook #1 was asked what she was going to chart as the result. Cook #1 stated, 120, but it is a little darker . Observation and interview on 3/10/2020 at 3:06 PM, Dietary Aide #1 performed a sanitizer test strip that read 150. Dietary Aide #1 was asked what the test strip for the sanitizer should read. She stated, 120. During an interview with the Dietary Manager on 3/10/2020 at 3:40 PM, the Dietary Manager was asked where the reading of 120 originated. The Dietary Manager stated, I always estimated 120. It has always been 120-130 . The Dietary Manager was asked how the 120 was calculated since there was no mark for 120 on the test strip. The Dietary Manager stated, I estimate when it isn't that dark . The Dietary Manager confirmed the sanitizer should read at least 150 and they had been recording the test results incorrectly. During an interview with the Registered Dietician (RD) on 3/11/2020 at 10:56 AM, the RD was asked who was responsible to oversee and train the Dietary Manager. The RD stated, I don't know . The RD confirmed she had reviewed the dish washing sanitation logs and that the Kitchen staff should have known how to test the sanitizer and document it properly. During an interview with the Administrator on 3/11/2020 at 3:52 PM, the Administrator was asked who should inservice the Dietary Manager regarding kitchen requirements. The Administrator stated, .the RD .

Based on facility policy review, medical record review, observation, and interview, the facility failed to develop a comprehensive Care Plan to reflect the resident's current status for antidepressant, anticoagulant, and antianxiety medication use for 2 of 21 sampled residents (Resident #21 and #28) reviewed. The findings include: Review of the facility's undated policy titled, Comprehensive Care Plan, showed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set) assessment . 1. Review of the medical record, showed Resident #21 had [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].[MEDICATION NAME] (an antidepressant) .50 mg (milligram) .QHS (every hour of sleep) . Review of the medical record, showed there was not a comprehensive Care Plan to reflect Resident #21's use of antidepressant medications. During an interview conducted on 3/12/2020 at 8:47 AM, the Minimum Data Set (MDS) Coordinator confirmed that the use of an antidepressant medication should have been on the comprehensive Care Plan. 2. Review of the medical record, showed Resident #28 had [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].[MEDICATION NAME] (an antianxiety medication) 0.5 mg .oral .prn (as needed) . Review of the physician's orders [REDACTED].Eliquis (an anticoagulant) 5 mg .oral .bid (twice daily) . Review of the medical record, showed there was not a comprehensive Care Plan to reflect Resident #28's use of antianxiety and anticoagulant medications. During an interview conducted on 3/12/2020 at 8:47 AM, the MDS Coordinator confirmed that the use of an antianxiety and anticoagulant medication should have been on the comprehensive Care Plan.

Based on review of the "National Pressure Advisory Panel Pressure Ulcer Prevention QUICK REFERENCE GUIDE," policy review, medical record review, observation and interview, it was determined the facility failed to prevent and identify the development of a pressure ulcer, assess a pressure ulcer and revise the care plan for pressure ulcers for 3 of 5 (Residents #3, 6 and 7) sampled residents with pressure ulcers. The failure to identify and prevent skin breakdown prior to the development of a Stage 3 pressure ulcer resulted in actual harm to Resident #3. The findings included: 1. Review of the "National Pressure Advisory Panel Pressure Ulcer Prevention QUICK REFERENCE GUIDE" documented, "...p. (page) 8... Category Stage III: Full Thickness skin loss... Full thickness tissue loss... slough may be present... p. 12... 3. Inspect skin regularly for signs of redness... Ongoing assessment of the skin is necessary to detect early signs of pressure damage. 4. Skin inspection should include assessment for localized heat, [MEDICAL CONDITION], or induration (hardness)..." 2. Review of the facility's "PRESSURE SORES" policy documented, "POLICY: ALL RESIDENTS WHO ENTER THE FACILITY WITHOUT PRESSURE SORES WILL RECEIVE PROPER CARE TO PREVENT PRESSURE SORES FROM OCCURRING TO THE DEGREE POSSIBLE BASED ON THE INDIVIDUAL'S CLINICAL CONDITION... RESIDENT'S HAVING PRESSURE SORES WILL RECEIVE NECESSARY TREATMENT AND SERVICES TO PROMOTE HEALING, PREVENT INFECTION AND PREVENT NEW AREAS FROM DEVELOPING..." Review of the facility's "WOUND DOCUMENTATION" policy documented, "POLICY: WOUND DOCUMENTATION MUST BE NOTED ON THE PRESSURE OR WOUND EVALUATION REPORTS... DOCUMENTATION... WEEKLY: ASSESS AND DOCUMENT THE WOUND / PRESSURE ULCER ON THE WOUND / SKIN DOCUMENTATION FORM... CARE PLAN REQUIREMENTS: A. ADD THE PRESSURE ULCER / WOUND TO THE PROBLEM LIST. SPECIFY THE LOCATION, SIZE AND CLASSIFICATION OF THE WOUND..." 3. Medical record review for Resident #3 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the recertification physician's orders [REDACTED]. "WOUND EVALUATION FLOW SHEET" dated 12/26/12 documented, "...Stage/Type... III... Measurements (cm) (centimeters) ...L (length) 1.0... W (width) 0.5...D (depth) 0.2... Exudate... Color... serous... Consistency... min (minimum)... Odor... faint... Wound Bed... Color, Tissue Type/ percent/ location... 50% (percent) slough... 50% [MEDICATION NAME] Periwound... Wound margins... defined... regular... Surrounding tissue... [DIAGNOSES REDACTED]..." Review of a physician's orders [REDACTED]." Review of the "WOUND EVALUATION FLOW SHEET" dated 8/29/12 documented, "...(checked box) Pressure Ulcer... ACQUIRED... (checked box) In House... DATE 8-29-12... Stage/Type... U (unstageable)... Wound Bed... Tissue Type, Color/ percent/ location: eschar... Periwound... Wound margins... regular defined... Surrounding tissue... [DIAGNOSES REDACTED] > (greater than) 1cm..." Review of the nurse's notes dated 8/29/12 documented, "...Treatment Note: Made aware by chg (charge) nurse of area of concern to R hip. Assessment reveals unstageable wound full thickness measuring (approximately) 1.5 cm x 1.0 cm x UTD (unable to determined depth) c slough / eschar covering wound bed..." Review of the care plan dated 2/21/11 and updated on 12/28/12 documented, "...Risk for skin breakdown R/T decreased mobility secondary to generalized weakness, chronic back pain..." The pressure ulcer to Resident #3's right hip was not documented on the comprehensive care plan. Observations in Resident #3's room on 12/28/12 at 7:45 AM, revealed Resident #3 had an open area on the right hip approximately dime-sized. The wound bed was pink, and the edges of the wound were well-defined. The periwound area was boggy with an area approximately silver dollar-sized anterior to the open area which was reddened and had a foul odor. During an interview in the Director of Nursing's (DON) office on 12/27/12 at 12:10 PM, Nurse #1 was asked to describe Resident #3's pressure ulcer when it was first assessed on 8/29/12. Nurse #1 stated, "...I staged it as unstageable because there was slough and I could not see the wound bed... but now is Stage III... there was no wound until August 29th (2012)..." Nurse #1 was asked if a wound with slough could be a Stage I or II. Nurse #1 stated, "No." During an interview in the conference room on 12/28/12 at 5:00 PM, the DON was asked how often a resident's skin is examined. The DON stated, "...the charge nurse or another nurse do weekly skin assessments... the resident's skin is looked at on a daily basis..." The DON was asked if a resident's skin could deteriorate from intact skin to an unstageable wound with slough in a day's time. The DON stated, "No, sir." The failure to identify and prevent skin breakdown prior to the development of a Stage 3 pressure ulcer resulted in actual harm to Resident #3. 4. Medical record review for Resident #6 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the "BRADEN SCALE" dated 8/13/12 documented, "...Total score of 12 or less represents HIGH RISK... TOTAL SCORE...1 0..." Review of the "BRADEN SCALE" dated 11/12/12 documented, "...Total score of 12 or less represents HIGH RISK... TOTAL SCORE... 11..." Review of a physician's orders [REDACTED]. dated 11/21/12 documented, "Made aware by chg (charge) nurse of reddened R heel. Skin intact, (no) blister apparent. N.O. (new order) faxed to Sure prep BID and to monitor heel for (change) in appearance..." Review of the nurse's notes dated 12/18/12 documented, "...Treatment Note: Sure prep continuous to SDTI (suspected deep tissue injury) to R (right) lateral heel... remains intact s (without) evidence of premature peeling. Will continue c POC (plan of care) and continue to monitor..." There was no documentation of an assessment of Resident #6's right lateral heel wound from 11/21/12 through 12/18/12. Observations in Resident #6's room on 12/28/12 at 8:07 AM, revealed Resident #6 had an oblong, darkened area approximately 4 centimeter (cm) by (x) 2 cm with intact skin on the right lateral heel. During an interview at the New Wing Nurses' Station on 12/28/12 at 10:00 AM, Nurse #1 confirmed there was no assessment documented of Resident #6's right lateral heel wound from 11/21/12 through 12/18/12. Nurse #1 was asked who was responsible for the assessment and the documentation of residents' wounds. Nurse #1 stated, "...when I am not here, there is no one to chart on the wounds..." 5. Medical record review for Resident #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].S. (normal saline) Apply Santyl then cover c [MEDICATION NAME] drsg (dressing) q 3 days & PRN until resolved..." Review of the care plan dated 7/18/05 and updated on 12/12/12 documented, "...Risk for skin breakdown R/T impaired physical mobility..." The pressure ulcer to Resident #7's right buttock was not documented on the comprehensive care plan. Observations in Resident #7's room on 12/28/12 at 12:00 PM, revealed Resident #7 had an approximate 1 cm linear scratch on the right buttock. The resident's skin around the scratch was intact with a few small areas of redness. During an interview in the conference room on 12/28/12 at 10:25 AM, Nurse #2 was asked whose was responsible for updating the care plan for wounds. Nurse #2 stated, "...for wounds, the treatment nurse..." Nurse #2 was asked if a wound should be documented on the care plan. Nurse #2 stated, "Yes, it should." During an interview in the conference room on 12/28/12 at 5:00 PM, the Director of Nursing (DON) was asked if wounds should be documented on the care plan. The DON stated, "Yes... any time there are skin issues, it should be on the care plan..."

Based on review of the event documentation forms, medical record review, observation and interview, it was determined the facility failed to ensure interventions were developed after each fall for 2 of 20 (Residents #3 and 8) sampled residents identified with falls. Resident #3 was assessed as being at risk for falls. Resident #3 sustained eight falls from 2/3/11 to 7/4/11, there were no new intervention developed to prevent further falls or injuries from falls for seven of those falls. Five falls resulted in serious injuries such as lacerations with sutures, one fall sustained a chipped tooth and the fall on 7/4/11 resulted in a fractured nose. The facility's failure to develop interventions to protect the resident after each of these falls placed Resident #3 in immediate jeopardy as evidenced by repeated falls with serious injuries that required medical interventions. A conference was held with the Administrator, in the Administrator's office on 7/14/11 at 5:17 PM, to inform him of the surveyors findings that placed Resident #3 in immediate jeopardy. The findings included: 1. Medical record review for Resident #3 documented an admission date of [DATE] and [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment, a quarterly assessment, for Resident #3 was completed 5/20/11. This assessment documented no problem with communication, she was understood by others and understood others. Resident #3's cognitive status was evaluated with brief interview of mental status (BIMS), with a score of 6, indicating severe cognitive impairment. Resident #3's care plan was documented with target dates of 3/4/11 and 5/27/11. The care plan documented problem of "Risk for falls r/t (related to) impaired physical mobility, psych (psychiatric) med (medication) use. Non-compliant with requesting assistance and safety interventions and non-compliant with alarms." The goal for this problem was documented as "No fall related injuries." a. Review of Resident #3's nurse's notes dated 2/13/11 documented, "At 0545 hrs (hours) alarm was heard in Res (Resident) room CNA (Certified Nurse Assistant) ...went to get alarm & (and) found Res face down on floor, blood under her head. CNA called this nurse to room ...LPN (Licensed Practical Nurse) also came to Res room. Pressure was applied to sight on (R) (Right) side of forehead. Gash approximated @ (at) 1 1/2 to 2 inches in length. Res had blood coming from (R) nostril. 911 was called..." Nurse's notes further documented the resident was returned to the facility the same day with sutures to the right forehead. Review of Resident #3's care plan for risk for falls revealed handwritten interventions of, "2/13/11, Fall; Medical Management Add alarming w/c (wheelchair) Pressure mat" were added to the care plan. "Under seat alarm" was previously listed as an intervention on this care plan for Resident #3. No new intervention was developed after this fall. b. Review of Resident #3's nurse's notes dated 3/11/11 at 2:00 AM documented, "Resident called for help. Upon entering room found resident lying beside bed (in lowest position) c (with) blankets in hand. No c/o's (complaints) verbalized... No injuries apparent." Review of Resident #3's care plan for risk for falls revealed no new intervention was developed after this fall. c. Review of Resident #3's nurse's notes dated 3/14/11 at 4:30 PM documented, "CNA heard resident moaning, walked into rm (room) found resident laying face down on the floor on left side of bed. Resdent (resident) cut (L) (left) forehead, glasses broke, large puddle of blood noted. Incision cleaned, steri strips applied. Hospice nurse to come eval (evaluate)." Subsequent nurse's notes documented the hospice nurse visited; the resident was transferred to the emergency room via ambulance and returned to the facility after having a CT (Computerized Tomography) scan of the head and receiving 7 sutures to the left forehead. The nurse's notes dated 3/14/11 documented, "Large amount of [MEDICAL CONDITION] et (and) discoloration noted to entire (L) orbital area." Review of Resident #3's care plan for risk for falls revealed a handwritten intervention added, "3/14/11, Add Grey floor Pressure mat to prevent injury." This care plan already documented "Lowbed with mats on floor." No new intervention was developed after this fall. d. Review of the nurse's notes dated 6/10/11 at 1:30 AM documented, "This nurse was called to Room (#) where Res was laying on the floor face up, on her back... LPN was applying pressure to wound (upper) (R) (right) eye to stop the bleeding of the open area. The area & (R) side of Res face was purple in color, edemitus ([MEDICAL CONDITION]) ...911 was called ...transferred via ambulance..." Nurse's notes documented the resident was sent to the emergency room and returned with sutures above the Right eye. The event documentation form dated 6/10/11 documented types of injury sustained included laceration, hematoma, skin tear and chipped front tooth. Review of Resident #3's care plan for risk for falls revealed a handwritten intervention added, "6/10/11, Fall; Floor mat alarm." This care plan also included an intervention of "Floor pressure sensitive alarm"; a single line was drawn through the intervention and "D/C" (discontinue) was written beside the intervention. There was no date documented for discontinuing this intervention and there was no new intervention developed after this fall. e. Review of the nurse's notes dated 6/12/11 at 11:30 AM, documented, "CNA reports that she heard alarm & entered Rm (#) & noted resident on floor on (L) side in front of W/C & recliner. Denies pain or discomfort. No injuries..." The event documentation form dated 6/12/11 documented, "Actions / Interventions" to be implemented were "Medical management - (UA (urinalysis) C&S (culture and sensitivity)) -per fall team." Laboratory (lab) reports reviewed revealed a urinalysis on 6/14/11 was negative and a urine culture collected 6/14/11 showed no growth. There was no documentation the lab results had been reviewed by the fall team, or any additional interventions had been attempted after the lab results were received. Review of Resident #3's care plan for risk for falls revealed an intervention added, "6/12/11, Fall; Medical mgmt (management)." This was not a new intervention and was not specific of what staff were to do to prevent injuries from falls. f. Review of the nurse's notes dated 6/14/11 at 12:00 PM documented, "This nurse called to resident's room per CNA - upon entering room noted resident lying on floor beside roommate's bed - prone position - resident states, "I got out w/c to go to BR (bathroom)" - chair alarms were in place- upon assessment noted a moderate amt (amount) sanguineous (bloody) drainage on floor - noted (3) lacerations forehead, noted open area bridge of nose - noted (upper) lip sl (slightly) swollen - resident c/o (complaint) HA (headache)." Subsequent notes documented the resident was sent to the ER (emergency room ) and returned with sutures to the left eyebrow, bridge of nose and left forehead." Review of Resident #3's care plan for risk for falls revealed a handwritten intervention added, "6/14/11, Fall; Redirect to social area or back to DR (dining room) during meals." The care plan documented interventions of, "Except for bed and bathroom times keep resident in lobby for observation." This intervention was not specific of what staff were to do to prevent injuries from falls. g. Review of the nurse's notes dated 7/4/11 at 3:00 PM documented, "This nurse called to resident's room per CNA - upon entering room- noted resident lying on floor - face down- mod (moderate) amt (amount) blood noted on floor- forehead states, 'I fell ' ...to ER..." Subsequent nurse's notes revealed a CT of the head revealed a nasal fracture and the resident received sutures before returning to the facility. Review of the care plan for risk for falls revealed interventions, "7/4/11, Fall; Medical management." This was not a new intervention and was not specific of what staff were to do to prevent injuries from falls. Observations in Resident #3's room on 7/11/11 at 11:18 AM, revealed Resident #3 in bed with dark brown eschar on her forehead, nose and chin and greenish-yellow discoloration to the right cheek. Resident #3 was receiving oxygen via binasal cannula at 2 liters a minute. Floor mats were observed on both sides of the very low bed, and falling star signs were on the foot of the bed and the door frame. A w/c was parked at the foot of the bed with a seat sensor and portable oxygen tank attached. During an interview with the fall team on 7/14/11 at 10:55 AM to 12:00 PM, the Director of Nurses (DON) was asked what interventions were in place to prevent falls for Resident #3. The DON stated, "...not trying to prevent her falls, just trying to prevent her injuries." The DON stated, "She (Resident #3) knows how to beat the alarms, when she had pressure chair alarms before, she knew to put a book in the chair so the alarm would not sound when she stood... She (Resident #3) had no falls from 11/28/09 until 2011. Every 90 days with no fall, we take away one intervention; we try to decrease an intervention every 90 days... Short of restraining her (Resident #3), it is difficult to prevent falls, she has the right to fall... They (indicating the federal surveyor from Centers for Medicare and Medicaid Services (CMS) present in the meeting) say she has the right to fall... Out of a hundred or so residents, she (Resident #3) is an isolated case. Alarms work more effectively on some than on others, we move from one alarm to another and revisit them quarterly and/or with falls. We have a lot of new and innovative interventions. We feel (Resident #3) is a very unique case and is looked at over the years. She (Resident #3) went a year without a fall and I'm very pleased." Resident #3 sustained eight falls from 2/13/11 to 7/4/11. Five falls resulted in lacerations that required sutures; she sustained a chipped tooth on 6/14/11 and a fractured nose on 7/4/11. The facility's failure to develop interventions to protect the resident after each of these falls placed Resident #3 in immediate jeopardy as evidenced by serious injuries that required medical interventions. Observations in Resident #3's room on 7/15/11 at 8:30 AM revealed Resident #3 was in her w/c at bedside, being fed breakfast by CNA #5. Resident #3 was noted to have a reverse torso support in place. At 9:30 AM, Resident #3 was observed in bed in her room, CNA #5 was seated at bedside. During an interview in Resident #3's room on 7/15/11 at 9:35 AM, CNA #5 stated her assignment for that shift was to provide 1 on (:) 1 care for Resident #3, document Resident #3's toileting concerns each hour and document any attempts to exit the bed or the w/c. CNA #5 stated she was told someone will be assigned to the resident for 30 days. During an interview at the #1 Nursing Station on 7/15/11 at 9:40 AM, Nurse #5 stated, "1:1 supervision will be continued 30 days and re-evaluated until we know she is safe at the highest level of functioning." The immediate jeopardy was identified on 7/14/11, was lifted on 7/15/11 at 5:05 PM and noncompliance continues at the lower scope and severity level of D. Refer to F323. 2. Medical record review for Resident #8 documented, an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the nurse's notes dated 4/2/11 at 1:00 PM documented, "...Resident up OOB (out of bed) for meal. Ambulate per self and ad lib (at liberty)... 5/20/11 11 AM ...Resident (symbol for up) ambulating in hallway... 6/4/11 4:15 PM ...Resident has been unsteady on his feet ..." Review of the nurse's notes dated 6/18/11 at 4:00 PM documented, "Resident stood up from W/C and fell backwards over back of the chair, hitting his head and shoulders first. Resident was unconscious X (times) 30 sec (seconds) to 1 min. (minute) Remained semiconscious X 20 min... send to ER evaluation and treatment..." Review of the "Progress Note - Psychiatric ...Date: 7/14/11... F/u (follow-up) readmission to facility 7/1/11 s/p (status [REDACTED]...6-18-11 Fall; Medical Management..." The care plan was not specific with what medical management interventions were to prevent injuries from falls. Observations in the Old Wing TV room on 7/12/11 at 7:40 AM, revealed Resident #8 seated in wheelchair. Observations in the TV room on the New Wing on 7/14/11 at 7:00 PM, revealed Resident #8 seated in a wheelchair with ear buds on. Smiling and appears to be moving with the music from the I Pod. During an interview with the fall team on 7/14/11 at 10:55 AM to 12:00 PM, when asked when Resident #8 began using a wheelchair, the OT (Occupational Therapist) stated, "...did not recommend a wheelchair... considered him ambulatory..." The DON stated, "...we can put them (indicating the residents) in a wheelchair can't we..." When asked for a plan to get Resident #8 back to baseline (ambulatory), there was no response from the fall team. 3. During an interview with the fall team on 7/14/11 at 10:55 AM to 12:00 PM, the DON stated the fall team included the DON, the MDS / care plan LPN, the Quality Assurance (QA) Registered Nurse (RN), the OT and the restorative CNA. The DON stated the fall team meets daily Monday through Friday in the morning meeting to discuss falls. The DON stated the nurses on the floor try to put an intervention in place immediately when a fall occurs. The fall team looks over the event report to determine if the proper intervention was implemented, to determine the root cause of the fall and try to address the cause with an intervention. The DON stated the proper intervention could be medical management. When asked to explain the intervention of medical management, the DON was unable to give a definite answer. The DON stated medical management could be antibiotics, fluids and cranberry juice for a urinary tract infection or it could be psychiatric medical management. The DON stated if a resident was sent to the emergency room after a fall, the intervention would be medical management.

Based on review of the "Falling Star Program" (policy/procedure for prevention of falls), review of Event Documentation forms, medical record review, observation and interview, it was determined the facility failed to implement care plan interventions for a resident at risk for falls for 1 of 20 (Residents #3) sampled residents identified with falls. Resident #3 was assessed as being at risk for falls. Resident #3 sustained eight falls from 2/3/11 to 7/4/11. Five falls resulted in serious injuries such as lacerations with sutures, one fall sustained a chipped tooth and the fall on 7/4/11 resulted in a fractured nose. The facility's failure to implement interventions to protect the resident after each of these falls placed Resident #3 in immediate jeopardy as evidenced by repeated falls with serious injuries that required medical interventions. A conference was held with the Administrator, in the Administrator's office on 7/14/11 at 5:17 PM, to inform him of the surveyors findings that placed Resident #3 in immediate jeopardy. The findings included: Review of the facility's "FALLING STAR PROGRAM", updated 4/5/10, documented, "All residents in the facility are at risk for falls, however, we are going to pay closer attention to those that score a 20 and above on their fall risk assessment, as well as those who have fallen in the last 3 months. As a facility, we will... 5. Look in residents room to check for safety during rounds and as we pass by the room. It is the responsibility of nursing and housekeeping staff to ensure a safe environment..." Medical record review for Resident #3 documented an admission date of [DATE] and [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment for Resident #3 was completed 5/20/11. This assessment documented no problem with communication, she was understood by others and understood others. Resident #3's cognitive status was evaluated with Brief Interview of Mental Status (BIMS), with a score of 6, indicating severe cognitive impairment. Review of Resident #3's care plan documented a problem of "Risk for falls r/t (related to) impaired physical mobility, psych (psychiatric) med (medication) use. Non-compliant with requesting assistance and safety interventions and non-compliant with alarms." The goal of this care plan was "No fall related injuries." The care plan was documented with target dates of 3/4/11 and 5/27/11. a. Review of Resident #3's nurse's notes dated 2/13/11 documented, "At 0545 hrs (hours) alarm was heard in Res (Resident) room CNA (Certified Nurse Assistant) ...went to get alarm & (and) found Res face down on floor, blood under her head. CNA called this nurse to room ...LPN (Licensed Practical Nurse) also came to Res room. Pressure was applied to sight on (R) (Right) side of forehead. Gash approximated @ (at) 1 1/2 to 2 inches in length. Res had blood coming from (R) nostril. 911 was called..." Nurse's notes further documented Resident #3 was returned to the facility the same day with sutures to the right forehead. The Event Documentation form for the fall of 2/13/11 documented the resident was trying to stand from the wheelchair (w/c) at the time of the fall. There was no evidence the care plan interventions for fall risks "...Dycem (non-slip material) to w/c, ...Except for bed and bathroom times keep resident in lobby or observation, ...Self release belt alarm in w/c..." were being implemented at the time of Resident #3's fall on 2/13/11. b. Review of Resident #3's nurse's notes dated 3/11/11 at 2:00 AM documented, "Resident called for help. Upon entering room found resident lying beside bed (in lowest position) c (with) blankets in hand. No c/o's (complaints) verbalized... No injuries apparent." The Event Documentation form for the fall of 3/11/11 documented no appliances/devices or interventions in place at the time of the fall. There was no evidence the care plan interventions for fall risks "...Lowbed with mats on floor, FALLING STARS PROGRAM... Bed pressure alarm, Toilet plan, ...Dycem under floor alarm mat..." were being implemented at the time of Resident #3's fall on 3/11/11. c. Review of Resident #3's nurse's notes dated 3/14/11 at 4:30 PM documented, "CNA heard resident moaning, walked into rm (room) found resident laying face down on the floor on left side of bed. Resdent (resident) cut (L) (left) forehead, glasses broke, large puddle of blood noted. Incision cleaned, steri strips applied. Hospice nurse to come eval (evaluate)." Subsequent nurse's notes documented the hospice nurse visited; the resident was transferred to the emergency room via ambulance and returned to the facility after having a CT (Computerized Tomography) scan of the head and receiving 7 sutures to the left forehead. The nurse's notes dated 3/14/11 documented, "Large amount of [MEDICAL CONDITION] et (and) discoloration noted to entire (L) orbital area." The Event Documentation form for the fall of 3/14/11 documented no appliances/devices in place at the time of the fall and documented, "What was resident doing at time of fall? Not sure." There was no evidence the care plan interventions for fall risks "...Lowbed with mats on floor, FALLING STAR PROGRAM, Keep wheelchair out of room, ...Except for bed and bathroom times keep resident in lobby for observation, ...Motion detector 'smart alarm' in bathroom on at all times, Bed pressure alarm, ...Hipsters as tolerated, Dycem to w/c, No bedside commode, Toilet plan, Under seat alarm, Dycem under floor alarm mat, Alarming w/c pressure mat" were being implemented at the time of Resident #3's fall on 3/14/11. d. Review of Resident #3's nurse's notes dated 3/26/11 at 5:10 PM documented, "Called to room by CNA who states she heard alarm in rm (room) & (and) upon entering noted resident face down on floor beside bed. Bleeding from R eyebrow - ice applied." Subsequent nurse's notes documented the resident was sent to the ED (emergency department) and returned with "steri strips D & I (dry and intact) (L) forehead. Bruising noted around ou (both eyes), nose et (and) forehead." The Event Documentation form for the fall of 3/26/11 documented no appliances/devices or interventions in place at the time of the fall and documented the resident was "Trying to get OOB (out of bed)" at the time of the fall. There was no evidence the care plan interventions for fall risks "...Lowbed with mats on floor, FALLING STAR PROGRAM, Keep wheelchair out of room, ...Except for bed and bathroom times keep resident in lobby for observation, ...Motion detector 'smart alarm' in bathroom on at all times, Bed pressure alarm, ...Hipsters as tolerated, ...No bedside commode, Toilet plan, ...Dycem under floor alarm mat, ...Grey floor pressure mat" were being implemented at the time of Resident #3's fall on 3/26/11. e. Review of the nurse's notes dated 6/10/11 at 1:30 AM documented, "This nurse was called to Room (#) where Res was laying on the floor face up, on her back... LPN was applying pressure to wound (upper) (R) (right) eye to stop the bleeding of the open area. The area & (R) side of Res face was purple in color, edemitus ([MEDICAL CONDITION]) ...911 was called ...transferred via ambulance..." Nurse's notes documented the resident was sent to the emergency room (ER) and returned with sutures above the Right eye. The Event Documentation form dated 6/10/11 documented types of injury included laceration, hematoma, skin tear and chipped front tooth and documented the resident was getting out of bed at the time of the fall. There was no evidence the care plan interventions for fall risks "...Lowbed with mats on floor, FALLING STAR PROGRAM, Keep wheelchair out of room, ...Motion detector 'smart alarm' in bathroom on at all times, ...Hipsters as tolerated, Dycem to w/c, No bedside commode, Toilet plan... Under seat alarm, Dycem under floor alarm mat, Alarming w/c pressure mat, Pad sharp edges in room to prevent injury" were being implemented at the time of Resident #3's fall on 6/10/11. f. Review of the nurse's notes dated 6/12/11 at 11:30 AM, documented, "CNA reports that she heard alarm & entered Rm (#) & noted resident on floor on (L) side in front of W/C & recliner. Denies pain or discomfort. No injuries..." The Event Documentation form dated 6/12/11 documented the resident was attempting to transfer from the wheelchair to the recliner without assistance at the time of the fall. There was no evidence the care plan interventions for fall risks "...FALLING STAR PROGRAM, ...Except for bed and bathroom times keep resident in lobby for observation, ...Hipsters as tolerated, Dycem to w/c, ...Pad sharp edges in room, Floor mat alarm" were being implemented at the time of Resident #3's fall on 6/12/11. g. Review of the nurse's notes dated 6/14/11 at 12:00 PM documented, "This nurse called to resident's room per CNA - upon entering room noted resident lying on floor beside roommate's bed - prone position - resident states, "I got out w/c to go to BR (bathroom)" - chair alarms were in place- upon assessment noted a moderate amt (amount) sanguinous (sanguineous) (bloody) drainage on floor - noted (3) lacerations forehead, noted open area bridge of nose - noted (upper) lip sl (slightly) swollen - resident c/o (complaint) HA (headache)." Subsequent notes documented the resident was sent to the ER and returned with sutures to the left eyebrow, bridge of nose and left forehead. There was no evidence the care plan interventions for fall risks "FALLING STAR PROGRAM... Except for bed and bathroom times keep resident in lobby for observation, ...Motion detector 'smart alarm' in bathroom on at all times, ...Dycem to w/c, No bedside commode, Toilet plan..." were being implemented at the time of Resident #3's fall on 6/14/11. h. Review of the nurse's notes dated 7/4/11 at 3:00 PM documented, "This nurse called to resident's room per CNA - upon entering room- noted resident lying on floor - face down- mod amt blood noted on floor- forehead states, 'I fell ' ...to ER..." Subsequent nurse's notes revealed a CT of the head revealed a nasal fracture and the resident received sutures before returning to the facility. The Event Documentation form for this fall documented the resident was attempting to get out of the wheelchair without assistance at the time of the fall. There was no evidence the care plan interventions for fall risks "...FALLING STAR PROGRAM, ...Except for bed and bathroom times keep resident in lobby for observation, ...Dycem to w/c, No bedside commode, Toilet plan, ...Grey floor pressure mat, ...Floor mat alarm, ...Redirect to social area or back to DR during meals..." were being implemented at the time of Resident #3's fall on 7/4/11. Observations in Resident #3's room on 7/11/11 at 11:18 AM, revealed Resident #3 in a low bed with dark brown eschar on her forehead, nose and chin and greenish-yellow discoloration to the right cheek. Resident #3 was receiving oxygen via binasal cannula at 2 liters a minute. Gray floor mats were observed on both sides of the very low bed, and falling star signs were on the foot of the bed and the door frame. A w/c was parked at the foot of the bed with a seat sensor and portable oxygen tank attached. There was no motion sensor alarms observed in the room, there was no padding to sharp edges of doors or furniture observed in the room as care planned. The interventions of keep w/c out of room, motion detector smart alarms in the bathroom, and pad sharp edges in room were not implemented as care planned. During an interview with the fall team on 7/14/11 at 10:55 AM to 12:00 PM, the Director of Nurses (DON) stated the fall team included the DON, the minimum data set (MDS) / care plan LPN, the Quality Assurance (QA) Registered Nurse (RN), the Occupational Therapist (OT) and the restorative CNA. The DON stated the fall team meets daily Monday through Friday in the morning meeting to discuss falls. She stated the nurses on the floor try to put an intervention in place immediately when a fall occurs. The fall team looks over the event report to determine if the proper intervention was implemented, to determine the root cause of the fall and try to address the cause with an intervention. The DON stated the proper intervention could be medical management. When asked what she would expect the nursing staff to implement for the intervention of medical management on a care plan, the DON stated it could be antibiotics, fluids and cranberry juice for a urinary tract infection or it could be psychiatric medical management. The DON stated if a resident was sent to the emergency room after a fall, the intervention would be medical management. The DON was asked what interventions were in place to prevent falls for Resident #3. The DON stated, "...not trying to prevent her falls, just trying to prevent her injuries." The DON stated, "She (Resident #3) knows how to beat the alarms, when she had pressure chair alarms before, she knew to put a book in the chair so the alarm would not sound when she stood... She had no falls from 11/28/09 until 2011. ...Short of restraining her (Resident #3), it is difficult to prevent falls, she has the right to fall... They (indicating the federal surveyor from Centers for Medicare and Medicaid Services (CMS) present in the meeting) say she has the right to fall... Out of a hundred or so residents, she (Resident #3) is an isolated case. Alarms work more effectively on some than on others, we move from one alarm to another and revisit them quarterly and/or with falls. We have a lot of new and innovative interventions. We feel (Resident #3) is a very unique case and is looked at over the years. She (Resident #3) went a year without a fall and I'm very pleased." Resident #3 sustained eight falls from 2/13/11 to 7/4/11. Five falls resulted in lacerations that required sutures; she sustained a chipped tooth on 6/14/11 and a fractured nose on 7/4/11. The facility's failure to implement interventions to protect the resident after each of these falls placed Resident #3 in immediate jeopardy evidenced by serious injuries that required medical interventions. Observations in Resident #3's room on 7/15/11 at 8:30 AM revealed Resident #3 was up in her w/c at bedside, with a reverse torso support in place, being fed breakfast by CNA #5. At 9:30 AM, Resident #3 was observed in bed in her room, CNA #5 was seated at bedside. During an interview in Resident #3's room on 7/15/11 at 9:35 AM, CNA #5 stated her assignment for that shift was to provide 1:1 care for Resident #3, document her toileting concerns each hour, and document any attempts to exit the bed or the w/c. CNA #5 stated she was told someone will be assigned to the resident for 30 days. During an interview on 7/15/11 at 9:40 AM at the #1 Nursing Station, Nurse #5 stated, "1:1 supervision will be continued 30 days and re-evaluated until we know she is safe at the highest level of functioning. The Immediate Jeopardy was lifted on 7/15/11 at 5:05 PM and noncompliance still continues at a lower scope and severity level of D. Refer to F323.

Based on policy review, review of the "Falling Star Program", review of "Event Documentation" forms, medical record review, observation and interview, it was determined the facility failed to ensure residents at risk for falls were adequately supervised and had interventions implemented after each fall for 2 of 20 (Residents #3 and 8) sampled residents identified with falls. Resident #3 was assessed as being at risk for falls. Resident #3 sustained eight falls from 2/3/11 to 7/4/11. Five falls resulted in serious injuries such as lacerations with sutures, one fall sustained a chipped tooth and the fall on 7/4/11 resulted in a fractured nose. The facility's failure to provide adequate supervision to prevent injuries from falls, and to develop and implement interventions to protect the resident after each of these falls placed Resident #3 in immediate jeopardy as evidenced by repeated falls with serious injuries that required medical interventions, and resulted in substandard quality of care. A conference was held with the Administrator, in the Administrator's office on 7/14/11 at 5:17 PM, to inform him of the surveyors findings that placed Resident #3 in immediate jeopardy. The findings included: 1. Review of the facility's "Standard Of Procedure For Falls" policy documented, "1. After assessment & (and) treatment of [REDACTED]. 2. Staff to address individual need. (ex: (example such as) toileting, bed, hunger, thirst, etc. (et cetera)) 3. If applicable, initiate Bowel and Bladder assessment x (times) 3 days 4. Complete Fall Risk Assessment..." 2. Review of the facility's "FALLING STAR PROGRAM", updated 4/5/10, documented, "All residents in the facility are at risk for falls, however, we are going to pay closer attention to those that score a 20 and above on their fall risk assessment, as well as those who have fallen in the last 3 months. As a facility, we will... 5. Look in residents room to check for safety during rounds and as we pass by the room. It is the responsibility of nursing and housekeeping staff to ensure a safe environment 6. Check the resident fall-prevention alarms for proper placement and function each shift and as needed. It is the charge nurses responsibility to audit resident safety devices each shift..." 3. Medical record review for Resident #3 documented an admission date of [DATE] and [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment for Resident #3 was completed 5/20/11. This assessment documented no problem with communication, she was understood by others and understood others. Resident #3's cognitive status was evaluated with brief interview of mental status (BIMS), with a score of 6, indicating severe cognitive impairment. Resident #3's care plan was documented with target dates of 3/4/11 and 5/27/11. The care plan documented problem of "Risk for falls r/t (related to) impaired physical mobility, psych (psychiatric) med (medication) use. Non-compliant with requesting assistance and safety interventions and non-compliant with alarms." The goal for this problem was documented as "No fall related injuries." a. Review of Resident #3's nurse's notes dated 2/13/11 documented, "At 0545 hrs (hours) alarm was heard in Res (Resident) room CNA (Certified Nurse Assistant) ...went to get alarm & found Res face down on floor, blood under her head. CNA called this nurse to room ...LPN (Licensed Practical Nurse) also came to Res room. Pressure was applied to sight on (R) (Right) side of forehead. Gash approximated @ (at) 1 1/2 to 2 inches in length. Res had blood coming from (R) nostril. 911 was called..." Nurse's notes further documented the resident was returned to the facility the same day with sutures to the right forehead. The Event Documentation form dated 2/13/11 documented the resident fell while trying to stand from the wheelchair (w/c). This form documented "Actions/interventions" implemented after this fall were "Add Alarming w/c pressure mat - fall team agrees." Review of Resident #3's care plan for risk for falls revealed the intervention of "2-13-11 Add Alarming w/c pressure mat" was handwritten on the care plan. "Under seat alarm" was in place prior to this fall. No new intervention was developed for this fall. There was no evidence the care plan interventions for fall risks "...FALLING STARS PROGRAM, Except for bed and bathroom times keep resident in lobby for observation, ...Dycem (non-skid material) to w/c..." were being implemented at the time of this fall. b. Review of Resident #3's nurse's notes dated 3/11/11 at 2:00 AM documented, "Resident called for help. Upon entering room found resident lying beside bed (in lowest position) c (with) blankets in hand. No c/o's (complaints) verbalized... No injuries apparent." The Event Documentation form for this fall documented "Actions/ Interventions (implemented): Add Alarming Bed Pressure Mat - per fall team." Review of Resident #3's care plan for risk for falls revealed the intervention of "Bed Pressure Alarm" was in place prior to this fall. No new intervention was developed after this fall. There was no evidence the care plan interventions for fall risks "...mats on floor, ...Bed pressure alarm, Toilet plan, ...Dycem under floor alarm mat..." were being implemented at the time of Resident #3's fall on 3/11/11. c. Review of Resident #3's nurse's notes dated 3/14/11 at 4:30 PM documented, "CNA heard resident moaning, walked into rm (room) found resident laying face down on the floor on left side of bed. Resdent (resident) cut (L) (left) forehead, glasses broke, large puddle of blood noted. Incision cleaned, steri strips applied. Hospice nurse to come eval (evaluate)." Subsequent nurse's notes documented the hospice nurse visited; the resident was transferred to the emergency room (ER) via ambulance and returned to the facility after having a CT (Computerized Tomography) scan of the head and receiving 7 sutures to the left forehead. The nurse's notes dated 3/14/11 documented, "Large amount of edema et (and) discoloration noted to entire (L) orbital area." The Event Documentation form for the fall of 3/14/11 documented no appliances/devices in place at the time of the fall and documented, "What was resident doing at time of fall? Not sure." This form documented, "Actions / Interventions ...Add floor pressure mat to prevent injury." Review of Resident #3's care plan for risk for falls revealed the intervention, "3-14-11 Add Grey floor pressure mat" was handwritten on the care plan. The intervention "Floor pressure sensitive alarm" was documented on the current care plan for risk for falls. This intervention had a single line marked through it and "D/C (discontinue)" written beside the intervention. There was no date to discontinue and the entry was not signed. No new intervention was implemented after this fall. There was no evidence the care plan interventions for fall risks "...Lowbed with mats on floor, FALLING STAR PROGRAM, Keep wheelchair out of room, ...Except for bed and bathroom times keep resident in lobby for observation, ...Motion detector 'smart alarm' in bathroom on at all times, Bed pressure alarm, ...Hipsters as tolerated, Dycem to w/c, No bedside commode, Toilet plan... Under seat alarm, Dycem under floor alarm mat, Alarming w/c pressure mat" were being implemented at the time of Resident #3's fall on 3/14/11. d. Review of Resident #3's nurse's notes dated 3/26/11 at 5:10 PM documented, "Called to room by CNA who states she heard alarm in rm & upon entering noted resident face down on floor beside bed. Bleeding from R eyebrow - ice applied." Subsequent nurse's notes documented the resident was sent to the ED (emergency department) and returned with "steri strips D & I (dry and intact) (L) forehead. Bruising noted around ou (both eyes), nose et (and) forehead." The Event Documentation form for the fall of 3/14/11 documented no appliances/devices in place at the time of the fall and documented the resident was trying to get out of bed at the time of the fall. There was no evidence the care plan interventions for fall risks "...Lowbed with mats on floor, FALLING STAR PROGRAM, Keep wheelchair out of room, ...Except for bed and bathroom times keep resident in lobby for observation, ...Hipsters as tolerated, No bedside commode, Toilet plan, Dycem under floor alarm mat, Grey floor pressure mat" were being implemented at the time of Resident #3's fall on 3/26/11. e. Review of the nurse's notes dated 6/10/11 at 1:30 AM documented, "This nurse was called to Room (#) where Res (Resident) was laying on the floor face up, on her back... LPN was applying pressure to wound (upper) (R) eye to stop the bleeding of the open area. The area & (R) side of Res face was purple in color, edemitus (edematous) ...911 was called ...transferred via ambulance..." Nurse's notes documented the resident was sent to the emergency room and returned with sutures above the Right eye. The Event Documentation form for the fall of 6/10/11 documented the resident was getting out of bed at the time of the fall, documented types of injury included laceration, hematoma, skin tear and chipped front tooth, and documented "Actions/Interventions: Reorientate Res on call light use. Remind Res of time of night d/t (due to) poss (possible) time confusion. Pharmacy review. Add floor pressure mat alarm - app. (approved) per fall team." Review of Resident #3's care plan for risk for falls revealed the intervention floor pressure sensitive alarm that had been marked through, and the intervention of "Grey floor pressure mat" added 3/14/11. There was no new fall intervention was developed or implemented after this fall. There was no evidence the care plan interventions for fall risks "...Lowbed with mats on floor, FALLING STAR PROGRAM, Keep wheelchair out of room, ...Motion detector 'smart alarm' in bathroom on at all times, ...Hipsters as tolerated, Dycem to w/c, No bedside commode, Toilet plan... Under seat alarm, Dycem under floor alarm mat, Alarming w/c pressure mat, Pad sharp edges in room to prevent injury" were being implemented at the time of Resident #3's fall on 6/10/11. f. Review of the nurse's notes dated 6/12/11 at 11:30 AM, documented, "CNA reports that she heard alarm & entered Rm (#) & noted resident on floor on (L) side in front of W/C & recliner. Denies pain or discomfort. No injuries..." The Event Documentation form for this fall documented the resident was trying to transfer from the wheelchair to the recliner at the time of the fall, and "Actions/Interventions: (Medical management -UA (urinalysis) C&S (culture and sensitivity)) per fall team." Review of the resident's laboratory results revealed a urine specimen, collected 6/14/11, urinalysis was negative, and urine culture revealed no growth. The laboratory results documented the physician was notified 6/15/11. There was no documentation the laboratory results had been reviewed by the fall team, or any additional interventions had been attempted after the laboratory results were received. There was no evidence the care plan interventions for fall risks "...FALLING STAR PROGRAM, ...Except for bed and bathroom times keep resident in lobby for observation, ...Hipsters as tolerated, Dycem to w/c, Dycem under floor alarm mat, ...Grey floor pressure mat, Pad sharp edges in room" were being implemented at the time of Resident #3's fall on 6/12/11. g. Review of the nurse's notes dated 6/14/11 at 12:00 PM documented, "This nurse called to resident's room per CNA - upon entering room noted resident lying on floor beside roommate's bed - prone position - resident states, "I got out w/c to go to BR (bathroom)" - chair alarms were in place- upon assessment noted a moderate amt (amount) sanguinous (sanguineous) (bloody) drainage on floor - noted (3) lacerations forehead, noted open area bridge of nose - noted (upper) lip sl (slightly) swollen - resident c/o (complaint) HA (headache)." Subsequent notes documented the resident was sent to the ER and returned with sutures to the left eyebrow, bridge of nose and left forehead. The Event Documentation form for this fall documented the resident was getting out of the wheelchair without assistance at the time of the fall. The event documentation dated 6/14/11 documented "Actions/Interventions" implemented as "Make sure resident does not go to room p (after) leaving DR - Keep DR (dining room) or TV (television) area until staff finished c (with) meals. Redirect to Social Area or DR at meals- per fall team." Review of Resident #3's care plan for risk for falls revealed a handwritten intervention added, "6/14/11, Fall; Redirect to social area or back to DR during meals." A prior intervention of "Except for bed and bathroom times keep resident in lobby for observation." There was no new intervention developed or implemented for this fall. There was no evidence the care plan interventions for fall risks "Keep wheelchair out of room, ...Except for bed and bathroom times keep resident in lobby for observation, ...Motion detector 'smart alarm' in bathroom on at all times, ...Dycem to w/c, No bedside commode, Toilet plan... Under seat alarm, Dycem under floor alarm mat, Alarming w/c pressure mat were being implemented at the time of Resident #3's fall on 6/14/11. h. Review of the nurse's notes dated 7/4/11 at 3:00 PM documented, "This nurse called to resident's room per CNA - upon entering room- noted resident lying on floor - face down- mod amt blood noted on floor- forehead states, 'I fell ' ...to ER..." Subsequent nurse's notes revealed a CT of the head revealed a nasal fracture and the resident received sutures before returning to the facility. The Event Documentation form for this fall documented the resident was attempting to get out of the wheelchair without assistance at the time of the fall. The form documented "head injury" and the Actions/Interventions for this fall were, "Resident sent to ED (Emergency Department) ...Medical Management per fall team." Nurse's notes documented the resident returned to the facility 7/4/11 at 9:00 PM. There were no new interventions developed or implemented to prevent injuries from fall after this fall. There was no evidence the care plan interventions for fall risks "...FALLING STAR PROGRAM, Keep wheelchair out of room, ...Except for bed and bathroom times keep resident in lobby for observation, ...Motion detector 'smart alarm' in bathroom on at all times, ...Dycem to w/c, No bedside commode, Toilet plan... Under seat alarm, ...Alarming w/c pressure mat, Grey floor pressure mat, ...Floor mat alarm, ...Redirect to social area or back to DR during meals..." were being implemented at the time of Resident #3's fall on 7/4/11. Fall risk assessments for Resident #3 were completed on 2/11/11, 3/3/11 and 5/25/11. Resident #3's total score for each assessment was 18. The "Fall Risk Assessment" form documented, "Total score of 10 or above represents HIGH RISK." There was no documentation a fall risk assessment was completed after the falls on 2/13/11, 3/10/11, 3/14/11, 3/26/11, 6/10/11, 6/12/11, 6/14/11 and 7/4/11. Observations in Resident #3's room on 7/11/11 at 11:18 AM, revealed Resident #3 in a low bed with dark brown eschar on her forehead, nose and chin and greenish-yellow discoloration to the right cheek. Resident #3 was receiving oxygen via binasal cannula at 2 liters a minute. Floor mats were observed on both sides of the low bed, and falling star signs were on the foot of the bed and the door frame. A w/c was parked at the foot of the bed with a seat sensor and portable oxygen tank attached. Observations in the TV area at Nursing Station 1 on 7/11/11 from 4:55 PM until 5:10 PM, revealed Resident #3 seated in a high back wheelchair, sitting erect, with her feet barely touching the floor, while the staff changed the portable oxygen tank on the back of the w/c. The resident sat erect, then would lean back and then erect again, to the edge of the seat. There was no motion sensor alarms observed in the room, there was no padding to sharp edges of doors or furniture observed in the room as care planned. The interventions of keep w/c out of room, motion detector smart alarms in the bathroom, and pad sharp edges in room were not implemented as care planned. Observations on 7/12/11 at 7:48 AM, revealed Resident #3 in a high back wheelchair, being wheeled to the TV area by a staff member. When the staff member stopped pushing, Resident #3 immediately began propelling her w/c toward the dining room. An LPN at the nurse's station asked Resident #3 if she was going to the dining room. The LPN told Resident #3 she would come help her with her breakfast in a few minutes. Observations in the dining room on 7/12/11 at 8:00 AM, revealed Resident #3 seated alone at a table in a high backed w/c. During an interview with the fall team on 7/14/11 at 10:55 AM to 12:00 PM, the Director of Nurses (DON) was asked what interventions were in place to prevent falls for Resident #3. The DON stated, "...not trying to prevent her falls, just trying to prevent her injuries." The DON stated, "She (Resident #3) knows how to beat the alarms, when she had pressure chair alarms before, she knew to put a book in the chair so the alarm would not sound when she stood... She had no falls from 11/28/09 until 2011 ...Short of restraining her (Resident #3), it is difficult to prevent falls, she has the right to fall... They (indicating the federal surveyor from Centers for Medicare and Medicaid Services (CMS) present in the meeting) say she has the right to fall... Out of a hundred or so residents, she (Resident #3) is an isolated case. Alarms work more effectively on some than on others, we move from one alarm to another and revisit them quarterly and/or with falls. We have a lot of new and innovative interventions. We feel (Resident #3) is a very unique case and is looked at over the years. She (Resident #3) went a year without a fall and I'm very pleased." Resident #3 sustained eight falls from 2/13/11 to 7/4/11. Five falls resulted in lacerations that required sutures; she sustained a chipped tooth on 6/14/11 and a fractured nose on 7/4/11. The facility's failure to develop and implement interventions to protect the resident after each of these falls placed Resident #3 in immediate jeopardy as evidenced by serious injuries that required medical interventions. Observations in Resident #3's room on 7/15/11 at 8:30 AM, revealed Resident #3 was up in her w/c at bedside, being fed breakfast by CNA #5 and was noted to have a reverse torso support in place. At 9:30 AM, Resident #3 was observed in bed in her room, CNA #5 was seated at the bedside. An Allegation of Compliance (AOC) was received from the facility on 7/14/11 at approximately 8:00 PM with additional information received and accepted on 7/15/11 at 5:05 PM. During an interview in Resident #3's room on 7/15/11 at 9:35 AM, CNA #5 stated her assignment for that shift was to provide 1 on (:) 1 care for Resident #3, document Resident #3's toileting concerns each hour, and document any attempts to exit the bed or the w/c. CNA #5 stated she was told someone will be assigned to the resident for 30 days. During an interview at the #1 Nursing Station, on 7/15/11 at 9:40 AM, Nurse #5 stated, "1:1 supervision will be continued 30 days and re-evaluated until we know she is safe at the highest level of functioning." The Immediate Jeopardy was lifted on 7/15/11 at 5:05 PM and noncompliance still continues at the lower scope and severity level of D. 2. Medical record review for Resident #8 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the nurse's notes dated 4/2/11 at 1:00 PM documented, " ...Resident up OOB (out of bed) for meal. Ambulate per self and ad lib (at liberty) ...5/20/11 11 AM ...Resident (symbol for up) ambulating in hallway... 6/4/11 4:15 PM ...Resident has been unsteady on his feet..." Review of the nurse's notes dated 6/18/11 at 4 PM documented, "Resident stood up from W/C and fell backwards over back of the chair, hitting his head and shoulders first. Resident was unconscious X (times) 30 sec (seconds) to 1 min. (minute) Remained semiconscious X 20 min... send to ER for evaluation and treatment..." Review of the "Progress Note - Psychiatric ...Date: 7/14/11... F/u (follow-up) readmission to facility 7/1/11 s/p (status [REDACTED]...6-18-11 Fall; Medical Management..." The facility failed to be specific with interventions put in place to prevent falls or injuries from falls. Observations in the Old Wing TV room on 7/12/11 at 7:40 AM, revealed Resident #8 seated in wheelchair. Observations in the TV room on the New Wing on 7/14/11 at 7:00 PM, revealed Resident #8 seated in a wheelchair with ear buds on. Smiling and appears to be moving with the music from the I Pod. During an interview with the fall team on 7/14/11 at 10:55 AM to 12:00 PM, when asked when did Resident #8 began using a wheelchair, the Occupational Therapist (OT) stated, "...did not recommend a wheelchair... considered him ambulatory..." The DON stated, "...we can put them (indicating the residents) in a wheelchair can't we..." When asked for a plan to get Resident #8 back to baseline (ambulatory), there was no response from the fall team. 3. During an interview with the fall team on 7/14/11 at 10:55 AM to 12:00 PM, the DON stated the fall team included the DON, the minimum data set (MDS) / care plan LPN, the Quality Assurance (QA) Registered Nurse (RN), the OT and the restorative CNA. The DON stated the fall team meets daily Monday through Friday in the morning meeting to discuss falls. She stated the nurses on the floor try to put an intervention in place immediately when a fall occurs. The fall team looks over the event report to determine if the proper intervention was implemented, to determine the root cause of the fall and try to address the cause with an intervention. The DON stated the proper intervention could be medical management. When asked what she would expect the nursing staff to implement for the intervention of medical management on a care plan, the DON stated it could be antibiotics, fluids and cranberry juice for a urinary tract infection or it could be psychiatric medical management. The DON stated if a resident was sent to the emergency room after a fall, the intervention would be medical management.

Amended 2567 Based on policy review, review of the "Falling Star Program", review of "Event Documentation" forms, medical record review, observation and interview, it was determined the facility failed to be administered in a manner that maintained the highest practical physical and psychosocial well being for all residents by failing to ensure residents at risk for falls were adequately supervised and had interventions developed and implemented after each fall for 2 of 20 (Residents #3 and 8) sampled residents identified with falls. Resident #3 was assessed as being at risk for falls. Resident #3 sustained eight falls from 2/3/11 to 7/4/11. Five falls resulted in serious injuries such as lacerations with sutures, one fall sustained a chipped tooth and the last fall on 7/4/11 resulted in a fractured nose. The facility's failure to develop and implement interventions to protect the resident after each of these falls placed Resident #3 in immediate jeopardy as evidenced by repeated falls with serious injuries that required medical interventions and resulted in substandard quality of care. A conference was held with the Administrator, in the Administrator's office on 7/14/11 at 5:17 PM, to inform him of the surveyors findings that placed Resident #3 in immediate jeopardy. The findings included: The administration failed to identify and address staff competency in developing and implementing interventions after each fall for residents identified as being at risk for falls and adequately supervising residents to prevent falls or injuries from falls for residents. Resident #3 sustained falls and experienced actual harm with injuries requiring medical intervention on 2/13/11, 3/14/11, 3/26/11, 6/10/11, 6/14/11 and 7/4/11. Continued failure of the staff to develop and implement interventions to prevent further injury from falls and provide adequate supervision to prevent injuries resulted in Immediate Jeopardy for Resident #3. Resident #8 fell backwards over back of the chair, hitting his head and shoulders on 6/18/11 sustaining an intercranial hemorrhage. The facility failed to be specific with interventions put in place to prevent falls or injuries from falls. Refer to F280, F282 and F323. The administration failed to ensure the Quality Assurance Committee established a method for identifying concerns in the facility. Refer to F520. The Immediate Jeopardy was lifted on 7/15/11 at 5:05 PM and noncompliance still continues at the lower scope and severity level of D.

Amended 2567 Based on policy review, review of the "Falling Star Program", review of "Event Documentation" forms, medical record review, observation and interview, it was determined the facility's administrative staff failed to identify and address quality of care issues such as failure to ensure adequate supervision of residents and failure to ensure adequate interventions were developed and implemented to prevent falls and injuries from falls for 2 of 20 (Residents #3 and 8) sampled residents identified with falls. Resident #3 was assessed as being at risk for falls. Resident #3 sustained eight falls from 2/3/11 to 7/4/11. Five falls resulted in serious injuries such as lacerations with sutures, one fall sustained a chipped tooth and the last fall on 7/4/11 resulted in a fractured nose. The failure of the Quality Assurance (QA) committee to identify and address these concerns resulted in actual harm to Resident #3, placed Resident #3 in immediate jeopardy as evidenced by repeated falls with serious injuries that required medical interventions, and resulted in substandard quality of care. A conference was held with the Administrator, in the Administrator's office on 7/14/11 at 5:17 PM, to inform him of the surveyors findings that placed Resident #3 in immediate jeopardy. The findings included: During an interview in the QA Nurse's office on 7/15/11 at 5:45 PM, the QA Nurse did not identify falls as a problem identified by the QA committee. The QA Nurse stated problems may be identified by anyone on the QA committee, but could not provide an established method for identifying QA concerns. The QA committee staff failed to identify and address the staff competency in developing and implementing interventions after each fall for residents identified as being at risk for falls and adequately supervising residents to prevent falls or injuries from falls for residents. Resident #3 sustained falls and experienced actual harm with injuries requiring medical intervention on 2/13/11, 3/14/11, 3/26/11, 6/10/11, 6/14/11 and 7/4/11. Continued failure of the staff to develop and implement interventions to prevent further falls and further injury from falls and provide adequate supervision to prevent injuries resulted in Immediate Jeopardy for Resident #3. Resident #8 fell backwards over back of the chair, hitting his head and shoulders on 6/18/11 sustaining an intercranial hemorrhage. The facility failed to be specific with interventions put in place to prevent falls or injuries from falls. Refer to F280, F282 and F323. The Immediate Jeopardy was lifted on 7/15/11 at 5:05 PM and noncompliance still continues at the lower scope and severity level of D.