Every finding on record at The Gables of Pelham Skilled Nursing & Rehab

Based on observations, interviews, and review of the facility policy, the facility failed to ensure foods that are stored in the freezer, refrigerators and dry food storage were appropriately sealed, labeled and dated with a use by date and/or discarded after the manufacturer's expiration date. In 2of 2Kitchens, 1of 2Freezers, 1of 2Refrigerators and 1 of 1 Dry Foods Storage.Review of the facility's policy titled Food Receiving and Storage last revised July 2024 revealed, Foods shall be received and stored in a manner that complies safe food handling practices. 7) Dry foods that are stored in bins will be removed from original packing, labeled and dated (use by date). Such food will be rotated using a first in - first out system. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date) . 14. C. Refrigerators must have working thermometers and be monitored for temperature according to state specific guidelines. E. other opened containers must be dated and sealed or covered during storage.During the initial kitchen tour on 07/22/25 at 9:14 AM, the following was observed:1. The Dry Food storage had 1 -12 ct. (count) pack of 6 inch flour tortillas with a prep date of 07/07/25 and a use by date of 07/14/25.2. The walk-in cooler had two bags of salad mix with a use by date 07/21/25, the salad mix was brown and wilted; one pan of cut lettuce with no prep or use by date; three 6-ounce (oz.) containers of blackberries with a white fuzzy substance on them; one 1 gallon (gal) container of bread & butter pickle slices with no open date or use by date.3. The walk-in freezer had one bag of frozen corn with no open and/or use by date and one open package of sausage with an open date 05/15/25 and a use by date 06/15/25. 4. The reach in freezer had one 15-pound (lb.) box of lasagna sheets marked with a prep date of 01/6/25 and a use by date of 02/06/25 and one bag of chicken tenders opened and not labeled or dated. During a follow- up observation of the main kitchen on 07/23/25 at 8:21 AM the following was observed again in the walk-in cooler:1. Two bags of brown and wilted salad mix with a best by date of 07/21/25. One of the bags was now opened and wrapped with plastic film without an open date or use by date.2. Four 16oz containers of fresh strawberries with white fuzzy debris and brown spots. Both items were noted in the kitchen on the previous day.During tour of the unit kitchen on 07/23/25 at 10:55 AM, the following was observed:1. One stained 10 oz. container of active food thicker opened with no open or use by date.2. One 24 oz. container of thick and easy food and beverage thickening power opened with no open or use by date.3. One storage container of brown sugar not labeled and without an open or no use by date.4. One 10.5 oz. box of Lucky Charms cereal open, bag not properly sealed inside box with a best by date of 02/23/25.5. One 24 oz. box of bite size frosted shredded wheat open and not properly sealed without an open date and a best by date of 02/10/25.During an interview on 07/23/25 at 8:30 AM the Dietary Manager (DM) revealed that her expectation is that when food items are received they are to be marked with the received date, then they are to be used by the first in and first out based on the date, when food are opened they are to be marked with an open date as well as a use by date, and all foods beyond the manufacturer's or marked use by date should be discarded. The DM states that she does a walk though of the kitchen daily checking food quality and ensuring that items are properly labeled and dated. DM also revealed that the bags of salad mix in the walk in cooler should have been discarded based on how they looked as well as be the use by date. The DM explains that staff should check food items, especially the fruit because it goes bad quick.During an interview on 07/23/25 at 11:05 AM dietary aide (DA) revealed the dates on the cereal were February 23, 2025, and February 10, 2025, and stated that both boxes belonged to a resident that was a respite resident and is no longer at the facility, and that they should have been tossed out. The DA explains that usually cereal kept only for about a week and discard after that. The DA continues to explain that the thicker in the kitchen is not used by the kitchen staff but should have an open date. The DA further explained that the container of brown sugar should have been labeled with contents and use by date. The DA further revealed that the food items in the kitchen should be checked by the staff in the kitchen, the supervisor or kitchen manager to make sure items are not expired and that they are labeled properly.During an interview on 7/23/25 at 1:40 PM the Administrator revealed that she oversees the kitchen and if there are issues, she needs to know about them. The Administrator explains that she conducts a walk though of the kitchen monthly and the unit dining room daily. The Administrator states that her expectation for food items is that they are stored at the proper temperature, labeled and dated per the facility's policy and the regulation.

Based on review of facility policy, record reviews, observation and interviews, the facility failed to assess a resident for safe self-administration of medication for 1 of 1 resident, Resident (R) 34 reviewed for self-administration of medication.Review of the facility policy titled, Self-Administration of Medication last revised February 2021, states, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.1. As a part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is reassessed periodically based on changes in the resident's medical and/or decision-making status. 8. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents.Review of the facility's policy titled Administering Medications states Medications are administered in a safe and timely manner, and as prescribed.27. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.Review of R34's Face Sheet revealed R34 was admitted to the facility on [DATE], with diagnoses including but not limited to: orthostatic hypotension, syncope, and collapse.Review of R34's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/21/25 revealed R34 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R34 is cognitively intact.Review of R34's Physician Orders revealed Deep Sea Nasal Spray Solution (Saline) 1 spray in both nostrils every six hours as needed for dry nasal passages. No orders for self-administration documented.Review of R34's Care Plan revealed no documentation to self-administer medications or to keep medications at the bedside.An observation on 07/22/25 at 10:57 AM, revealed, two nasal sprays in R34's window seal. The first nasal spray container's label read Nasal Spray 12-Hour Relief Over-the-Counter (OTC). The resident's attached label was faded and difficult to read. The second nasal spray was labeled Nasal Moisturizing Spray also with the residents' label faded.During an interview on 07/22/25 at 10:57 AM, R34 stated, I have been here about 2 weeks. I used my nasal sprays at night because I need it for my breathing due to my sinuses being operated on. It helps me to breathe.During an interview on 07/23/25 at 2:31 PM, the Director of Nursing (DON) stated, We reordered his nasal medications. I realized the labels were unreadable. It is the Registered Nurse (RN) and the Medical Director (MD)'s responsibility to decide if the residents can self-administer medications. We will educate families about bringing in medications without notifying the staff. We will have the families check with the nurses before bringing in medications. We will also make sure the medication is on their medication list and get approval from the Medical Director (MD) as well as get an order. He told me this morning he was stuffy last night, and he could hardly breathe. His new medications were delivered last night. We completed a self-assessment form. R34 demonstrated how to administer the medications properly.

Based on review of facility policy, observations and interviews, the facility failed to ensure that expired medications and biologicals were removed from the refrigerator in 1 of 1 medication storage rooms.Review of the facility policy titled Medication Labeling and Storage last revised February 2023, states 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.During an observation of the medication storage room on 07/22/25 at 12:25 PM, the following was observed:1. 1 dose of Covid 19 Vaccine with an expiration date of 05/09/252. 12 doses of Influenza Vaccine Adjuvanted with an expiration date of 04/24/253. 1 does Influenza Vaccine Adjuvanted with an expiration date of 06/02/25. During an interview on 07/22/25 at 12:33PM, Licensed Practical Nurse (LPN)1 stated, I was unable to determine who was responsible for discarding expired medications from the refrigerator. I am unsure how to discard them; I will find out.During an interview on 07/22/25 at 01:18 PM, the Director of Nursing (DON) stated, The pharmacist comes and does the audits monthly. The nurses should be checking weekly on the day shift for expired medications in the refrigerator.

Based on review of facility policy, manufactures instructions, observations and interviews, the facility failed to: 1. Ensure the safe handling and preparation of meals when during meal preparation a metal can lid was noted in a pan of cooked desert 2. Follow appropriate infection control practices during medication administration when Licensed Practical Nurse (LPN)1 failed to clean the top of the insulin syringe before administration of insulin. 1. Review of the facility's policy, titled Food Preparation and Service, last revised November 2022, revealed, Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices.During an observation of the main kitchen on 07/23/25 at 11:44 AM a Dietary Aide (DA) was observed plating an apple crisp dessert when she pulled a metal can lid out of the bottom of the prepared pan with her gloved hand. She then discarded the lid into the trash, followed by the contents of the pan and any dessert that had already been plated. The DA then proceeded to use a second prepared pan of apple crisp. Halfway through serving, she again encountered a metal can lid at the bottom of this second pan, she discarded the lid, the contents of the pan, and any plated dessert.During an interview on 07/23/25 at 12:11 PM, the Dietary Manager DM confirmed that the DA found lids in the apple crisp and states that she will conduct an in-service with staff regarding the lids found in the prepared food.During an interview on 07/23/25 at 12:57 PM, [NAME] (C)1 revealed that she cooked the apple crisp. Then stated she doesn't know what happened today, and that it's usually not like this.During an interview on 07/23/25 at 1:40 PM, the Administrator revealed that she oversees the kitchen. The Administrator explained that when preparing food, the cooks should check to ensure all foods are free of objects and can lids should not be in prepared food.Follow up interview on 07/23/25 at 2:39 PM, The DM explained that some food items are usually prepped and prepared the day before. She states that when using items that come from a can, the can is opened, the lid is removed and that food contents are dumped into a bowl and prepared.2. Review of the facility's policy title, Insulin Administration last revised March 2025, revealed, Purpose: to provide guidelines for safe administration of insulin. Steps in the procedure (Insulin injections via Syringe) 10. Disinfect the top of the vial with an alcohol wipe.Review of the manufacturer's instructions for the use of lispro insulin injection revealed step 2: wipe the rubber stopper with an alcohol swab.During an observation on 07/23/25 at 08:23 AM, LPN1 did not use an alcohol wipe to clean the hub of the Lispro insulin syringe.During an interview on 07/23/25 at 08:23, LPN1 stated, We only clean the hub with alcohol after we initially open the insulin cartridge. The nurse proceeded to prime and restated that we do clean off the hub with an alcohol swab. In my haste, I didn't do it. Too much coffee this morning.During an observation on 07/23/25 at 08:26 AM, LPN1 removed the needle and wiped the insulin syringe hub off with alcohol and reprimed the insulin syringe.During an interview on 07/23/25 at 2:42 PM, DON stated, I will have an in-service and huddle, and have everyone sign off on the proper procedure of administering insulin using insulin syringes. We in-service the nurses any time anything like this comes up.

Based on manufacturer's recommendation, review of the facility policy, record review, and interviews, the facility failed to ensure Resident (R)1 was free from chemical restraints, when it was identified that R1 was administered Haloperidol Deaconate (Haldol) for exit seeking, entering patient rooms. The medication was not ordered for an approved indication of use. On 02/07/25 at 2:20 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 02/07/25 at 2:23 PM, the Administrator was notified that the facility's failure to have systems in place to monitor for chemical restraints constituted Immediate Jeopardy (IJ) at F605. On 02/10/25 at 9:37 AM, the facility provided an acceptable IJ Removal Plan. On 02/10/25 at 10:00 AM, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F605 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F605, constituting substandard quality of care. Findings include: Review of the Manufacturer's Recommendation for the medication Haldol revealed, Increased Mortality in Elderly Patients with Dementia-Related Psychosis treated with antipsychotic drugs are at an increased risk for death. Observational studies show that, similar too atypical antipsychotics drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to antipsychotic drugs as opposed to some characteristics of patient is not clear. Haldol Deaconate 50 and Haldol Deaconate 100 are indicated for the treatment of patients with schizophrenia who required prolonged antipsychotic therapy. Review of the undated facility policy titled, Use of Restraints revealed under the policy, Ensure that chemical restraints are only used when needed to treat the residents medical symptoms and then, only use the least restrictive alternate for the least amount of time. Prior to the initiation of psychotropic medication, clinicians will thoroughly assess resident's mental/cognitive, behavior and physical status. This assessment will address other interventions that may be symptoms or the cause of the situation. A physicians order is necessary for the initiation of any restraint or psychotropic medication . that order will include the physicians diagnosis .it will also include the expected duration. Record review of R1's facesheet revealed he was admitted to the facility on [DATE] with diagnoses that include but are not limited to Alzheimer's disease, type 2 diabetes, chronic obstructive pulmonary disease and anemia. Review of R1's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/24 revealed the Brief Interview for Mental Status (BIMS) score could not be conducted and was checked as, rarely understood. Review of R1's Physician orders revealed, an order dated 12/21/24 for Haldol Deaconate Inject 0.2 milliliter (ml) 10 milligrams (mg) intramuscularly (IM) as needed for agitation. Every 8 hours. End date Indefinite. It had 3 warnings, including Back Box warning, Alert Dose warning and Drug interaction warning. The alert dose warning stated, The frequency of daily exceeds the usual frequency of every 28 days. Record review of R1's medication administration record (MAR) dated December 24 revealed R1 received 3 doses of Haldol Deaconate, recorded as given on 12/21/24, 12/23/24 and 12/29/24. The medication remained active on R1's MAR for 17 days. There was no monitoring of the medication for adverse effects or behaviors. Review of R1's care plan dated 12/17/24 revealed, [R1 uses psychotropic medications, dementia and that he will be free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment.] Record review of R1's progress notes dated 12/21/24 at 01:58 revealed Licensed Practical Nurse (LPN)1 reported exit seeking behavior, entering patient rooms and is in constant need of redirection. [Nurse Practitioner] NP called back and said she will fax order in the morning and stated he can have 10 mg IM of Haldol. Record review of a fax confirmation dated 12/21/24 revealed an order from the NP for Haldol 10 mg IM x 1, as needed for agitation for R1. This was received at 6:00 PM. Record review of the Emergency Drug Kit #1 revealed there was Haloperidol 5 milligram/milliliter injection in the drug kit. Record review of R1's Order Audit Form revealed 2 dates the pharmacy sent the Haldol Deaconate, on 12/21/24 and 12/27/24. Record review of the pharmacy packing slip dated 12/21/24 and 12/28/24 revealed R1's medication of Haloperidol Deaconate was delivered to the facility. During an interview on 02/06/25 at 4:30 PM, with the Director of Nursing (DON) revealed, that she monitors the antipsychotic medication, and the scripts are for 14 days. The DON stated she was not aware the medication had been ordered for longer than 14 days without a diagnosis. She said the physician should give the diagnosis and the nurses should ask. She stated, I am aware the NP was called for R1 when the order was given. On 02/06/25 at 5:07 PM, an interview with the NP confirmed she was the on-call provider and did order an injection. She stated, As far as I know, yes, he can receive that, we do give Haldol sometimes. I know of the Black Box Warning. I've never received an alert dose warning on administration like that. For acute conditions, it can be anywhere from 1 to 5 to 10 mg. The maximum daily dose is 20 mg. We were trying to choose medication from their formulary. I didn't specify a diagnosis. I didn't get a call back on the warning. Ordering every 8 requires constant monitoring. I'm concerned it may have been a 1-time order. I need to review my documentation on this and refer to my Physician and I will call you back. I'll get clarification on the Haldol Deaconate versus the Haldol injection. On 02/06/25 at 5:30 PM, during a follow-up interview with the NP, revealed, Regular Haldol is not the same as Haldol Deaconate, it's usually given once a month. The NP said, They gave the wrong medication, and confirmed she ordered the Haldol 10 mg, as a 1 time dose only. During a follow up interview with the DON at 6:25 PM, the DON stated she spoke to the NP and she said it was the wrong medication. The DON stated, Somehow the pharmacy ordered it as a 1-time dose as needed, and it ended up being input as 0.2 mg IM Q 8 hours. We expect the nurses to ask for the diagnosis. If the pharmacy puts it in correctly, the behaviors and the side effects would be there, but they did not. Those warnings are confirmed by the nurse after the order is placed by the pharmacy. The DON also stated, I believe those warnings also go to our Medical Director. During an interview on 02/06/25 at 7:38 PM, LPN1 stated, R1 was exit seeking and trying every door. We would try to redirect him, and he was aggressive and very unaware of his surroundings. We had given him Ativan, it didn't help. So, I called the NP on call. She asked me what all his medications were. She said she was going to put an order in for Haldol and to discontinue the Ativan. She said to wait for the fax order, but don't give it until confirmed with the pharmacy. On 02/07/25 at 10:20 AM, a follow up interview with the DON revealed, I spoke to pharmacy several times yesterday and they confirmed it was their transcription error for R1's Haldol. A request was made by the surveyor to review the Haldol removed from the drug kits in December 24. The DON said, Our Social Services Director (SSD) does the consents for Psychotropic medications. She was not doing that. On 02/07/25 at 10:45 AM, a phone interview was conducted with the Pharmacist Consultant. She said, When the nurse gets the order and it is available, they can get the medication from the e-kits. The pharmacy enters the orders into the system and pushes it back over into their electronic system. The facility can also enter orders. After hours, if the medication is not a controlled med, the nurse can pull the medication from the e-kit without going through the pharmacy to open the kit, that is not required. The regular Haldol is short acting, the other was long acting. Excessive lethargy and multiple drug interactions are just a few adverse effects that can occur. The nurses should be monitoring for drug side effects, and behaviors. The facility is responsible for putting those behaviors and side effects into the system. On 02/07/25 at 11:15 AM, an interview was conducted with the Pharmacy Director. He confirmed they did in fact send the Haldol Deaconate, and confirmed that was a pharmacy error. He stated, The medication was a 1-time only order, not every 8 hours. I'm not sure where that came from. The facility's removal plan dated 02/07/25; 1) R1 was discharged from the facility to another facility on 01/06/25. 2) Immediately on 02/07/25, the DON, MDS or Designee conducted an audit of residents to identify those residents with potential risk for chemical restraints. 3) Immediately on 02/07/25, the DON, MDS Nurse, Administrator or Designee will conduct nurse and or provider in-service education of Guardian Pharmacy Psychotropic PRN Medication Regulation in LTC and medication Monitoring Management - Policy regarding F758 Psychotropic Medication and PRN use. 4) Immediately on 02/07/25 the Director of MDS Nurse, Administrator or designee will conduct nurse inservice education on (6) rights of Medication Administration. 5) Immediately on 02/07/25 the Director of MDS Nurse, Administrator or designee will conduct in-service/education on AASC Agitation in Alzheimer's Screener for Caregivers. 6) Immediately on 02/07/25 the Director of MDS Nurse, Administrator or designee will conduct in-service/education on Policy for Medication Variance Report. 7) Immediately on 02/07/25 the Director of MDS Nurse, Administrator or designee will conduct in-service/education on New Order Tracking Form. 8) Immediately on 02/07/25 the Director of MDS Nurse, Administrator or designee will conduct in-service/education on CMS Revises Several Regulations in Appendix PP- Chemical Restraints/Unnecessary Psychotropic Medications. Monitoring and Follow Up Plan; The facility will monitor compliance with the corrected procedures to ensure the IJ issue does not recur by; 1. Reminders of At- Risk residents at Daily Stand Up and on 24 HOUR NURSE REPORT by DON/ADON/Nurse Supervisors each shift. 2) Weekly Ad Hoc Meetings of each resident identified AT Risk: Review effectiveness interventions in place and/or recommended change in interventions and update team members, MD, and POA. Behavioral interventions will be developed for the individual resident and communicated to team members, MD, and POA. EHR/PCC was updated with these identified interventions. 3) Inclusion of Therapy ie; PT/OT/ST, plus IDT team members and ED in determination of appropriate therapy and other interventions as identified. 4) Inservice will be ongoing until all appropriate facility have signed off, during orientation and annually. 5) An audit of the inservice/education training will be conducted by the Administrator weekly x 6 weeks and annually. 6) The Administrator will send in audit findings to corporate compliance and bring to QAPI for review monthly. 7) Anticipated correction date 02/07/25.

Based on review of the facility policy, record review, and interviews, the facility failed to ensure that adequate supervision was in place to prevent Resident (R)1 from eloping from the facility. On 12/17/24 at approximately 9:33 PM, R1 was found outside of an exit door on the C-Unit of the facility. Licensed Practical Nurse (LPN)1 stated that they heard the alarm sounding off from another unit and felt cold air coming from the door while walking down the hallway. R1 was observed outside of the door in his wheelchair and stated that he was picking berries from the bush. On 12/17/24 at approximately 9:33 PM, the weather was 54 degrees Fahrenheit (F). On 02/05/25 at 7:34 PM the Administrator was electronically notified that the failure to ensure Resident (R)1 was free from accidents/hazards related to a succesful elopement on 12/17/24 constituted Immediate Jeopardy (IJ). The IJ was related to S483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 02/06/25 at 10:40 AM the facility provided an acceptable IJ Removal Plan. On 02/06/25 at 10:40 AM, the survey team validated the facility's corrective action and verified the removal of the IJ related to F689 on 02/05/25. An extended survey was conducted in conjunction with the Complaint Survey as a result of substandard quality of care. Findings include: Review of the facility's policy titled, Elopement Risk-RM-2, Category/Sub-Function: Clinical Services, Applies to: Skilled Nursing Communities with a revision date of 07/2015 revealed, Policy Overview: Residents who are at risk for elopement should be identified. Elopement occurs when a cognitively impaired resident leaves the community undetected and unsupervised. A. Evaluating for Elopement Risk Prior to Admission. 1) Admission Associate will identify potential risk for elopement and notify the Director of Clinical Services/designee of the following: The resident has a pertinent diagnosis of dementia, Alzheimer's/anxiety disorder, delusions and is the resident currently capable of independent mobility. A history of exit seeking, wandering away, or getting lost. A history of unmet needs, alcohol or drug abuse. 2) The Interdisciplinary Team will approve/decline all potential admissions based on the resident's exit seeking/elopement risk and safety measures in place at the Community. B. Admission to and/or Residence within the Community 1) Resident accepted for admission will be assessed upon admission into the Community and appropriate interventions will be established to respond to the resident's potential exit/elopement seeking behavior. 2) Intervention may include, but are not limited to: Frequent monitor (Q 15-minute checks) Activities specific to resident needs Family/companion services Electronic Monitoring/Elopement System Pain Management Room Location Assess for cause of Delirium signage placed to assist resident with directions to room. Knowledge of dominant hand 3) Completion of Elopement Risk Data Sheet with photograph. Place in Elopement Risk binder at Nursing Station and/or Receptionist Desk. 4) Communication of Elopement Risk to nursing associates and ancillary departments. 5) Director of Clinical Services or designee will review and maintain the accuracy of Resident Identification and Wandering Resident Binders. 6) Residents will be assessed on admission and a minimum of quarterly or as condition change warrants. 7) Interventions will be documented in the Resident's Plan of Care and reviewed/updated a minimum of quarterly or as condition warrants. C. Additional Interventions for Communities with Resident Monitoring System 1) The Admission Team will assess the resident for appropriate placement of the Community's wandering resident monitor system on admission and a minimum of quarterly or as condition change warrants to promote resident safety in least restricted environment. 2) Interventions/approaches will be documented in the Resident's Plan of Care and reviewed/updated a minimum of quarterly or as conditions warrants. 3) Initiate Resident Monitoring System as follows: Obtain Physician Orders for monitoring system. Inform resident/legal representative. Apply the personal monitoring device in accordance with the manufacturer's instructions. Monitor resident's comfort relative to the fit of device. Verify proper functioning of alarm after application by following manufacturer's activation instructions. Record review of R1's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to; acute respiratory failure with hypoxia, Alzheimer's disease, age related physical debility, and muscle weakness. Record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/24 revealed R1 has the Brief Interview of Mental Status (BIMS) score of 00 out of 15, which indicates that he is not cognitively intact. Further review of the MDS revealed that during the assessment period, R1 had delusions (misconceptions or beliefs that were firmly held and contrary to reality. Further review of the Admission MDS revealed R1 had verbal behavioral symptoms directed towards others (threatening others occurred one to three days during the assessment. R1's behavioral impact significantly interfered with the residents care and interfered with the resident's participation in activities/ social interactions. R1 had a wandering presence, and this behavior occurred four to six days but less than lately and wandering placed the resident at significant risk of getting into a potentially dangerous place during this assessment period. Record review of R1's Electronic Medical Record (EMR) Care Plan revealed Focus: The resident is an elopement risk/wanderer AEB [as evidenced by] Disoriented to place, History of attempts to leave community unattended, Impaired safety awareness, Resident wanders aimlessly Goal: The resident will have no injury related to exit seeking behavior through the next review date. Date Initiated: 12/18/2024 Interventions/Tasks include Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Resident prefers. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Resident prefers. Identify pattern of wandering. Intervene as appropriate. Record review of R1's EMR Nurses Notes dated 12/17/24 revealed Patient continues to exit seek, he has attempted to exit out of all 3 doors, I have called and spoke with R1's Resident Representative (RR)2 however, he is out of state and stated that patient was restrained while in the hospital. I then called R1's other Resident Representative (RR)1 to come and sit with the patient. However, I got a voicemail and left a message, Director of Nursing (DON) and Assistant DON aware of patient's exit seeking behaviors, patient is now in day area wit the TV. Record review of R1's EMR Nurses Note dated 12/18/24 of a Comprehensive Nursing Note revealed Patient is alert and oriented X1. Patient can recall past events, patient continues to receive skilled nursing care, patient is exit-seeking and trying doors throughout the shift. Patient medicated per Medication Administration Record (MAR), patient is now resting in his bed eye closed and RR1 present, bed is low and locked with fall mat on the ground. Record review of R1's EMR Nurses Notes dated 12/18/24 revealed On 12/17/24 at 9:33 PM, R1 was exit seeking at the end of hall C. LPN1 was in a room passing medications when she returned, she felt cold air coming through the door and the alarm sounds from the door at the end of hall C. She discovered the resident outside. He stated he was picking berries from a bush by the door. No injuries were noted .appropriate parties were notified. A state reportable was made regarding the incident, a body audit and elopement risk assessment was completed on admission and again on 12/18/24. Investigation is in progress; the front lobby door was on lock down on 12/17/24. Record review of R1's EMR Social Services Progress Note dated 12/18/24 revealed Writer attempted to call R1's RR1 to get admission paperwork and discuss getting a sitter, no answer. Record review of R1's EMR General Note dated 12/18/24 revealed New admit on 12/16/24 following hospital stay for acute respiratory failure. He has Alzheimer's dementia with sundowning behavior. He arrived soaked in urine from hospital, needed bath. Had been strapped in bed prior to admit, difficult to redirect propels self around facility. Elopement out of C- door evening before, prior to hospital has been in multiple facilities, son wants to send back to previous facility. Speech Therapy observed R1 standing and messing with clothing, he did sit when asked but upset pants do not fit well and will not fasten. Social Services to notify daughter of need for clothing, working with Physical Therapy and Occupational Therapy. Record review of R1's EMR Nursing Note dated 12/18/24 revealed Resident has increased agitation, behaviors, exit seeking behavior. Resident being constantly redirected, constant supervision needed. Record review of R1's EMR General Note dated 12/19/24 revealed Documentation for 12/18/24 attempted to call R1's RR1 and was unsuccessful, was able to contact RR2. RR2 stated that he will be willing to check into a private sitter, spoke with RR1 and they stated they were unable to drive at night due to poor vision and working during the day, unable to be present with Medical Director (MD) visit but will be available by phone. An interview on 02/05/25 at 12:11 PM with Licensed Practical Nurse (LPN)1 revealed R1 was constantly attempted to exit-seek throughout that evening and night and was unable to be redirected. I was passing medications in another resident's room and when I finished, I heard the alarm to the door sounding off and I also felt a cool breeze down the hallway as well. When I found the resident, his was in his wheelchair and right beside the door and attempting to pick the berries from off the bush. The resident had been outside alone for about 30 seconds prior to me coming outside and finding him. An observation and interview with LPN1 on 02/05/25 at 12:25 PM revealed the location of where R1 eloped from the facility, at the time of the observation the door was in working order. Record review of LPN1's Witness Statement dated 12/17/24 revealed I heard (the) alarm door and walked from A-Hall towards (the) Nurses Station, I felt cold air and walked towards C-Hall door and it was opened. R1 was just outside the door in his wheelchair. The resident's Certified Nursing Assistant (CNA) was in (the) dayroom, the other staff member was on the B-Hall. I called to them and they helped me get R1 inside safely, no harm to patient. A phone interview on 02/05/25 at 2:37 PM with RR1 revealed that they were notified when the resident eloped from the facility on 12/17/24. RR1 further stated that when the facility notified her of the resident's elopement they insisted that they hire a private sitter to adequately supervise R1. RR1 stated, I refused to pay anyone to sit with R1 because it's their job (the facility) to make sure he doesn't get out. RR1 further mentioned that they felt pressure by facility staff to hire an outside sitter but did not because of the financial strain. An interview with the Director of Nursing (DON) and Administrator on 02/05/25 at 5:37 PM, revealed that they were unable to recall when exactly they were notified of R1's elopement from the facility because it happened at night. The DON further stated that the facility does not utilize electronic monitoring devices on residents that are at risk for elopement, but have a program called the 'Sunflower Program' that alerts staff to keep an extra eye on those high-risk residents. The DON further stated that after R1 eloped from the facility, they spoke with R1's family to determine if they could hire a private sitter for extra supervision for R1. When it was determined that was not feasible for R1's family, R1 was moved to a room closer to the nurse's station and was placed on the Sunflower Program to alert staff of his high-risk elopement status. Further interview with the Administrator and DON revealed that the facility does not currently have electronic monitoring devices for the residents and staff are to monitor residents adequately. The facility's removal plan included the following: 1. Resident 1 (who allegedly eloped) was discharged from the facility to another facility on 01/06/2025. 2. The Director of Nursing, MDS Nurse, Administrator or Designee will conduct an audit before admission and within 24 hrs after admission to evaluate residents for possible elopement risk, initiate interventions, notify MD and POA, then document on the Interim Care Plan. Residents identified at risk for elopement should be reassessed each quarter. Audit will continue daily for 3 months. 3. Immediately on 2/5/25-The Director of Nursing, MDS Nurse or Designee conducted an audit of residents to identify those residents with potential elopement risk. 4. Immediately on 2/5/25-The Director of Nursing and Administrator Completed Elopement Risk Assessments for the residents identified to be a potential elopement risk, initiated interventions, notified MD and POA, then documented on the Interim Care Plan. Residents identified at risk for elopement should be reassessed each quarter. 5. Immediately on 2/5/25-The Director of Nursing and Administrator initiated The Sunflower Elopement Program was for those identified residents considered to be a potential elopement risk. A Sunflower magnet was placed on the resident's door, wheelchair and assistive device. 6. Immediately on 2/5/25-The Director of Nursing and Administrator updated The Elopement Risk Binder with a profile page including a photo for those identified residents considered to be a potential elopement risk. 7. Immediately on 2/5/25-The Director of Nursing and Administrator in serviced/educated team members on the Sunflower Program-Elopement Risk Management & Interventions, signing acknowledgement of understanding and compliance. Team Members were also educated on the alarm system in use in the [NAME] SNF and are required to respond immediately to any exit door opening. In communities with a centralized alarm system, the control panel is in a team member accessible location. lnservice will be ongoing until all facility staff have signed off, during orientation and annually. 8. An audit of the in-service/education training will be conducted by the administrator weekly x 6 weeks and annually. Monitoring and Follow-up Plan: The facility will monitor compliance with the corrected procedures to ensure the IJ issue does not recur by: 1. Reminders of At- Risk residents at Daily Stand-Up and by DON/ADON/Nurse Supervisors each shift. 2. Weekly At- Risk Meetings of each resident identified at-risk: Review effectiveness of interventions in place and/or recommended change in interventions and update team members, MD and POA. Residents identified at risk for elopement will be reviewed each week during the At-Risk Meeting. Elopement prevention interventions will be developed for the individual resident and communicated to team members, MD and POA. EHR/ PCC was updated with these identified interventions. 3. Inclusion ofTherapy ie.PT/ OT/ST, plus IDT team members and ED in determination of appropriate therapy and other interventions as identified. 4. To maximize safety for residents in the community, each exit door at The [NAME] SNF is equipped with a sounding alarm device that is activated when the door is opened. In some communities, this is audible and of sufficient volume to be heard by team members. 5. Include plans for ongoing staff education of new and existing staff, monthly elopement drills, competency assessments and any noted areas of identified improvements related to the IJ issue. 6. The Administrator will send in audit findings to corporate compliance and bring to QAPI for review monthly. Anticipated Correction Date 02/05/25.

Based on review of the facility policy, interviews, and record review, the facility failed to implement their policy, Abuse Prevention Program to provide protection for the identified resident (Resident (R)4) for 1 of 3 residents reviewed for abuse. Findings include: Review of the undated facility policy titled, Abuse Prevention Policy states under the policy, The abuse prevention program provides policies and procedures that govern at a minimum; protection of residents during investigations of abuse, including prohibiting and preventing retaliation. Under Procedure 4, Appropriate steps will be taken, as directed by the administrator to provide protection for the identified resident prior to conducting the investigation of the alleged violation. Record review of the facility's facesheet revealed R4 was admitted on [DATE] with diagnosis including but not limited to; displaced intertrochanteric fracture right femur, sciatica right side, and hypothyroidism. Record review of R4's Minimum Data Set (MDS) with an Assessment Reference Date of 10/09/24 revealed R4's Brief Interview of Mental Status (BIMS) score was 15 out of 15, indicating she was cognitively intact. Record review of the South Carolina Department of Public Health (SCDPH) report submitted on 12/13/24 revealed an allegation of neglect or exploitation, suspected or confirmed abuse stated, reported to Licensed Practical Nurse (LPN), Certified Nurse Assistant (CNA) had been rough with her during toileting and her mother called her multiple nights and is afraid. CNA has been removed from the floor. An interview with LPN1 on 02/06/25 at 10:55 AM revealed she worked the night of the allegation and remembered the daughter came up here and overheard a conversation with the CNA and witnessed, The CNA jerked the covers off her mom and was handling her roughly. I called my Director of Nurses (DON) and was told to Take CNA off her mom's assignment. She continued the same assignment, just not that room. I learned in the morning I was supposed to have CNA leave the building right away, that if there is an allegation of abuse, the person is supposed to leave the building right away to determine if it was actual abuse. An interview with R4's daughter on 02/06/25 at 12:09 PM, confirmed she came in during the night because her mom called. She stated, She was confused and thought she'd been kidnapped. Mama's light was on. There were people in the room. I said get away from my mother, I'll take care of her. She pushed mom's leg that had the surgery, and it hurt my mom. She told mom, you can pee 5 times in that diaper. Mother had a Urinary Tract Infection (UTI). She told me she was scared to death of her and was afraid she was going to be killed by the nurse. They didn't allow the lady back in there. I stayed all night. An interview with the DON on 02/06/25 at 1:30 PM revealed, The LPN called me that night. She was accusing the CNAs of being rough. I told her to start gathering witness statements. It was aimed at CNA1. She was removed from her care. She was asked not to go back in there. When I came in, it was right at the end of the shift. I make the determination of an allegation after I gather the information. I should make the allegation of abuse and had her gather the information. It sounds like I probably should have asked her (LPN) to send her home. When it is an allegation of abuse, the policy states that we would send them home pending an investigation. The employee was suspended that morning. She had already left for the day, she went home. An interview with the Administrator on 02/06/25 at 1:51 PM revealed, I am the abuse coordinator. If an incident happened, she, (the DON) gets the records and statements. When we have an allegation, we will suspend the person who was named. Then we will investigate it out. I think it was on 12/13/24. Around 7:03 AM, the DON informed me of it. The daughter reported to the LPN that the CNA had been rough with her. The CNA had been removed from the floor. She should have been asked to go home.

Based on policy review record review, and interview, the facility failed to develop a comprehensive plan of care for caregivers to follow for 1 Resident (R)24 of 6 residents reviewed for falls and accidents in a total sample of 12 residents. This failure resulted in harm when one staff instead of two staff changed R24's position in bed resulting in R24 rolling off the bed, sustaining a fracture of two bones in the leg, requiring an extended hospital stay, and resulting in a decline in functional mobility. Findings include: Review of the policy entitled, Comprehensive Care Plan, documented, Purpose: Each resident will have a person-centered comprehensive care plan developed and implemented to meet his/her preferences and goals and address the resident's medical, physical, mental, and psychosocial needs. Review of a policy entitled, Resident Assessment Instrument Process (RAI/MDS) documented, Purpose: The MDS [Minimum Data Set] coordinator and Nursing Staff are key members of the interdisciplinary team in this facility. One of the functions in the RAI/MDS process is to gather data in order to develop comprehensive and individualized care plans that meet the medical, nursing, mental and psychosocial needs of each resident. Each care plan will describe services furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. Review of R24's Medical Diagnosis, located in the Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS), located in the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 04/26/22 indicated R24 required extensive assistance of two people for bed mobility. R24 had a Brief Interview for Mental Status (BIMS) score of two out of 15 indicating severely impaired cognition, had no functional limitations to the upper or lower body, and used a wheelchair for mobility. Review of R24's Care Plan, revised on 04/11/22 and located in the Care Plan tab of the EMR, documented has bowel incontinence .Provide peri care, and/or assistance after each incontinent episode. Review of R24's Care Plan, revised on 04/15/22 and located in the Care Plan tab of the EMR, documented, has potential for impairment to skin integrity, impaired mobility, dependent staff transfer help. Review of all care plans prior to the accident on 05/10/22, revealed no care plan in place for two-person assistance for ADLs or bed mobility for R24 even though the MDS with an ARD of 04/26/22 assessed her as requiring extensive assistance of two staff for bed mobility. Review of a Progress Note, dated 05/10/22 at 7:15 PM and located in the Progress Note tab of the EMR, revealed Licensed Practical Nurse (LPN)1 wrote Nursing staff was in room with patient providing ADL[activity of daily living] care, during care patient turned onto right side, brief was being placed onto patient, patient started to move and started to roll off the bed, Nursing staff was able to assist patient by lowering her to the floor safely. Patient was assisted back into the bed by two staff members. Patient c/o pain in right knee currently, on call from [name of physician's group] notified, DON [Director of Nursing] notified, and RR [responsible party] notified. X-ray orders were obtained. Review of a Progress Note, dated 05/11/22 at 8:50 AM and located in the Progress Note tab of the EMR, documented X-ray results received via fax. Results state suspected fibular [bone of the lower portion of the leg] fracture. Notified DON, On-call, and RR. Order to send resident out to ER [emergency room ] for further evaluation. Resident sent to [name of hospital] ER. Review of the ER Progress Note, located in R24's paper chart and dated 05/11/22 at 1:03 PM, revealed the orthopedic surgeon documented Consult received: Right tibial [shin bone] plateau fracture and right radial head fracture. Patient to be admitted by hospitalist. Awaiting CT scan of right tibia. We will see patient for formal consult in a.m. Review of hospital Therapy Notes, dated 05/12/22 at 1:34 PM and located in R24's paper chart, documented [resident's name] is currently requiring total A [assist] for mobility with limited tolerance due to increased pain. Pt is conversant with PT and responding to questions however pt. is confused with PMH [past medical history] of dementia. Pt with recent fall at LTC [long term care] facility .Pt appears to have contractures [fixed deformity of a joint] of BLE [bilateral lower extremities] but unsure if this positioning is more related to recent fall and R [right] LE [lower extremity] fractures versus pt. being w/c [wheelchair] bound/bed bound at facility .Pt unable to perform any AROM [active range of motion exercises] or tolerate any PROM [passive range of motion] of LE [lower extremity] at this time secondary to increased pain. During an interview on 06/29/22 at 12:16 PM, LPN1 said R24 had always been a one person check and change (checking for incontinence and changing the brief). During an interview on 06/29/22 at 6:13 PM, Certified Nursing Assistant (CNA)3 said she was providing care on 05/11/22 when R24 rolled out of the bed. CNA3 said she had worked at the facility for two years and was familiar with R24. CNA3 said she was comfortable turning and repositioning R24 in the bed by herself. During an interview on 06/29/22 at 1:02 PM, the DON stated she was not aware R24 was assessed as a two-person extensive assist for bed mobility. The DON confirmed R24 should have been turned using two CNAs and it should have been addressed in the care plan. The DON said the care plans are developed offsite, making it very difficult. Cross Reference: F689 Accident Hazards, Supervision, and Devices.

Based on policy review, observation, interview, and record review, the facility failed to provide care in a manner that prevented injuries for 1 Resident (R) 24 of 6 residents reviewed for falls/accidents in a total sample of 12 residents. R24 was rolled onto her side away from the staff caring for her and continued to roll off of the bed onto the floor. This resulted in harm to R24 who sustained broken bones in her leg, a hospitalization of nine days, and functional limitations of movement and mobility. Findings include: Review of the undated facility policy titled, Condition Change of the Resident, documented the procedure to be .After all resident falls, possible injuries, or changes in physical or mental function .7. Monitor resident's condition frequently until stable. 8. Document assessment observations in medical record. Review of R24's Medical Diagnosis, located in the Medical Diagnosis tab of the electronic medical record (EMR), documented an admitted [DATE] with diagnoses which included unspecified dementia without behaviors, dysphasia (swallowing difficulties) and long-term use of anticoagulants related to blood clots. Review of the annual Minimum Data Set (MDS), located in the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 04/26/22 indicated R24 required extensive assistance of two people for bed mobility. R24 had a Brief Interview for Mental Status (BIMS) score of two out of 15 indicating severely impaired cognition, had no functional limitations to the upper or lower body, and used a wheelchair for mobility. Review of R24's Care Plan, revised on 04/11/22 and located in the Care Plan tab of the EMR, documented has bowel incontinence .Provide peri care, and/or assistance after each incontinent episode. Review of R24's Care Plan, revised on 04/15/22 and located in the Care Plan tab of the EMR, documented, has potential for impairment to skin integrity, impaired mobility, dependent staff transfer help. Review of all care plans prior to the accident on 05/10/22, revealed no care plan in place for two-person assistance for ADLs or bed mobility for R24 even though the MDS with an ARD of 04/26/22 assessed her as requiring extensive assistance of two staff for bed mobility. Review of a Progress Note, dated 05/10/22 at 7:15 PM and located in the Progress Note tab of the EMR, revealed Licensed Practical Nurse (LPN)1 wrote Nursing staff was in room with patient providing ADL[activity of daily living] care, during care patient turned onto right side, brief was being placed onto patient, patient started to move and started to roll off the bed, Nursing staff was able to assist patient by lowering her to the floor safely. Patient was assisted back into the bed by two staff members. Patient c/o pain in right knee currently, on call from [name of physician's group] notified, DON [Director of Nursing] notified, and RR [responsible party] notified. X-ray orders were obtained. Review of the Radiology Report, dated 05/11/22 and located in the Forms tab of the EMR, revealed the x-rays were obtained on 05/10/22 but does not document a time. Review of the Change in Condition Evaluation-V5.1, dated 05/10/22 at 7:21 PM and located in the Forms tab of the EMR, documented R24 had a pain level of nine out of 10 in the right knee. Review of the EMR Orders tab revealed a physician's order current on 05/10/22 for Tylenol 325 mg (milligrams) two by mouth every six hours as needed for pain. Review of the Medication Administration Record (MAR), located in the Orders tab of the EMR, revealed the nursing staff did not administer any pain medication to R24 after the accident with a documented pain level of nine. Further review of the Progress Notes revealed Licensed Practical Nurse (LPN) 3, working the night shift from 7:00 PM on 05/10/22 until 7:00 AM on 05/11/22, failed to document any monitoring of R24 during the night. Further review of the MAR revealed LPN3 made one entry on the MAR and documented a pain level of zero on 05/10/22, but nothing related to accident. LPN2 documented on the MAR on 05/11/22 at 8:25 AM, R24's pain level was a five out of 10 and administered two 325 mg of Tylenol. Review of a Progress Note, dated 05/11/22 at 8:50 AM and located in the Progress Note tab of the EMR, documented X-ray results received via fax. Results state suspected fibular [bone of the lower portion of the leg] fracture. Notified DON, On-call, and RR. Order to send resident out to ER [emergency room ] for further evaluation. Resident sent to [name of hospital] ER. Review of the ER Progress Note, located in R24's paper chart and dated 05/11/22 at 1:03 PM, revealed the orthopedic surgeon documented Consult received: Right tibial [shin bone] plateau fracture and right radial head fracture. Patient to be admitted by hospitalist. Awaiting CT scan of right tibia. We will see patient for formal consult in a.m. Review of the hospital MAR, located in R24's paper chart and dated 05/11/22, revealed R24 was administered 50 mg of [MEDICATION(S)] for moderate pain on 05/11/22 at 7:02 PM and 1 mg of [MEDICATION(S)] IV (intravenous) on 05/12/22 at 2:23 AM. Review of the Hospitalist Progress Note, located in R24's paper chart and dated 05/12/22 at 10:28 AM, documented, Orthopedics has recommended non-operative for right tib/fib fractures .Niece is aware expected poor prognosis with prolonged bedrest but will help and plan for the best. Goal of hospital stay next few days is titration of analgesic support/IV hydration-with current analgesia patient's oral intake is poor to negligible. Review of hospital Therapy Notes, dated 05/12/22 at 1:34 PM and located in R24's paper chart, documented [resident's name] is currently requiring total A [assist] for mobility with limited tolerance due to increased pain. Pt is conversant with PT and responding to questions however pt. is confused with PMH [past medical history] of dementia. Pt with recent fall at LTC [long term care] facility .Pt appears to have contractures of BLE [bilateral lower extremities] but unsure if this positioning is more related to recent fall and R [right] LE [lower extremity] fractures versus pt. being w/c [wheelchair] bound/bed bound at facility .Pt unable to perform any AROM [active range of motion] or tolerate any PROM [passive range of motion] of LE [lower extremity] at this time secondary to increased pain. Review of the Hospitalist Discharge Summary, located in R24's record and dated 05/19/22, documented Hospital Course: Patient found to have multiple fractures proximal tib/fib right knee .Fortunately all were nondisplaced [in alignment] .Orthopedic recommended nonsurgical intervention and no need for stabilization. Review of the significant change MDS with an ARD of 06/01/22, located in the MDS tab of R24's EMR, documented after returning to the facility on [DATE], R24 required extensive assistance with two people for bed mobility, had functional limitations on both sides of her lower body, and had not used a wheelchair. During an interview on 06/28/22 at 9:58 AM, Family Member (FM)1 stated the family was told the CNA dove over the bed and holding onto the resident's nightgown, and gently lowered R24 to the floor. During a phone interview on 06/28/22 at 6:31 PM, FM2 stated the Executive Director told her there was one CNA doing care and rolled her away from her, the bed did not have rails, and the resident kept going, and rolled onto the floor. FM2 said the facility told her the CNA dove across the bed and held her by the nightgown and gently rolled her to the floor. FM2 stated she did not receive a phone call from the facility about the fall until the next day, more than 14 hours later. FM2 said when she got to the hospital ER, R24 was in intense pain, and receiving [MEDICATION(S)]. During an interview on 06/29/22 at 12:16 PM, LPN1 stated she was working on the unit when CNA3 called her into R24's room. LPN1 stated R24 was lying on the floor in her room, by the bed, on her right side and CNA3 told her R24 rolled off of the bed while changing her brief. LPN1 said they picked R24 up off of the floor and put her into the bed. LPN1 stated R24 began complaining of pain in her right leg. LPN1 said R24's knee looked swollen and discolored. LPN1 stated she called the on-call Nurse Practitioner (NP), who ordered x-rays. LPN1 said the NP wanted to get the results of the x-ray before sending R24 to the hospital. LPN1 said R24 had always been a one person check and change (checking for incontinence and changing the brief). LPN1 said there were no side rails on the resident's bed at the time of the accident. The NP was not available for interview, as the company providing medical services at the time of the accident is no longer contracted with the facility. During an interview on 06/29/22 at 1:02 PM, the DON stated she was not aware R24 was assessed as a two-person extensive assist for bed mobility and transfers prior to the accident on 05/10/22. The DON confirmed R24 should have been turned using two CNAs and it should have been addressed in the care plan. The DON also confirmed before the accident the facility did not have a policy for turning and position residents in bed. The DON stated at the time of the accident the facility did not allow any bedrails. The DON confirmed on 06/29/22 at 3:48 PM, LPN3 (the night shift nurse) failed to document any monitoring of R24 post-accident, and her expectation was for the nurses to document and monitor residents frequently after an accident with injury. During an interview on 06/29/22 at 6:13 PM, CNA3 said she was providing care on 05/11/22 when R24 rolled out of the bed. CNA3 said she had worked at facility for two years and was familiar with R24. CNA3 said she was comfortable turning and repositioning R24 in the bed by herself. CNA3 stated as she went to turn R24 to get her ready for bed, the resident had a bowel movement. CNA 3 said when she pulled the gown out from under R24, R24 started to roll off of the side of the bed. CNA3 stated she leaned over the bed, grabbed the gown, and lowered R24 to the floor. CNA3 stated she asked the resident if she was okay and R24 replied, get me off of the floor, I am cold. CNA3 said she covered R24 with a blanket and went to get the nurse. During a phone interview on 06/29/22 at 6:22 PM, CNA4 stated she worked the night shift on 05/11/22 and was assigned to care for R24. CNA4 stated R24 slept during the night. CNA4 stated R24 was always in pain and did not notice anything out of the ordinary. CNA4 stated R24 did not scream or moan or favor her knee and that the nurse checked on her multiple times during the night. During an interview on 06/30/33 at 9:06 AM, CNA5 stated she was assigned to R24 on the morning of 05/11/22. CNA5 said when she completed her morning rounds, R24 was asleep. Shortly after she arrived, R24 was sent to the hospital. CNA5 stated night shift had already dressed her for the day. During a phone interview on 06/30/22 at 2:22 PM, LPN2 said R24 was in pain when she arrived on duty the morning of 05/11/22 and she gave her Tylenol. LPN2 said the imaging company faxed the x-ray results to the facility and she notified the on-call physician. R24 was then transported to the hospital at 9:35 AM on 05/11/22.

Based on policy review, observation, and interview, the facility failed to ensure that 1 of the 2 dumpsters were kept closed to keep pests out and/or to keep the garbage contained in the dumpsters. The facility also failed to ensure the area around the dumpster was clean and free of debris and failed to ensure the other dumpster was clean. This failure had the potential to cause insects and rodents near the dumpster, which could potentially be a health hazard. Findings include: Review of the policy Disposal of Garbage/Rubbish, dated 05/02/21 provided by the Executive Director documented .All garbage and rubbish containing food wastes will be kept in container .Garbage and rubbish containing food wastes will be stored in such a way that it is inaccessible to vermin. Storage areas will be always kept clean. Outside dumpsters provided by garbage pickup services will be kept closed and the surrounding area will be kept free of litter . Observation and interview with the Maintenance Director (MD) on 06/29/22 at 12:15 PM revealed the dumpster used for garbage and trash had a missing door, thus exposing the trash inside the dumpster. The Maintenance Director said the door had not been on the dumpster for the past four to five months. He stated he notified the contracted dumpster company approximately one month ago regarding the missing door and had not heard from the company. MD verified that the dumpster was missing a door that was to be closed unless staff were emptying trash/garbage or the company was emptying the dumpster. Further observations revealed used papers, cigarette butts, and a plastic bag with a used brief and other items on the ground next to the dumpster. MD stated the items must have tumbled out of the dumpster through the open door. The Maintenance Director said the staff smoke in that area and are not supposed to leave their cigarette butts on the ground. Observed next to the dumpster were two uncovered toilets that contained leaves and brown material, a sofa, and a chair. The Maintenance Director said these items had been outside for the past month and he was trying to get another dumpster, as they were not allowed to place those items in the current dumpster. Further observation revealed a dumpster that contained used grease from the kitchen. There was a moderate amount of built-up black grease piled around the outside of the dumpster opening. The inside of the dumpster contained black grease that filled 1/2 of the dumpster. During observation and interview on 06/30/22 at 9:09 AM, the Dietary Manager (DM) stated one dumpster contained the facility's garbage and the other contained the grease from the fryer used in the kitchen. In addition to confirming the above observations, two used masks and two empty water bottles were on the ground near the dumpster. The DM verified the area around the dumpsters was not clean and stated when the dumpster was emptied or near full, items could spill out from the opening, where the door was supposed to be. The Dietary Manager stated the grease build up around the grease dumpster was from spillage when emptying the fry grease into the dumpster. During an interview on 06/30/22 at 9:10 AM, the Executive Director stated everyone who brings trash to the dumpster was responsible for keeping the area around the dumpster clean. He stated the overall responsibility of maintaining the area around the dumpsters was the Maintenance Director. The Executive Director stated he observed the area on 06/29/22 and verified there was no door on the dumpster and the area needed to be cleaned.

Based on policy review, record review, observations and interviews, the facility failed to ensure that 2 residents, Resident (R)14 and R22, of 3 residents reviewed for provision of activities of daily living (ADL) out of a total sample of 12 residents, received appropriate grooming, specifically related to the removal of facial hair. Failure to remove facial hair for a resident could result in a decrease in body image, depression, and isolation. Findings include: Review of the Shaving the Resident policy, dated 05/22/21, revealed it was the basic responsibility of the licensed nurse, Certified Nursing Assistant (CNA) .to remove facial hair to improve the resident's appearance and morale . 1. Review of R14's Face Sheet, located in the electronic medical record (EMR) under the Face Sheet tab, indicated R14 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R14's annual Minimum Data Set (MDS) located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 05/10/22, revealed a Brief Interview for Mental Status (BIMS) score of zero out of 15, which indicated R14 had severely impaired cognition. R14 was assessed as exhibiting physical behavior symptoms directed toward others, which did not include resisting and/or rejecting care. R14 was dependent on staff for personal hygiene, including shaving. Review of R14 Care Plans, dated 04/26/21 and located in the EMR under the Care Plan tab, revealed R14 required assistance with ADLs. Observation of R14, who was sitting in her wheelchair in the day room next to the nurses' station on 06/28/22 at 3:27 PM and on 06/29/22 at 11:35 AM, revealed R14 had strands of white hair on her chin that measured 1/4 to 3/4 inch in length. During an interview on 06/29/22 at 1:40 PM, Licensed Practical Nurse (LPN)1 confirmed R14 had facial hair and needed to be shaved. LPN1 stated she shaved R14 last week and R14 had no behaviors while being shaved. When asked how she monitors care given to residents, LPN1 stated she usually checks residents' ADL care during rounds and when passing medications, and checks the resident if staff tell her they have an issue. LPN1 stated she would expect the CNAs to ensure the facial hair was removed during daily care and notify her if a resident refused or had behaviors while shaving. LPN1 stated none of the staff reported they had issues while shaving R14. During an interview on 06/29/22 at 12:03 PM, the Director of Nurses (DON) stated R14 is occasionally combative during personal care. The DON stated that shaving was part of the resident's daily care, and she expected staff to remove facial hair during ADL care, if the resident allowed. The DON stated she was not aware the staff had reported any concerns related to the shaving of R14 to the nurse. During an interview on 06/30/22 at 1:46 PM, CNA2 stated she is usually assigned to provide care to R14. CNA2 stated R14 was never combative during personal care, and she usually shaved R14 in the morning, if needed. 2. Review of R22's Face Sheet indicated R22 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R22's admission MDS with an ARD of 06/06/22, revealed a BIMS score of zero out of 15, which indicated R22 had severely impaired cognition. R22 was assessed as exhibiting physical and behavior symptoms directed toward others, which did not include resisting and/or rejecting care. R22 was dependent on staff for personal hygiene, including shaving, and dressing, which included how the resident puts on, fastens, and takes off all items of clothing. The Nursing Admission Data Collection, dated 05/24/22 and located in R22's EMR under the Forms tab, documented R22 had an ADL self-care performance deficit. During an interview on 06/28/22 at 2:30 PM, R22's Power of Attorney (POA) stated when R22 lived in an assisted living facility prior to this facility, he shaved R22, who always liked to be well groomed. He stated when R22 was admitted to the facility, the staff told him they would provide shaving, nail care, and other cares R22 required. He stated R22 would not like to have facial hair and would want the staff to shave her. Observation of R22 on 06/28/22 at 10:01 AM and at 3:50 PM sitting in the dayroom revealed R22 with a moderate amount of dark brown hair on her chin. Observation on 06/29/22 at 11:30 AM sitting in the dayroom revealed R22 had a moderate amount of dark brown hair on her chin. During an interview on 06/29/22 at 1:14 PM, CNA1 stated the staff were to provide personal care and hygiene to R22, which included shaving and dressing. CNA1 stated R22 was combative during shaving. CNA1 stated although frequently assigned to provide care to R22, she never shaved her as she was combative. CNA1 stated she did not notify the nurse as everyone knew R22 was combative with care and CNA1 never asked anyone else to shave R22. During an interview on 06/28/22 at 3:15 PM, LPN1 stated R22 was occasionally combative with care and the staff were to notify her if she was combative. LPN1 stated R22 was dependent on the staff for personal care, hygiene, and dressing. During further interview with LPN1 on 06/29/22 at 11:40 AM, she verified R22 had brown facial hair that needed to be shaved. LPN1 stated she shaved R22 last week and R22 was not combative. She stated the CNAs were to shave residents as needed unless contraindicated per their care plan. LPN1 stated the staff never told her they were unable to shave R22 because she was combative when they attempted to shave her. During an interview on 06/29/22 at 12:03 PM, the DON stated R22 was sometimes combative, and the staff were to notify the nurse if unable to provide care. She stated she was not aware of any issues related to shaving R22. The DON stated shaving was a part of the resident's daily care and she expected the staff to shave a resident during ADL care.

Based on interview, record review, and policy review, the facility failed to notify the resident representative in a timely manner, for an accident with change of condition for 1 resident Resident (R) 24 of 6 residents reviewed for falls/accidents. Findings include: Review of the undated policy titled Condition Change of the Resident, revealed the procedure to be Documentation guidelines .Notification of the resident's responsible party, including date and time. Review of a Progress Note documented by Licensed Practical Nurse (LPN) 1, located in the Progress Note tab of R24's electronic medical record (EMR) and dated 05/10/22 at 7:15 PM, revealed Nursing staff was in room with patient providing ADL [activity of daily living] care, during care patient turned onto right side, brief was being placed onto patient, patient started to move and started to roll off the bed Nursing staff was able to assist patient by lowering her to the floor safely. Patient was assisted back into the bed by two staff members. Patient c/o [complained of] pain in right knee currently, on call from [name of physician's group] notified, DON [Director of Nursing] notified, and RR [responsible party] notified. X-ray orders were obtained. Review of the Change in Condition Evaluation-V5/1, located in the Forms tab of the EMR and dated 05/10/22 at 7:21 PM, documented resident representative [name of representative] was notified on 05/10/22 at 7:20 PM by LPN1 about R24's accident. Review of an Incident Report, completed by LPN1 on 05/10/22 at 6:30 PM, documented patient was being changed after voiding, patient rolled onto right side, brief was being tucked under pt. Patient kept rolling and slid down, staff attempted to readjust patient with no avail, patient was lowered to ground safely, did not hit her head, c/o right knee pain. LPN1 documented the resident representative (RR) was notified on 05/10/22 at 7:15 PM and the RR responded on 05/10/22 at 7:30 PM. During a phone interview on 06/28/22 at 6:31 PM, Family Member (FM) 2, said she did not receive a phone call from the facility about R24's accident until the next day, more than 14 hours later. FM2 stated she would have come to the facility the evening of the accident if she would have known. FM2 said when she saw R24 in the ER, R24 was in intense pain, and receiving [MEDICATION(S)]. During an interview on 06/29/22 at 12:16 PM, LPN1 stated she attempted to call the family, but there was no voice mail set up to leave a message. When showing LPN1 the incident report with her signature, documenting the family responded, she said the 7:30 PM entry on 05/10/22 about the RR responding was just a second attempt to call the family. LPN1 confirmed on 06/29/22 at 12:16 PM, she did not speak to any family members about the accident. LPN1 stated she did not try to call any additional emergency contacts listed in R24's EMR. There is no documentation in the EMR of any other attempts to notify the RR until 05/11/22 at 8:50 AM when R24 was transferred to the hospital. During an interview on 06/29/22 at 11:39 AM, the Social Service Director (SSD) stated she was with the family when the Executive Director told the family what had happened. The SSD stated the RR was upset about not being called until the day after the accident. Cross Reference: F689 Free of Accident Hazards, Supervision, and Devices.

Based on record review, interview, review of facility policy and review of the facility's investigation, the facility failed to provide services that meet professional standards of quality. The deficient practice did not impact the care of any current residents. The facility investigation revealed Registered Nurse (RN) #1 diverted discontinued controlled substances from the narcotic destruction cabinet for 8 of 15 discharged residents. The findings included: Review of the facility investigation, on 10/7/21 at 10:30 AM, revealed on 9/15/21 the facility discovered a bottle of [MEDICATION(S)] [MEDICATION(S)] 100 milligrams per 5 milliliter solution was missing from the narcotic destruction cabinet. The [MEDICATION(S)] sulfate had been prescribed to Resident 8, who had recently passed away. The facility conducted an audit of of the narcotic destruction cabinet, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #1, who was the Director of Nursing (DON), was the only staff person with a key to the narcotic destruction cabinet. Per the facility investigation, RN #1 was interviewed on 9/16/21 and admitted to taking the [MEDICATION(S)] [MEDICATION(S)] and many other controlled substances from the narcotics destruction cabinet. The facility investigation contained a handwritten statement signed and dated by RN #1 on 9/16/21. The statement indicated RN #1 took discontinued controlled substances from the narcotics destruction cabinet. After completing the investigation, RN #1 was terminated for misconduct/stealing narcotics and violating Nurse Practice Act and Ethics. During an interview with Licensed Practical Nurse (LPN) #1, on 10/7/21 at 10:45 AM, LPN #1 stated all of the diverted medications were taken from the narcotics destruction cabinet. All of the medications diverted were taken after the residents had discharged from the facility or had the medication discontinued by the provider. LPN #1 stated that when a resident is discharged , any narcotics remaining are signed off by two nurses to be destroyed. The count is verified and the medication and count sheet are given to the Director of Nursing, who then places the medication in the locked narcotics destruction cabinet. LPN #1 stated as a result of this incident, the narcotics destruction policy had been revised with stricter control over discontinued narcotics. LPN #1 stated Drug Control authorities have also been investigating this incident and it appears none of the diverted medications were taken from any residents with active orders. LPN #1 provided audit results indicating which medications were diverted from the narcotics destruction cabinet. Record review of the Discharge Report from 7/12/21-9/21/21 and Order Summary Report, on 10/7/21 at 12:33 PM, confirmed all diverted medications were taken from residents who discharged from the facility or had the medication discontinued by the provider. Review of facility Pharmacy polices revealed pharmacy comes to the facility at least every 90 days to pick up discontinued controlled substances for destruction. Review of the revised Narcotics Control Safe policy revealed the narcotics destruction cabinet could only be accessed by 2 qualified staff and an inventory must be completed by the 2 staff persons each time the cabinet is accessed. The Executive Director has control of the key to the secured cabinet located in the medication room, but does not have a key to the medication room.

Based on interview and record review, the facility failed to prevent accident hazards for 1 of 3 residents reviewed for quality of care and neglect. Resident #1 fell during care because their mattress and bed were not the same size. Interviews with staff and administration confirmed it was the facility's responsibility to ensure resident mattresses and beds are compatible, to protect residents from accidents. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including but not limited to unspecified dementia without behavioral disturbance, [CONDITION(S)], and unspecified open wound of the left lower extremity. Review of Resident #1's incident reports on 4/8/21 at approximately 11:30 AM revealed that on 3/15/21 at around 11 AM, two certified nursing aides (CNAs) were providing care to the resident. The mattress slipped off the bed, and the resident rolled out and hit their forehead. The facility's intervention was to ensure that the resident's mattress was appropriately sized. Interviews with Director of Clinical Services, Admissions Director, and Associate Executive Director on 4/8/21 at approximately 11:45 AM confirmed Resident #1 had a mattress that was larger than the bed frame. All the mattresses in the beds are bariatric, and the resident's bed lacked extender rails that run beneath the bed to widen it, supporting the mattress. The standard in the facility is for a bariatric mattress to be on a bariatric bed with extenders. Admissions and maintenance are supposed to ensure that extenders are appropriate for the mattress and bed. Review of Physical Environment policy on 4/8/21 at approximately 12 PM revealed that the facility must provide A clean, comfortable mattress. Conduct regular inspection of all bed frames, mattresses and bed rails to identify areas of possible entrapment. The facility must ensure that bed rails, mattresses and bed frames are compatible if bed rails are and mattresses are used and purchased separately from the bed frame. Interview with CNA #1 on 4/8/21 at approximately 12:36 PM confirmed that if the mattress had not been larger than the bed frame, the resident likely wouldn't have fallen. The CNA did not know when performing care that the mattress was inappropriately sized, as there was no way to tell from just looking at the bed. CNA #1 also revealed that after Resident #1 fell , they were shaken up and bleeding. The resident did not require stitches or bandages. There were no neurological changes. Interview with CNA #2 on 4/8/21 at approximately 12:40 PM confirmed the mattress was too big for the frame. This was not immediately apparent when performing care. Because there were no extensors on the bed for the larger mattress, the resident fell from the bed. CNA #2 assumed maintenance was supposed to make sure mattress and bed fit, although now the CNA double checks before providing care. After Resident #1 fell , they were shaken up and quiet. The resident was upset at first, but after being cleaned, the resident was in better spirits and joking about the incident. To the CNA's knowledge, the resident did not need stitches or bandages. There were no noticeable cognitive or neurological changes in the resident because of the incident. Review of Accidents policy on 4/8/21 at approximately 1 PM revealed the following: 1. The facility must make sure the resident's environment remains as free from accident hazards as is possible. 2. The intent of this policy is to ensure that this facility provides an environment that is free from accident hazards over which the facility has control.

Based on observation and interview, the facility failed to properly store and label food items in both walk-in cooler and walk-in freezer . During the initial tour of the kitchen with the Associate Director of Dining on [DATE] at 10:35 am, a bag of havarti cheese cubes and swiss cheese was identified with expiration date of [DATE], grated parmesean cheese, expiration date [DATE], a bag of catfish filets, expiration date [DATE], and a bag of potato wedges, expiration date [DATE]. The tour also identified a bag of beef hamburger patties, fried okra and a bag of chicken fritters in the walk-in freezer without a date or labeled when the items were opened. A interview with Associate Director of Dining confirmed the havarti cheese cubes, swiss cheese cubes, grated parmesean cheese, bag of catfish filet, and bag of potato wedges had expired. S/he also confirmed the beef hamburger patties, fried okra, and bag of chicken fritters were stored without a date and labeled when the items were opened. A follow-up visit to the dry storage room on [DATE] at 11:30 AM with the Director of Dining, identified a pack of hamburger buns with a mold-like substance stored on the bread rack in the dry storage room. An interview with Director of Dining confirmed the hamburger buns were molded. Review of the facility's policy on Storage of Food in Refrigeration stated, 1. Fresh fruits, vegetables, eggs, cheeses and other perishable items will be stored in refrigeration of at 41 degrees F or below. 2. Store raw meats on the bottom shelves to prevent contamination of other perishable items. 3. Food being returned to storage after cooking or preparation must be covered. 4. All containers must be labeled with the contents and date food items was placed in storage. 5. Previously cooked foods can be held in refrigeration of 41 degrees F or lower for up to 3 days and then must be discarded. 6. Food items that remain sealed from the supplier may be held until the expiration date of unopened items.

Based on observation, interview and review of facility policy, the facility failed to ensure medication storage areas were free of expired medications. Expired medications were observed in 1 of 1 medication storage rooms and 1 of 3 medication carts. The findings included: Observation of the facility's medication storage room, on 1/6/2021 at 9:44 AM, revealed 1 container of Geri-Care Vitamin B1 100 milligram (mg) tablets with an expiration date of February 2020, 1 container of Geri-Care Vitamin B12 100 microgram (MCG) tablets with an expiration date of February 2020, and 3 containers of Geri-Care Vitamin D 400 International Units (IU) tablets, each with an expiration date of August 2020. In addition, observation of refrigerated medications in the storage room revealed 1 bottle of FIRVANQ ([MEDICATION NAME]) for oral solution 50 mg per milliliter with an expiration date of 1/1/2021. During an interview with the Director of Nursing (DON), on 1/6/2020 at 9:50 AM, the DON confirmed the medications were expired. The DON stated nurses were to check the medication storage room for expired medications, along with the supply clerk responsible for restocking the vitamins and other House Stock medications. The DON stated expired medications are to be destroyed per policy. The DON provided documentation indicating the FIRVANQ had not been administered since 12/23/2020. Observation of the A Hall medication cart, on 1/6/2020 at 10:09 AM, revealed a 30 count punch card of [MEDICATION NAME] 1 mg tablets belonging to Resident #1 with an expiration date of 8/31/2020. In addition, a 15 count and a 30 count punch card of [MEDICATION NAME] 0.5 mg tablets belonging to Resident #3 was observed with expiration dates of 8/31/2020. During an interview with Licensed Practical Nurse (LPN) #1, on 1/6/2021 at 10:09 AM, LPN #1 confirmed the medications were expired. LPN #1 stated it was the responsibility of her/himself and the other nurses to ensure the medication carts were free of expired medications. Review of the facility's Storage of Medications policy revealed No discontinued, outdated or deteriorated medications are to be used for use in this facility. All such medications are destroyed according to facility policy. Record review revealed Resident #1 had not received any of the expired [MEDICATION NAME]. Resident #3 had received 1 dose of the expired [MEDICATION NAME]. Resident #3 was sampled and reviewed with no adverse effects noted from being administered expired [MEDICATION NAME].

Based on record review and interviews, the facility failed to provide a documented rational for continued use of as needed (PRN) [MEDICAL CONDITION] medication ([MEDICATION NAME]) beyond 14 days for Resident #3. Resident #3 Medication Administration Record [REDACTED]. [MEDICATION NAME] was given per MARS on 8/11/2020 through 8/14/2020 and 8/16/2020 without written orders. (1 of 5 sampled residents reviewed for unnecessary medications). The findings included: The facility admitted Resident #3 on 10/05/2018 with [DIAGNOSES REDACTED]. A review of the medical record on 1/06/2021 at approximately 2:05 PM revealed a PRN order for [MEDICATION NAME] at 0.5 mg (milligrams) every two hours as needed for agitation on the computerized MARS for 7/23/2020 to 9/08/2020. There was no written documentation to indicate why the order should be written beyond 14 days. The August 2020 MAR indicated [REDACTED]. An interview and review of the MAR for August 2020 on 1/7/2021 at approximately 9:52 AM with Director of Nursing (DON) confirmed the computerized PRN order for 7/23/2020 to 9/08/2020 and stated there was no documentation to indicated the use of the PRN medication beyond the 14 days. The DON further confirmed the PRN [MEDICATION NAME] was given 8/11/2020 through 8/14/2020 and 8/16/2020 without a written physician's orders [REDACTED]. An interview on 1/07/2021 at approximately 10:04 AM with the DON revealed he/she had contacted hospice services related the PRN [MEDICATION NAME] Order. Later during the morning, the hospice nurse wrote a physician's orders [REDACTED]. An interview on 1/07/2021 at approximately 11:04 AM with the DON who provided written documentation of the August 2020 PRN [MEDICATION NAME] order being written today.

Based on record review and interviews, the facility failed to provided documented medically social services that addressed the resident's mental and psychosocial well being at least on a quarterly bases. Resident #3 and #18 received psych medication with no documented social services interactions with the resident. (2 of 5 resident reviewed for unnecessary medications). The findings included: The facility admitted Resident #3 on 10/05/2018 with [DIAGNOSES REDACTED]. A review of the medical record on 1/06/2021 at approximately 2:05 PM revealed social services notes from 3/2020 to present. There were no documented social services notes related to any interactions with resident since 3/17/2020. There were social services notes from 4/2020 to present to indicated multiple contacts were made with family members. Resident #3 had social services notes dated 6/01/2020 and 6/30/2020 about a room change being address with family. There was no documentation in the medical record to determine if the room change was addressed with the resident. The facility admitted Resident #18 on 9/11/2020 with [DIAGNOSES REDACTED]. A review of the electronic medical record on 1/07/2021 at approximately 8:14 AM revealed social notes from 9/14/2020 to present. There were no documented social services notes related to any interactions with the resident since an admission assessment being completed on 9/11/2020. There were multiple documented social notes of the facility's interaction with family members. Resident #18 had social services notes dated 9/16/2020, 9/21/2020 and 9/24/2020 about a room change being addressed with family. There was no documentation in the medical record to determine if the room change was addressed with the resident. An interview on 1/07/2021 at approximately with the Social Services Director (SD) confirmed that he/she did not have documentation of interactions regarding Resident #3 and Resident #18. The SD further acknowledged that documentation of contact with family members would infer that resident contact was made.

Based on record review and interviews, the facility failed to ensure that a resident's medical record was accurately documented for medications given. Resident #18 electronic medical record was not accurately documented related what route medication should be given as ordered. (1 of 5 residents reviewed for unnecessary medications). The findings included: The facility admitted Resident #18 on 9/11/2020 with [DIAGNOSES REDACTED]. A review of the electronic medical record on 1/07/2021 at approximately 8:14 AM revealed that resident had an order for [REDACTED]. An interview and review of the electronic medical record on 1/07/2021 at approximately 9:29 AM with the Director of Nursing (DON) and Registered Nurse (RN) #1 revealed the [MEDICATION NAME] medications was discontinued on 11/24/2020 but a written order could not be located. A follow up interview on 1/07/2021 at approximately 10:47 AM with the DON and RN #1 revealed the order to discontinue the [MEDICATION NAME] still could not be located. A review of the January 2021 Monthly physician's orders [REDACTED].#18 was still receiving Trazadone at 50 mg at bedtime. An interview on 1/07/2021 at approximately 11:16 AM with RN #1 revealed after looking through the electronic Medication Administration Record [REDACTED]. RN #1 stated the resident's medication for [MEDICATION NAME] changed from being given by gastrointestinal tube to being given by mouth. RN #1 stated there was no written physician's orders [REDACTED].

Based on record review and interviews, the facility failed to ensure that a resident was given the opportunity to formulate his/her own advance directive for Do Not Resuscitate (DNR). Resident #9 advance directive for DNR was not signed by the resident and there was no documentation by physicians to determine the resident could not make health care decisions. (1 of 16 initial pool residents reviewed for advance directives). The findings included: The facility admitted Resident #9 on 3/16/2018 and re-admission on 9/29/2020 with [DIAGNOSES REDACTED]. A review of the medical record on 1/05/2021 at approximately 12:13 PM revealed the resident had an advance directive for DNR that was not signed by the resident. An interview on 1/06/2021 at approximately 12:29 PM with the Director of Nursing (DON) and Social Services Director (SSD) revealed the resident did not sign his/her advance directive for DNR due to the not being able to make that decision. The DON and SSD further confirmed they could not locate the statement signed by a physician that determined the resident did not have decisional capacity.

Based on observation, interview, record review, and review of facility policies, the facility failed to ensure two of 17 sampled residents (Resident #4 and Resident #12) received adequate supervision and appropriate care to prevent harm. Resident #4 suffered a fall with the harm of a [MEDICAL CONDITION] when left unattended for toileting. Resident #12 suffered the harm of a dislocated hip which required surgical intervention related to the improper use of a mechanical lift. The failure to provide necessary supervision and the provision of safe care has the potential to affect any resident who requires supervision to prevent falls and the use of a mechanical lift for care. Findings include: 1. A review of Resident #12's Face Sheet in the electronic medical record (EMR), indicated Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. A review of Resident #12's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/27/19, specified a Brief Interview for Mental Status (BIMS) could not be completed by Resident #12 and was scored as 99 which meant Resident #12 was severely cognitively impaired. The assessment documented Resident #12 was totally dependent on two facility staff for bed mobility. A review of Resident #12's Care Plan problem dated, 04/25/19, indicated Resident #12 had deficits related to performing activities of daily living (ADLs) due to weakness, immobility, pain and musculoskeletal deficit. The Care Plan listed interventions dated 06/19/19 required the use of a mechanical lift and two staff while transferring the resident. Review of the facility reported investigation (FRI), dated 06/11/19, revealed Resident #12's orthopedic physician reported to the facility that Resident #12 had a dislocated left hip, discovered during an outpatient visit. The incident report indicated Resident #12 was weighed by CNA #1 on 06/10/19 at approximately 1:00 PM using a mechanical lift. In addition, the facility's investigation revealed CNA #1 failed to request additional assistance with the use of the lift to weigh Resident #12. The facility's investigation further revealed CNA #4 witnessed CNA #1 using the mechanical lift without assistance. According to the facility's investigation, Resident #12 was directly admitted to the local hospital from the orthopedic physician's office for repair of the dislocated left hip and was readmitted to the facility on [DATE]. The written statement of CNA #1 revealed the CNA admitted to improperly using the mechanical lift to weigh Resident #12 and the facility retrained CNA #1 on the proper use of a mechanical lift requiring return demonstration and CNA #1 received written disciplinary action from the facility. Observations throughout the three-day survey dates of 08/25/20 through 08/27/20 of residents with the same type of [DIAGNOSES REDACTED]. Resident #12 no longer resided in the facility therefore could not be observed. On 08/26/20 at 9:48 AM, an interview was conducted with the CNA #1. CNA #1 recalled the incident with Resident #12 and stated he/she was weighing the resident on 06/10/19. CNA #1 admitted he/she used the mechanical lift without requesting assistance from additional staff. On 08/26/20 at 10:00 AM, an interview was conducted with CNA #4. CNA #4 recalled the incident involving Resident #12 and CNA #1. CNA #4 stated he/she witnesses CNA #1 weighing Resident #12 using a mechanical lift and recalled Resident #12 having visible pain. An interview with a CNA #3 on 08/26/20 at 9:27 AM stated CNAs were provided training on safety of resident transfers and care of residents with cognition impairment. CNA #3 stated mechanical lifts were often used to weigh residents when a resident needed assistance with bed mobility. CNA #3 further stated using mechanical lifts required two facility staff. On 08/26/20 at 11:15 AM an interview was conducted with the Administrator. The Administrator stated Resident #12 had chronic problems related to the left hip joint replacement. The Administrator confirmed CNA #1 should have requested additional assistance when using the mechanical lift to weigh Resident #12. The Administrator stated CNA #1's work history indicated CNA #1 was reliable with providing good care to residents at the facility and the facility chose to re-educate CNA #1 on the proper use of mechanical lifts and provide CNA #1 with formal, written disciplinary action due to the outcome of improperly operating the mechanical lift. Review of the facility policy, Mechanical/Assistive Lifts, dated revised 09/2017, stated the use of mechanical lift equipment should be used, according to the manufacturer's guidelines. Review of the manufacturer's guidelines for the facility's mechanical lift titled, lnvocare Reliant 450 RPL450-2/lnvocare Reliant 600 RPL600-2 Battery Powered Patient Lift User Manual, dated 2018, stated, lnvacare recommends that two assistants be used for all lifting preparation and transferring to/from procedures. Example one is related to SC 194. 2. A review of Resident #4's Face Sheet in the electronic medical record (EMR), indicated Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #4's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/22/19, specified a Brief Interview for Mental Status (BIMS) was completed and Resident #4 scored a five out of 15 which meant Resident #4 was severely cognitively impaired. The assessment documented Resident #4 was totally dependent on staff assistance of one to two for activities of daily living (ADL) specifically transfers and toileting. A review of Resident #4's Care Plan problem dated, 11/15/19 Resident #4 was assessed to be at risk for falls, with a goal to not sustain serious injury through the next review date. One of the listed interventions dated 11/15/19 was for staff to ensure the resident's call light was in reach, encourage the resident to use the call light for assistance and the resident would need prompt staff response to all requests for assistance. Another listed intervention dated 12/05/19 was for staff to ensure the resident remained in the common area when out of bed for increased supervision. The Care Plan problem dated, 11/15/19 Resident #4 was assessed to have a self-care performance deficit related to weakness, impaired balance and decline in activity tolerance and would require staff assistance throughout the day. One of the listed interventions was that Resident #4 would require staff assistance with toileting, peri care and brief placement. Review of the facility reported investigation (FRI), dated 01/04/20, revealed Resident #4 had a fall with injury on 01/04/20 at approximately 12:35 PM. The incident report indicated Resident #4 was assisted to the bathroom and onto the toilet from the wheelchair. The staff member then left Resident #4 unattended and when returning discovered Resident #4 was on the floor next to the toilet with his/her head resting against the wall and had stated, I hit my head. When staff were post fall assessing Resident #4 for injury, Resident #4 complained of pain to the right hip. Resident #4 was sent to the emergency room for further evaluation. Resident #4 was admitted with a left femur fracture and did not return to the facility post-surgery. Documented on the FRI, Resident #4's prior level of condition was documented as being alert to self only and would wheel self about the facility. Review of the hospital records for Resident #4 dated 01/04/20, revealed Resident #4 was evaluated with x-rays and was admitted for an intertrochanteric [MEDICAL CONDITION] femur. Review of the statement from the staff member involved in the incident dated 01/04/20 and again on 01/06/20 revealed on 01/04/20 at approximately 12:35 PM, Resident #4 was taken to the bathroom via wheelchair to be assisted to the toilet by the Certified Nursing Assistant (CNA) prior to dinner. The CNA assisted Resident #4 to the toilet and after that the CNA stepped out of the room to take meal tickets to the dining room. The CNA stated, within a few seconds the CNA was told by the nurse that Resident #4 had fallen off the toilet and was in the floor. Upon evaluation of Resident #4, he/she complained of hip and leg pain. Observations throughout the three-day survey dates of 08/25/20 through 08/27/20 of residents with the same type of [DIAGNOSES REDACTED]. Resident #4 no longer resided in the facility therefore could not be observed. An interview with the CNA involved in the incident was not able to be obtained. The CNA no longer worked in the facility and an attempt was made to contact the CNA with no success. The staff involved in the incident were no longer employee by the facility and were unavailable for interview. An Interview with a CNA #3 on 08/26/20 at 9:27 AM revealed that CNA #3 had worked at the facility and been a CNA for many years. CNA #3 stated CNAs were provided training on safety of resident transfers and care of residents with cognition impairment. CNA #3 stated, when transferring residents to the bathroom, keeping them safe was the first priority. CNA #3 stated residents with cognition impairment should not be left alone in the bathroom nor would a resident with severely impaired cognitive status be able to remember to call for assistance. CNA #3 stated, the CNA task located in the computer would provide information on the type of assistance a resident would need and if in doubt the CNA should ask the charge nurse. Interview with the Administrator on 08/27/20 at 5:40 PM revealed the Administrator confirmed the care plan intervention dated 11/15/19 of encouraging Resident #4 to call for assistance would not be an appropriate intervention due to Resident #4's cognitive status. The Administrator confirmed Resident #4 should have been supervised during the assisted toileting. The Administrator stated the CNA involved had no prior history of discipline related to resident care, however, the facility chose to give the CNA a written warning along with re-education due to the outcome of the fall. Example two is related to SC 161.

Based on observation, interview, and record review the facility failed to ensure two of three residents (Residents #6 and Resident #13) were free of significant medication errors. Resident #6 failed to receive timely administration of an intravenous (IV) antibiotic which resulted in the harm of a decline in his/her health requiring transfer to a hospital. Resident #13 was prescribed a steroidal medication that was to be given in a taper and end in a set number of days however the facility transcribed the physician's order incorrectly and the resident received 91 doses of the medication instead of 13 as ordered. Findings include: 1. Review of Resident #6's electronic medical record (EMR) revealed she/he had been admitted for therapy after a hospital stay for a hypoglycemic (low blood sugar) episode and while in the emergency room had a [MEDICAL CONDITION]. She/he had [DIAGNOSES REDACTED]. One of his/her admission medications was oral [MEDICATION NAME] for three days one time a day. Review of the Medication Administration Record [REDACTED]. Review of the electronic MAR (e-MAR) for ,[DATE] revealed the IV administration of [MEDICATION NAME] was to start on [DATE]. It was signed off on [DATE], [DATE] and [DATE] with a code indicating it was held and to see the Progress Notes. Review of the Progress Notes in the EMR dated [DATE] at 14:39 (2:39 PM) read, . Rales heard in bilateral lungs, vitals unstable, NP (nurse practitioner) rounding. Stat chest x-ray ordered, labs (cmpl, BMp UA) (sic) complete awaiting results also orders for ABT (antibiotic) to start . Review of the nurse practitioner (NP) notes from the hard chart for [DATE] (no time) revealed a note reading, Ordered stat (immediate) CBC, CMP (labs) and 2 view chest x-ray, [MEDICATION NAME] (an antibiotic) 1 gram IV, . UTI vs Pneumonia . (sic) A review of the Progress Notes dated [DATE] and [DATE] revealed there was no mention of the intravenous administration of [MEDICATION NAME] antibiotic. They documented the general status of the resident but nothing about the antibiotic. Review of the [DATE] NP History of Present Illness included, .the nursing staff report that the patient did not receive any .antibiotics over the weekend that were ordered, as they report that it was documented medication not available . On [DATE] at 13:56 (1:56 PM) a Progress Note documented, Rales heard in bilateral lungs, IV started to right hand for IV antibiotics related to pneumonia .SOB noted with activity and rest, breathing treatment complete as ordered . and at 17:10 (5:10 PM) the same day, noted pt ashen color, respirations 28, oxygen Saturation 82 after breathing treatment. Lungs sounds with many wheezes and tightness bilaterally. Pt alert and answers questions appropriately . ambulance was called for patient to be transported to hospital. Notified on call NP. Notified pt son who chose SFE hospital . at 17:11 (5:17 PM) EMR documented, .Resident's primary nurse had concerns due to resident's O2 (oxygen) sat being 82% on 3 L of oxygen .skin color was gray instead of pink. Called 911 and resident was transferred .NP on call notified. Resident's son .notified . Review of the hospital Discharge Summary dated [DATE] revealed her admitting [DIAGNOSES REDACTED].#6 expired on [DATE] with [DIAGNOSES REDACTED]. The summary stated, .pt required 5L to maintain adequate SaO2 (O2 saturation) .noted to have bibasilar crackles and [MEDICAL CONDITION] on exam . (sic) It revealed the cause of death was GI (gastrointestinal) hemorrhage. An interview with the Unit Manager at 1:30 PM on [DATE] revealed he/she remembered the resident from the fall of last year. He/she stated Resident #6 had been pleasant and they had to send him/her to the emergency room . (The resident) didn't look good and the antibiotic hadn't been given after it was ordered. When asked why not s/he responded, I'm not sure. An interview was conducted on [DATE] at 2:00 PM with licensed practical nurse (LPN) 1 revealed s/he had worked with the resident during his/her stay. She/he stated, You know it's been almost a year, it's hard to remember things from that long ago. LPN #1 stated she/he could not remember why the antibiotic had not been given during the weekend. She/he thought the resident had a cough but really could not remember specifics. During an interview with the Administrator conducted on [DATE] at 3:30 PM she/he stated, The medication was not available for some reason and was not given as a result. She/he did not offer a reason as to why the nurses had not contacted the Nurse Practitioner with the concern. The failure to provide the antibiotic medication as ordered on [DATE] contributed to the resident being sent to the ER for evaluation and hospital admission on [DATE]. The facility failed to provide a policy on procedure when medications are not provided as ordered or not available to administer as ordered. 2. Review of Resident #13's EMR revealed she/he was admitted with [DIAGNOSES REDACTED]. Review of the hospital discharge orders dated [DATE] revealed an order for [REDACTED].for 5 days, THEN 1 tab daily for 5 days . [MEDICATION NAME] is a steroid that can be used to treat breathing problems. The medication started on [DATE] and should have been discontinued on [DATE] as ordered. Review of the ,[DATE], ,[DATE], ,[DATE], and ,[DATE] eMAR revealed the resident received 20 mg of [MEDICATION NAME] from [DATE] through [DATE]. On [DATE] the error was noted by a nurse and an incident report was written and orders were obtained to gradually taper the medication then to discontinue the medication. Review of the facility Preliminary Draft Notes of a Reported Incident for Rehabilitation/Skilled Nursing Product Type revealed Resident #13 received the medication [MEDICATION NAME] 20 mg from [DATE] to [DATE]. The medication should have been discontinued after tapering him/her on [DATE]. In the box Follow-Up Information was written, .will taper down over the next 2 weeks . Attached to the incident report was a .Discontinue Order . reflecting that [MEDICATION NAME] 20 mg was discontinued. The [MEDICATION NAME] 20 mg daily order was replaced by a [MEDICATION NAME] 10 mg for six days ending on [DATE] then 10 mg daily for seven days ending on [DATE]. A telephone interview was attempted with the nurse that wrote the incident report on [DATE] and [DATE] but no return call was received. An interview with the Unit Manager was conducted on [DATE] at 10:00 AM and he/she stated the nurse who transcribed the original order from the hospital stay did not included the full order. When asked if it was a transcription order leading to a significant medication error, he/she hesitated to answer the question. The Director of Nursing was new to the position and had provided no information. A telephone interview was conducted with the Consultant Pharmacist on [DATE] at 10:08 AM revealed prolonged use of the [MEDICATION NAME], Possibly could have negative effects and could be negative with anxiety. Review of the drug insert information titled, [MEDICATION NAME] Tablets USP, 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg, and 50 mg/ [MEDICATION NAME] Oral Solution USP, 5 mg per 5 mL and [MEDICATION NAME] Oral Solution (Concentrate), 5 mg per mL revealed . who are on corticosteroids are more susceptible to infections than are healthy individuals. There may be decreases resistance and inability to localize infection . in the case of an infection. Further review of the information revealed a section titled, .Geriatric Use . It stated, .In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease .In particular, the increased risk of . fluid retention and hypertension in elderly patients treated with corticosteroids should be considered. Review of the facility policy titled, Reconciliation of Medications on Admission/Re-Admission and Monthly Orders last revised in ,[DATE] revealed, .Policy Overview .The charge nurse will perform medication reconciliation upon admission, readmission or transition of care from prior levels of care for the purpose of providing an accurate and current medication regimen . Under the section titled Policy Detail it stated, .The Admission Team should upload the discharging entity's orders, history and physical, discharge summary .into Point Click Care (PCC) .Medication reconciliation reduces medication errors and enhances resident safety during the admission/transfer process . The process included, .enter all orders into Point Click Care (PCC): list the dose, route and frequency for all medications or treatments .The second charge nurse is responsible for the following: Review and reconcile the Discharge Summary from the referring community and Order Summary for accuracy . This citation is related to SC 537.

Based on review of facility files and interview, the facility failed to include an assessment of the resident. Resident #1 was noted to elope from the facility while wearing a wander guard. The resident was noted to be missing when staff could not find him/her. The wander guard alarm was sounding and staff did not note the alarm sounding. The resident was last seen at approximately 6:45 PM and was found at 9:00 PM. Resident #1 was noted to have a wander guard with no physician's order, assessment, or care plan in place. Resident #2 was noted to exhibit exit seeking behavior with no interventions ordered until a month later. Resident #3 had a wander guard ordered with no documentation that the resident was exhibiting exit seeking behaviors. Three of three residents reviewed for wander guards. The findings included: The facility reported a resident elopement for Resident #1 to the State Agency. The facility's Five-Day Follow-Up Report dated 10/18/17 indicated Resident #1 exited A hall door, walked around the building, entered the front doors and walked to an assisted living facility. Resident #1 was found at 9:00 PM with no injuries noted to the resident. Staff was educated on alarms, wander guard and elopement procedures. Resident #1 was admitted to the facility from home on 10/6 /17. Review of the resident's History and Physical dated 10/10/17 revealed [DIAGNOSES REDACTED]. Review of Resident #1's Progress Notes revealed a note dated 10/6/17 that indicated the resident required a 24/7 sitter due to confusion and wandering. Review of Resident #1's Daily Skilled Notes dated 10/7/17, 10/8/17, 10/9/17, and 10/11/17 indicated the resident exhibited wandering behavior. The Focus Charting dated 10/10/17 indicated the resident had a wander guard in place and functioning. The note dated 10/8/17 indicated the resident was alert to person and pleasantly confused. The resident tends to wander if left alone. The Nursing Progress Note dated 10/14/17 at 9:30 PM indicated around 6:45 PM walked resident from dining room to the chair out in the sitting area round the double doors that lead to the outside parking lot and asked the resident not to get up. Then around 7:10-7:15 PM the agency CNA came to me and asked where this resident was that s/he was not in his/her room. At that time we began to look for the resident and was unable to find him/her. The resident did have his/her wander guard on right ankle at that time. We looked several times in all the resident rooms, outside and around the building and still unable to find the resident. At this time the on call was called around 7:45 PM, DON notified Executive Director, and other responsible notified of the situation. We continued to look for the resident until DON arrived to help. Around 8:00 PM notified the Power Of Attorney of resident to let him know of the situation. Around 8:30 PM police showed up to get information about the situation and not to long after that they had found resident in assisted living in an apartment. The resident came back to the skilled unit. Review of Resident #1's Physician Telephone Orders revealed an order dated 10/14/17 for wander guard placement to the right ankle. There were no previous orders for a wander guard in the resident's medical record. Review of the resident's care plan revealed resident is an elopement risk/wanderer as evidenced by disoriented to place, history of attempts to leave community unattended, impaired safety awareness, and resident wanders aimlessly was identified as a problem area on 10/17/17. Interventions were included on the care plan and included wander guard as ordered. Review of the facility's Statement of Events related to the resident's elopement on 10/14/17 revealed Resident #1 was found in a vacant assisted living apartment sitting in a rocking chair looking out the window. The resident's wander guard was still present on the resident and verified to be working properly. All doors were checked for proper function. Staff interviewed and re-educated on the wander guard system, fire panel notifications, etc. Both nurses on shift were interviewed and neither stated that they ever heard the wander guard alarm sound. CNA (Certified Nurse Aide) staff working were also interviewed who confirmed the same. Review of the DON's (Director of Nursing) statement revealed s/he arrived at the facility at 8:20 PM and entered the skilled nursing lobby. S/he spoke with nurses and staff. One staff member stated that s/he saw Resident #1 in the parking lot earlier walking around, s/he thought around 6:30 PM. Noted the alarm to the exit door at the end of A hall was sounding, as if a wander guard device was setting it off. Review of the Assistant Director of Nursing's statement indicated after the resident was found education was provided to the nurses and CNAs that were on duty that night. They showed them the alarm on the switch board and how to read it so that they can identify what door has been triggered. They also showed them how the wander guard is activated and what it sounds like. In an interview with surveyor on 11/5/17 at approximately 2:20 PM, both the Executive Director and Director of Nursing reviewed the incident. The DON was notified by the nurse around 7:40 PM that Resident #1 was missing. The resident was last witnessed at 6:45 PM in the skilled lobby. The resident was sitting in a chair and the DON stated the resident can walk. They were unable to locate the resident. They had done room sweeps and checked the property and were unable to locate Resident #1. The DON arrived at the facility around 8:15-8:20 PM. They continued to search the facility, including assisted living and the grounds for the resident. Staff was also driving around the area. They notified the resident's family at 8:20 PM. The police were notified at 8:25 PM and arrived at 8:35 PM. The resident was found at 9:00 PM in an assisted living room on the first floor. The resident was sitting in an empty apartment in a rocking chair facing the window. They glimpsed something through the window in the apartment and knew it was empty so they went and checked the room. If you opened the door to the apartment and looked in, you could not see the resident sitting in the rocking chair. They noticed the alarm on A hall door at the end of the hall was sounding at approximately 8:20 PM. The alarm was the wander guard alarm and the resident was wearing a wander guard. The resident has to wear a wander guard bracelet and if they get close to the door it will start to alarm at the door that resident is at. It just alarms at that door and there is an alarm on the fire panel by the nurses' station. They can hit a button on the fire panel and it will tell them what door is alarming. The door does not lock, it just alarms. The door alarm does not stop until someone resets it by going to that door and entering the code into the keypad at that door. The fire panel will continue to alarm until the code is reset at the door. The doors that lead to outside have wander guards. There is a door on A hall that leads to assisted living and it does not have a wander guard alarm on it. When you go through the door it takes you to a service area, where the breakroom, laundry, back of the kitchen and then if you keep following the hall then you pass the memory care unit and eventually arrive at the common areas of assisted living. Resident #1 was admitted on [DATE] and the wander guard was ordered 10/14/17. The resident had the wander guard on prior to the 14th. On admission they assess residents for elopement and the resident did not assess for high risk. The resident became more ambulatory and started wandering into other residents' rooms so a wander guard was placed on the resident. There should be another assessment completed when the wander guard goes on them, but there was no assessment completed for Resident #1 when the wander guard was placed. They have a form with a picture of the resident they put in the at risk for elopement book. The resident's form with a picture was not placed until after the incident. They should write an order when the wander guard is placed. The assessment usually shows why it is done. They confirmed that there was no assessment and no physician's order for the wander guard prior to the incident. The DON spoke with the employees and asked them if they heard the alarm and the ones they spoke to were not aware that it was sounding. All staff working on the unit reported they did not hear the alarm. The DON heard the alarm at the door and at the fire panel. There is no way to know what time the alarm started sounded. Review of Resident #2's medical record revealed a physician progress notes [REDACTED]. S/he is often exit seeking. Review of Resident #2's Nursing Quarterly Data Collection dated 8/14/17 revealed the resident was coded as yes for a potential elopement risk. The resident was coded yes as having a history of exit seeking, wandering away or getting lost. The form indicated if a resident is considered to be a potential elopement risk, initiate elopement risk interventions and document on the care plan. Review of the resident's Elopement Risk Data Collection dated 9/2/17 revealed the resident wanders and was a potential elopement risk. Review of the resident's Care Plan Conference Summary dated 8/29/17 indicated the resident was more confused at times and not as easily redirectable. The resident does go to the doors in the afternoons wanting to go out. Review of Resident #2's medical record revealed a Physician's Order dated 9/2/17 to apply wander guard to resident's right ankle related to wandering. Check function of wander guard. Record review on 11/16/17 revealed no documentation that the facility was checking the function of the residents wander guard as ordered. In an interview with the Assistant Director of Nursing (ADON) on 11/16/17 the ADON stated that the order to check the function of the wander guard was not put on the residents Treatment Administration Record (TAR) and there was no other documentation that the facility had checked the function of the residents wander guard. The surveyor reviewed Resident #2's Progress Notes 7/7/17-10/27/17. There was no documentation in the progress notes related to the resident wandering or exit seeking. The DON (Director Of Nursing) confirmed there was no documentation in the resident's Nurses' Notes related to the resident exhibiting behaviors of wandering or exit seeking. The DON stated there were no Incident Reports for the resident during the time frame of (MONTH) (YEAR)-November (YEAR). Review of Resident #2's care plan revealed resident is an elopement risk/wanderer as evidenced by history of attempts to leave community unattended, impaired safety awareness, resident wanders aimlessly was identified as a problem area on 9/20/17. Interventions were included on the care plan and included wander guard as ordered. In an interview with the surveyor on 11/5/17 at approximately 4:30 PM, the DON stated the resident started attempting to exit seek and that is why the wander guard was ordered in September. The DON stated that the behavior should be documented in the nurses' notes. In an interview with the surveyor on 11/5/17 at approximately 5:00 PM, the DON stated Resident #2 had a wander guard placed on 9/2/17 because s/he was exit seeking. The DON stated the Interdisciplinary team does not review the Nursing Quarterly Data Collection forms and would not have seen the resident had been coded as an elopement risk. The DON stated s/he did not know the resident was having exit seeking behaviors until (MONTH) when the 9/2/17 elopement assessment was done and the wander guard was placed. The DON stated the charge nurse on the floor that cares for the resident completes the Nursing Quarterly Data Collection forms. The DON stated there should have been follow-up on Resident #2's exit seeking behavior when the medical director saw the resident on 8/1/17 and noted the behavior. The DON stated they have a rounding nurse who rounds with the physician who should have brought the information to the DON or ADON so they could have gotten the wander guard implemented sooner. Resident #3 was admitted to the facility on [DATE] and discharged to another facility on 10/20/17. Review of Resident #3's Progress Notes 10/11/17-10/20/17 revealed no documentation related to the resident exhibiting wandering or exit-seeking behaviors. Review of Resident #3's medical record revealed a Physician Order dated 10/13/17 for wander guard to right lower extremity related to exit seeking. Review of the resident's Nursing Admission Data Collection dated 10/11/17 revealed the resident was not a potential elopement risk. The resident was noted not to have a history of exit seeking, wandering away or getting lost. Review of the resident's Elopement Risk Data Collection dated 10/13/17 revealed the resident was a potential elopement risk and indicated the resident had a history of [REDACTED]. Review of the resident's care plan revealed resident is an elopement risk/wanderer as evidenced by disoriented to place, history of attempts to leave community unattended, impaired safety awareness, resident wanders aimlessly was identified as a problem area on 10/13/17. Interventions listed on the care plan included wander guard as ordered. In an interview with the surveyor on 11/5/17 at approximately 4:30 PM, the DON stated Resident #3 was making attempts to exit. The DON stated nursing should document that information in the nurses' notes. In an interview with the surveyor on 11/5/17 at approximately 4:55 PM, the DON stated the resident was more ambulatory, wandering and exit seeking after his/her first couple of days there. The DON stated nurses should document wandering/exit seeking behavior on the resident's Daily Skilled Note or the focused admission charting. They talk about residents in the Interdisciplinary team daily meetings, they review the Nurses' Progress Notes and Daily Skilled Notes to check for changes with the resident - exit seeking potential. If a resident exhibits exit seeking behavior they assess the resident, obtain an order for [REDACTED]. On (MONTH) 16, (YEAR) at 1:00 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at a scope and severity of J. The Immediate Jeopardy and Substandard Quality of Care existed in the facility on (MONTH) 14, (YEAR) related to Resident #1's elopement when facility staff neglected to respond to wander guard alarms and Resident #1 managed to elope and was later found in an empty apartment on facility campus.

Based on review of facility files and interview, the facility failed to ensure residents were free from neglect. Resident #1 was noted to elope from the facility while wearing a wander guard. The resident was noted to be missing when staff could not find him/her. The wander guard alarm was sounding and staff did not note the alarm sounding. The resident was last seen at approximately 6:45 PM and was found at 9:00 PM. One of three residents reviewed for abuse/neglect. The findings included: The facility reported a resident elopement for Resident #1 to the State Agency. The facility's Five-Day Follow-Up Report dated 10/18/17 indicated Resident #1 exited A hall door, walked around the building, entered the front doors and walked to an assisted living facility. Resident #1 was found at 9:00 PM with no injuries noted to the resident. Staff was educated on alarms, wander guard and elopement procedures. Resident #1 was admitted to the facility from home on 10/6 /17. Review of the resident's History and Physical dated 10/10/17 revealed [DIAGNOSES REDACTED]. Review of Resident #1's Progress Notes revealed a note dated 10/6/17 that indicated the resident required a 24/7 sitter due to confusion and wandering. Review of Resident #1's Daily Skilled Notes dated 10/7/17, 10/8/17, 10/9/17, and 10/11/17 indicated the resident exhibited wandering behavior. The Focus Charting dated 10/10/17 indicated the resident had a wander guard in place and functioning. The note dated 10/8/17 indicated the resident was alert to person and pleasantly confused. The resident tends to wander if left alone. The Nursing Progress Note dated 10/14/17 at 9:30 PM indicated around 6:45 PM walked resident from dining room to the chair out in the sitting area round the double doors that lead to the outside parking lot and asked the resident not to get up. Then around 7:10-7:15 PM the agency CNA came to me and asked where this resident was that s/he was not in his/her room. At that time we began to look for the resident and was unable to find him/her. The resident did have his/her wander guard on right ankle at that time. We looked several times in all the resident rooms, outside and around the building and still unable to find the resident. At this time the on call was called around 7:45 PM, DON notified Executive Director, and other responsible parties notified of the situation. We continued to look for the resident until DON arrived to help. Around 8:00 PM notified the Power Of Attorney of resident to let him know of the situation. Around 8:30 PM police showed up to get information about the situation and not too long after that they had found resident in assisted living in an apartment. The resident came back to the skilled unit. Review of Resident #1's Physician Telephone Orders revealed an order dated 10/14/17 for wander guard placement to the right ankle. There were no previous orders for a wander guard in the resident's medical record. Review of the resident's care plan revealed resident is an elopement risk/wanderer as evidenced by disoriented to place, history of attempts to leave community unattended, impaired safety awareness, and resident wanders aimlessly was identified as a problem area on 10/17/17. Interventions were included on the care plan and included wander guard as ordered. Review of the resident's Treatment Administration Record for (MONTH) (YEAR) revealed wonder guard placement to right ankle, check skin and function every shift ordered 10/15/17 and first signed as completed on day shift on 10/15/17. Review of Resident #1's Elopement Risk Data Sheet in the Elopement Risk binder was dated 10/15/17. Review of the facility's Statement of Events related to the resident's elopement on 10/14/17 revealed Resident #1 was found in a vacant assisted living apartment sitting in a rocking chair looking out the window. The resident's wander guard was still present on the resident and verified to be working properly. All doors were checked for proper function. Staff interviewed and re-educated on the wander guard system, fire panel notifications, etc. Both nurses on shift were interviewed and neither stated that they ever heard the wander guard alarm sound. CNA (Certified Nurse Aide) staff working were also interviewed who confirmed the same. Review of the DON's (Director of Nursing) statement revealed s/he arrived at the facility at 8:20 PM and entered the skilled nursing lobby. S/he spoke with nurses and staff. One staff member stated that s/he saw Resident #1 in the parking lot earlier walking around, s/he thought around 6:30 PM. Noted the alarm to the exit door at the end of A hall was sounding, as if a wander guard device was setting it off. Review of the Assistant Director of Nursing's statement indicated after the resident was found education was provided to the nurses and CNAs that were on duty that night. They showed them the alarm on the switch board and how to read it so that they can identify what door has been triggered. They also showed them how the wander guard is activated and what it sounds like. Review of the Human Resources Director's facility-obtained statement dated 10/17/17 indicated that at 7:42 PM assisted living staff reported to human resources that the assisted living front door wander guard alarm was going off. When the staff went outside to check, skilled nursing facility staff were walking around the building to search, so s/he started to help them and never thought to call HR back. At 7:49 PM human resources received a call that a skilled nursing facility resident was missing. At 8:10 PM, arrived at the community and noted wandering patient alarm near the therapy door was going off. Details reported to human resources were that Resident #1 was last seen at 6:45 PM in the lobby by nurses. The resident was seen walking through the parking lot by an agency care aide. Noticed the resident was missing around 7:10 PM when the certified nurse aide went to the room to put the resident to bed. The resident was found at 9:01 PM. The HR Director watched the DON and ADON check the resident's wander guard against all doors and confirm it was working. There were no apparent issues with wander guard, doors or panel, all alarms sounding as indicated. In an interview with surveyor on 11/5/17 at approximately 2:20 PM, both the Executive Director and Director of Nursing reviewed the incident. The DON was notified by the nurse around 7:40 PM that Resident #1 was missing. The resident was last witnessed at 6:45 PM in the skilled lobby. The resident was sitting in a chair and the DON stated the resident can walk. They were unable to locate the resident. They had done room sweeps and checked the property and were unable to locate Resident #1. The DON arrived at the facility around 8:15-8:20 PM. They continued to search the facility, including assisted living and the grounds for the resident. Staff was also driving around the area. They notified the resident's family at 8:20 PM. The police were notified at 8:25 PM and arrived at 8:35 PM. The resident was found at 9:00 PM in an assisted living room on the first floor. The resident was sitting in an empty apartment in a rocking chair facing the window. They glimpsed something through the window in the apartment and knew it was empty so they went and checked the room. If you opened the door to the apartment and looked in, you could not see the resident sitting in the rocking chair. They noticed the alarm on A hall door at the end of the hall was sounding at approximately 8:20 PM. The alarm was the wander guard alarm and the resident was wearing a wander guard. The resident has to wear a wander guard bracelet and if they get close to the door it will start to alarm at the door that resident is at. It just alarms at that door and there is an alarm on the fire panel by the nurses' station. They can hit a button on the fire panel and it will tell them what door is alarming. The door does not lock, it just alarms. The door alarm does not stop until someone resets it by going to that door and entering the code into the keypad at that door. The fire panel will continue to alarm until the code is reset at the door. The doors that lead to outside have wander guards. There is a door on A hall that leads to assisted living and it does not have a wander guard alarm on it. When you go through the door it takes you to a service area, where the breakroom, laundry, back of the kitchen and then if you keep following the hall then you pass the memory care unit and eventually arrive at the common areas of assisted living. Resident #1 was admitted on [DATE] and the wander guard was ordered 10/14/17. The resident had the wander guard on prior to the 14th. On admission they assess residents for elopement and the resident did not assess for high risk. The resident became more ambulatory and started wandering into other residents' rooms so a wander guard was placed on the resident. There should be another assessment completed when the wander guard goes on them, but there was no assessment completed for Resident #1 when the wander guard was placed. They have a form with a picture of the resident they put in the at risk for elopement book. The resident's form with a picture was not placed until after the incident. They should write an order when the wander guard is placed. The assessment usually shows why it is done. They confirmed that there was no assessment and no physician's order for the wander guard prior to the incident. The DON spoke with the employees and asked them if they heard the alarm and the ones they spoke to were not aware that it was sounding. All staff working on the unit reported they did not hear the alarm. The DON heard the alarm at the door and at the fire panel. There is no way to know what time the alarm started sounded. Review of the facility's Elopement Risk Policy revealed residents who are at risk for elopement should be identified. The policy indicated completion of Elopement Risk Alert with photograph and place in Elopement Risk binder at the nursing station. Initiate Resident Monitoring System as follows: obtain physician orders for monitoring system, inform resident/legal representative, apply the personal monitoring device in accordance with the manufacturer's instructions, monitor resident's comfort relative to the fit of the device, and verify proper functioning of alarm after application by following manufacturer's activation instructions. The section Elopement System Alarm Activation included the steps to take if the Elopement System Activates the alarm: designated associates and all available associates will immediately go to the site of activation, alarmed door will remain alarming until the associates have secured the door, identify the unsupervised resident. If the unsupervised resident or reason for alarm activation cannot be identified or determined immediately, assure that every resident with a personal elopement device is accounted for as well as all other residents. On (MONTH) 16, (YEAR) at 1:00 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at a scope and severity of J. The Immediate Jeopardy and Substandard Quality of Care existed in the facility on (MONTH) 14, (YEAR) related to Resident #1's elopement when facility staff neglected to respond to wander guard alarms and Resident #1 managed to elope and was later found in an empty apartment on facility campus.

Based on review of facility files and interview, the facility failed to accurately complete assessments for three of three residents reviewed for wander guards. Resident #1 was noted to have a wander guard with no physician's order, assessment, or care plan in place. Resident #2 was noted to exhibit exit seeking behaviors with no interventions ordered until a month later. Resident #3 had a wander guard ordered with no documentation that the resident was exhibiting exit seeking behaviors. The findings included: Resident #1 was admitted to the facility from home on 10/6 /17. Review of the resident's History and Physical dated 10/10/17 revealed [DIAGNOSES REDACTED]. In an interview with surveyor on 11/5/17 at approximately 2:20 PM, with both the Executive Director and Director of Nursing revealed that Resident #1 was admitted on [DATE] and the wander guard was ordered 10/14/17. The resident had the wander guard on prior to 10/14/17. On admission they assess residents for elopement and the resident did not assess for high risk. The resident became more ambulatory and started wandering into other residents' rooms so a wander guard was placed on the resident. There should be another assessment completed when the wander guard goes on them, but there was no assessment completed for Resident #1 when the wander guard was placed. They have a form with a picture of the resident they put in the at risk for elopement book. The resident's form with a picture was not placed until after the elopement incident on 10/14/17. They should write an order when the wander guard is placed. The assessment usually shows why it is done. They confirmed that there was no assessment and no physician's order for the wander guard prior to the incident. Review of Resident #2's medical record revealed a physician progress notes [REDACTED]. S/he is often exit seeking. Review of Resident #2's Nursing Quarterly Data Collection dated 8/14/17 revealed the resident was coded as yes for a potential elopement risk. The resident was coded yes as having a history of exit seeking, wandering away or getting lost. The form indicated if a resident is considered to be a potential elopement risk, initiate elopement risk interventions and document on the care plan. Review of the resident's Elopement Risk Data Collection dated 9/2/17 revealed the resident wanders and was a potential elopement risk. Review of the resident's Care Plan Conference Summary dated 8/29/17 indicated the resident was more confused at times and not as easily redirectable. The resident does go to the doors in the afternoons wanting to go out. Review of Resident #2's medical record revealed a Physician's Order dated 9/2/17 to apply wander guard to resident's right ankle related to wandering. Check function of wander guard. Record review on 11/16/17 revealed no documentation that the facility was checking the function of the residents wander guard as ordered. In an interview with the Assistant Director of Nursing (ADON) on 11/16/17 the ADON stated that the order to check the function of the wander guard was not put on the residents Treatment Administration Record (TAR) and there was no other documentation that the facility had checked the function of the residents wander guard. The surveyor reviewed Resident #2's Progress Notes 7/7/17-10/27/17. There was no documentation in the progress notes related to the resident wandering or exit seeking. The DON (Director of Nursing) confirmed there was no documentation in the resident's Nurses' Notes related to the resident exhibiting behaviors of wandering or exit seeking. The DON stated there were no Incident Reports for the resident during the time frame of (MONTH) (YEAR)-November (YEAR). In an interview with the surveyor on 11/5/17 at approximately 4:30 PM, the DON stated the resident started attempting to exit seek and that is why the wander guard was ordered in September. The DON stated that the behavior should be documented in the nurses' notes. In an interview with the surveyor on 11/5/17 at approximately 5:00 PM, the DON stated Resident #2 had a wander guard placed on 9/2/17 because s/he was exit seeking. The DON stated the Interdisciplinary team does not review the Nursing Quarterly Data Collection forms and would not have seen the resident had been coded as an elopement risk. The DON stated s/he did not know the resident was having exit seeking behaviors until (MONTH) when the 9/2/17 elopement assessment was done and the wander guard was placed. The DON stated the charge nurse on the floor that cares for the resident completes the Nursing Quarterly Data Collection forms. The DON stated there should have been follow-up on Resident #2's exit seeking behavior when the medical director saw the resident on 8/1/17 and noted the behavior. The DON stated they have a rounding nurse who rounds with the physician who should have brought the information to the DON or ADON so they could have gotten the wander guard implemented sooner. Resident #3 was admitted to the facility on [DATE] and discharged to another facility on 10/20/17. Review of Resident #3's Progress Notes 10/11/17-10/20/17 revealed no documentation related to the resident exhibiting wandering or exit-seeking behaviors. Review of Resident #3's medical record revealed a Physician Order dated 10/13/17 for wander guard to right lower extremity related to exit seeking. Review of the resident's Nursing Admission Data Collection dated 10/11/17 revealed the resident was not a potential elopement risk. The resident was noted not to have a history of exit seeking, wandering away or getting lost. Review of the resident's Elopement Risk Data Collection dated 10/13/17 revealed the resident was a potential elopement risk and indicated the resident had a history of [REDACTED]. Review of the resident's care plan revealed resident is an elopement risk/wanderer as evidenced by disoriented to place, history of attempts to leave community unattended, impaired safety awareness, resident wanders aimlessly was identified as a problem area on 10/13/17. Interventions listed on the care plan included wander guard as ordered. In an interview with the surveyor on 11/5/17 at approximately 4:30 PM, the DON stated Resident #3 was making attempts to exit. The DON stated nursing should document that information in the nurses' notes. In an interview with the surveyor on 11/5/17 at approximately 4:55 PM, the DON stated the resident was more ambulatory, wandering and exit seeking after his/her first couple of days there. The DON stated nurses should document wandering/exit seeking behavior on the resident's Daily Skilled Note or the focused admission charting. They talk about residents in the Interdisciplinary team daily meetings, they review the Nurses' Progress Notes and Daily Skilled Notes to check for changes with the resident - exit seeking potential. If a resident exhibits exit seeking behavior they assess the resident, obtain an order for [REDACTED]. Review of the facility's Elopement Risk Policy revealed residents who are at risk for elopement should be identified. The policy indicated completion of Elopement Risk Alert with photograph and place in Elopement Risk binder at the nursing station. Initiate Resident Monitoring System as follows: obtain physician orders for monitoring system, inform resident/legal representative, apply the personal monitoring device in accordance with the manufacturer's instructions, monitor resident's comfort relative to the fit of the device, and verify proper functioning of alarm after application by following manufacturer's activation instructions. On (MONTH) 16, (YEAR) at 1:00 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at a scope and severity of J. The Immediate Jeopardy and Substandard Quality of Care existed in the facility on (MONTH) 14, (YEAR) related to Resident #1's elopement when facility staff neglected to respond to wander guard alarms and Resident #1 managed to elope and was later found in an empty apartment on facility campus.

Based on review of facility files and interview, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents. Resident #1 was noted to elope from the facility while wearing a wander guard. The resident was noted to be missing when staff could not find him/her. The wander guard alarm was sounding and staff did not note the alarm sounding. The resident was last seen at approximately 6:45 PM and was found at 9:00 PM. Resident #1 was noted to have a wander guard with no physician's order, assessment, or care plan in place. Resident #2 was noted to exhibit exit seeking behavior with no interventions ordered until a month later. Resident #3 had a wander guard ordered with no documentation that the resident was exhibiting exit seeking behaviors. Three of three residents reviewed for wander guards. The findings included: The facility reported a resident elopement for Resident #1 to the State Agency. The facility's Five-Day Follow-Up Report dated 10/18/17 indicated Resident #1 exited A hall door, walked around the building, entered the front doors and walked to an assisted living facility. Resident #1 was found at 9:00 PM with no injuries noted to the resident. Staff was educated on alarms, wander guard and elopement procedures. Resident #1 was admitted to the facility from home on 10/6 /17. Review of the resident's History and Physical dated 10/10/17 revealed [DIAGNOSES REDACTED]. Review of Resident #1's Progress Notes revealed a note dated 10/6/17 that indicated the resident required a 24/7 sitter due to confusion and wandering. Review of Resident #1's Daily Skilled Notes dated 10/7/17, 10/8/17, 10/9/17, and 10/11/17 indicated the resident exhibited wandering behavior. The Focus Charting dated 10/10/17 indicated the resident had a wander guard in place and functioning. The note dated 10/8/17 indicated the resident was alert to person and pleasantly confused. The resident tends to wander if left alone. The Nursing Progress Note dated 10/14/17 at 9:30 PM indicated around 6:45 PM walked resident from dining room to the chair out in the sitting area round the double doors that lead to the outside parking lot and asked the resident not to get up. Then around 7:10-7:15 PM the agency CNA came to me and asked where this resident was that s/he was not in his/her room. At that time we began to look for the resident and was unable to find him/her. The resident did have his/her wander guard on right ankle at that time. We looked several times in all the resident rooms, outside and around the building and still unable to find the resident. At this time the on call was called around 7:45 PM, DON notified Executive Director, and other responsible notified of the situation. We continued to look for the resident until DON arrived to help. Around 8:00 PM notified the Power Of Attorney of resident to let him know of the situation. Around 8:30 PM police showed up to get information about the situation and not to long after that they had found resident in assisted living in an apartment. The resident came back to the skilled unit. Review of Resident #1's Physician Telephone Orders revealed an order dated 10/14/17 for wander guard placement to the right ankle. There were no previous orders for a wander guard in the resident's medical record. Review of the resident's care plan revealed resident is an elopement risk/wanderer as evidenced by disoriented to place, history of attempts to leave community unattended, impaired safety awareness, and resident wanders aimlessly was identified as a problem area on 10/17/17. Interventions were included on the care plan and included wander guard as ordered. Review of the resident's Treatment Administration Record for (MONTH) (YEAR) revealed wonder guard placement to right ankle, check skin and function every shift ordered 10/15/17 and first signed as completed on day shift on 10/15/17. Review of Resident #1's Elopement Risk Data Sheet in the Elopement Risk binder was dated 10/15/17. Review of the facility's Statement of Events related to the resident's elopement on 10/14/17 revealed Resident #1 was found in a vacant assisted living apartment sitting in a rocking chair looking out the window. The resident's wander guard was still present on the resident and verified to be working properly. All doors were checked for proper function. Staff interviewed and re-educated on the wander guard system, fire panel notifications, etc. Both nurses on shift were interviewed and neither stated that they ever heard the wander guard alarm sound. CNA (Certified Nurse Aide) staff working were also interviewed who confirmed the same. Review of the DON's (Director of Nursing) statement revealed s/he arrived at the facility at 8:20 PM and entered the skilled nursing lobby. S/he spoke with nurses and staff. One staff member stated that s/he saw Resident #1 in the parking lot earlier walking around, s/he thought around 6:30 PM. Noted the alarm to the exit door at the end of A hall was sounding, as if a wander guard device was setting it off. Review of the Assistant Director of Nursing's statement indicated after the resident was found education was provided to the nurses and CNAs that were on duty that night. They showed them the alarm on the switch board and how to read it so that they can identify what door has been triggered. They also showed them how the wander guard is activated and what it sounds like. Review of the Human Resources Director's facility-obtained statement dated 10/17/17 indicated that at 7:42 PM assisted living staff reported to human resources that the assisted living front door wander guard alarm was going off. When the staff went outside to check, skilled nursing facility staff were walking around the building to search, so s/he started to help them and never thought to call HR back. At 7:49 PM human resources received a call that a skilled nursing facility resident was missing. At 8:10 PM, arrived at the community and noted wandering patient alarm near the therapy door was going off. Details reported to human resources were that Resident #1 was last seen at 6:45 PM in the lobby by nurses. The resident was seen walking through the parking lot by an agency care aide. Noticed the resident was missing around 7:10 PM when the certified nurse aide went to the room to put the resident to bed. The resident was found at 9:01 PM. The HR Director watched the DON and ADON check the resident's wander guard against all doors and confirm it was working. There were no apparent issues with wander guard, doors or panel, all alarms sounding as indicated. In an interview with surveyor on 11/5/17 at approximately 2:20 PM, both the Executive Director and Director of Nursing reviewed the incident. The DON was notified by the nurse around 7:40 PM that Resident #1 was missing. The resident was last witnessed at 6:45 PM in the skilled lobby. The resident was sitting in a chair and the DON stated the resident can walk. They were unable to locate the resident. They had done room sweeps and checked the property and were unable to locate Resident #1. The DON arrived at the facility around 8:15-8:20 PM. They continued to search the facility, including assisted living and the grounds for the resident. Staff was also driving around the area. They notified the resident's family at 8:20 PM. The police were notified at 8:25 PM and arrived at 8:35 PM. The resident was found at 9:00 PM in an assisted living room on the first floor. The resident was sitting in an empty apartment in a rocking chair facing the window. They glimpsed something through the window in the apartment and knew it was empty so they went and checked the room. If you opened the door to the apartment and looked in, you could not see the resident sitting in the rocking chair. They noticed the alarm on A hall door at the end of the hall was sounding at approximately 8:20 PM. The alarm was the wander guard alarm and the resident was wearing a wander guard. The resident has to wear a wander guard bracelet and if they get close to the door it will start to alarm at the door that resident is at. It just alarms at that door and there is an alarm on the fire panel by the nurses' station. They can hit a button on the fire panel and it will tell them what door is alarming. The door does not lock, it just alarms. The door alarm does not stop until someone resets it by going to that door and entering the code into the keypad at that door. The fire panel will continue to alarm until the code is reset at the door. The doors that lead to outside have wander guards. There is a door on A hall that leads to assisted living and it does not have a wander guard alarm on it. When you go through the door it takes you to a service area, where the breakroom, laundry, back of the kitchen and then if you keep following the hall then you pass the memory care unit and eventually arrive at the common areas of assisted living. Resident #1 was admitted on [DATE] and the wander guard was ordered 10/14/17. The resident had the wander guard on prior to the 14th. On admission they assess residents for elopement and the resident did not assess for high risk. The resident became more ambulatory and started wandering into other residents' rooms so a wander guard was placed on the resident. There should be another assessment completed when the wander guard goes on them, but there was no assessment completed for Resident #1 when the wander guard was placed. They have a form with a picture of the resident they put in the at risk for elopement book. The resident's form with a picture was not placed until after the incident. They should write an order when the wander guard is placed. The assessment usually shows why it is done. They confirmed that there was no assessment and no physician's order for the wander guard prior to the incident. The DON spoke with the employees and asked them if they heard the alarm and the ones they spoke to were not aware that it was sounding. All staff working on the unit reported they did not hear the alarm. The DON heard the alarm at the door and at the fire panel. There is no way to know what time the alarm started sounded. Review of Resident #2's medical record revealed a physician progress notes [REDACTED]. S/he is often exit seeking. Review of Resident #2's Nursing Quarterly Data Collection dated 8/14/17 revealed the resident was coded as yes for a potential elopement risk. The resident was coded yes as having a history of exit seeking, wandering away or getting lost. The form indicated if a resident is considered to be a potential elopement risk, initiate elopement risk interventions and document on the care plan. Review of the resident's Elopement Risk Data Collection dated 9/2/17 revealed the resident wanders and was a potential elopement risk. Review of the resident's Care Plan Conference Summary dated 8/29/17 indicated the resident was more confused at times and not as easily redirectable. The resident does go to the doors in the afternoons wanting to go out. Review of Resident #2's medical record revealed a Physician's Order dated 9/2/17 to apply wander guard to resident's right ankle related to wandering. Check function of wander guard. Record review on 11/16/17 revealed no documentation that the facility was checking the function of the residents wander guard as ordered. In an interview with the Assistant Director of Nursing (ADON) on 11/16/17 the ADON stated that the order to check the function of the wander guard was not put on the residents Treatment Administration Record (TAR) and there was no other documentation that the facility had checked the function of the residents wander guard. The surveyor reviewed Resident #2's Progress Notes 7/7/17-10/27/17. There was no documentation in the progress notes related to the resident wandering or exit seeking. The DON (Director Of Nursing) confirmed there was no documentation in the resident's Nurses' Notes related to the resident exhibiting behaviors of wandering or exit seeking. The DON stated there were no Incident Reports for the resident during the time frame of (MONTH) (YEAR)-November (YEAR). Review of Resident #2's care plan revealed resident is an elopement risk/wanderer as evidenced by history of attempts to leave community unattended, impaired safety awareness, resident wanders aimlessly was identified as a problem area on 9/20/17. Interventions were included on the care plan and included wander guard as ordered. In an interview with the surveyor on 11/5/17 at approximately 4:30 PM, the DON stated the resident started attempting to exit seek and that is why the wander guard was ordered in September. The DON stated that the behavior should be documented in the nurses' notes. In an interview with the surveyor on 11/5/17 at approximately 5:00 PM, the DON stated Resident #2 had a wander guard placed on 9/2/17 because s/he was exit seeking. The DON stated the Interdisciplinary team does not review the Nursing Quarterly Data Collection forms and would not have seen the resident had been coded as an elopement risk. The DON stated s/he did not know the resident was having exit seeking behaviors until (MONTH) when the 9/2/17 elopement assessment was done and the wander guard was placed. The DON stated the charge nurse on the floor that cares for the resident completes the Nursing Quarterly Data Collection forms. The DON stated there should have been follow-up on Resident #2's exit seeking behavior when the medical director saw the resident on 8/1/17 and noted the behavior. The DON stated they have a rounding nurse who rounds with the physician who should have brought the information to the DON or ADON so they could have gotten the wander guard implemented sooner. Resident #3 was admitted to the facility on [DATE] and discharged to another facility on 10/20/17. Review of Resident #3's Progress Notes 10/11/17-10/20/17 revealed no documentation related to the resident exhibiting wandering or exit-seeking behaviors. Review of Resident #3's medical record revealed a Physician Order dated 10/13/17 for wander guard to right lower extremity related to exit seeking. Review of the resident's Nursing Admission Data Collection dated 10/11/17 revealed the resident was not a potential elopement risk. The resident was noted not to have a history of exit seeking, wandering away or getting lost. Review of the resident's Elopement Risk Data Collection dated 10/13/17 revealed the resident was a potential elopement risk and indicated the resident had a history of [REDACTED]. Review of the resident's care plan revealed resident is an elopement risk/wanderer as evidenced by disoriented to place, history of attempts to leave community unattended, impaired safety awareness, resident wanders aimlessly was identified as a problem area on 10/13/17. Interventions listed on the care plan included wander guard as ordered. In an interview with the surveyor on 11/5/17 at approximately 4:30 PM, the DON stated Resident #3 was making attempts to exit. The DON stated nursing should document that information in the nurses' notes. In an interview with the surveyor on 11/5/17 at approximately 4:55 PM, the DON stated the resident was more ambulatory, wandering and exit seeking after his/her first couple of days there. The DON stated nurses should document wandering/exit seeking behavior on the resident's Daily Skilled Note or the focused admission charting. They talk about residents in the Interdisciplinary team daily meetings, they review the Nurses' Progress Notes and Daily Skilled Notes to check for changes with the resident - exit seeking potential. If a resident exhibits exit seeking behavior they assess the resident, obtain an order for [REDACTED]. The DON stated Resident #3 did not have any Incident Reports while at the facility. Review of the facility's Elopement Risk Policy revealed residents who are at risk for elopement should be identified. The policy indicated completion of Elopement Risk Alert with photograph and place in Elopement Risk binder at the nursing station. Initiate Resident Monitoring System as follows: obtain physician orders for monitoring system, inform resident/legal representative, apply the personal monitoring device in accordance with the manufacturer's instructions, monitor resident's comfort relative to the fit of the device, and verify proper functioning of alarm after application by following manufacturer's activation instructions. The section Elopement System Alarm Activation included the steps to take if the Elopement System Activates the alarm: designated associates and all available associates will immediately go to the site of activation, alarmed door will remain alarming until the associates have secured the door, identify the unsupervised resident. If the unsupervised resident or reason for alarm activation cannot be identified or determined immediately, assure that every resident with a personal elopement device is accounted for as well as all other residents. On (MONTH) 16, (YEAR) at 1:00 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at a scope and severity of J. The Immediate Jeopardy and Substandard Quality of Care existed in the facility on (MONTH) 14, (YEAR) related to Resident #1's elopement when facility staff neglected to respond to wander guard alarms and Resident #1 managed to elope and was later found in an empty apartment on facility campus.

Based on record review and interview, the facility failed to develop a comprehensive care plan for Resident #10 to meet the resident's needs related to pressure ulcers 1 of 3 residents reviewed for care plans related to pressure ulcers. There was no evidence that a comprehensive care plan to include off loading of the heels was in place prior to the development of pressure ulcers on his/her heels. The findings included: The facility admitted Resident #10 with current [DIAGNOSES REDACTED]. Review of the Weekly Wound Documentation Progress Sheets on 12-16-14 at approximately 9:15 AM confirmed that the new pressure ulcers on the heels were acquired on 7/1/14: An "unstageable" area on the right heel measured 3.8 centimeters (cm) x 3.3 cm x 0 cm an "unstageable" area on the left heel measured 6.0 cm x 7.8 cm x 0 cm. On 7/9/14, the right heel measured 5.3 cm x 7.2 cm x 0 cm and the left heel measured 6.4 cm x 7.3 cm x 0 cm. Each of the areas were described as "an intact fluid filled blister with purple discoloration beneath fluid." Based on review of the Weekly Wound Documentation Progress Sheet, a Stage II pressure ulcer may "present as an intact or open/ruptured serum-filled blister." An unstageable wound is described as "Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed." The Nurse Practitioner's note dated 7-15-14, documented the pressure ulcer measurement for Resident #10's right heel as 3.9 cm ? 8.0 cm. with 75% wound granulated tissue and a mild drainage-no odor. A small necrotic area to the center of the wound where an initial non-blanchable area was noted. The left heel measured 6.7 cm ? 8.0 cm and was described as an intact blister with purple discoloration at the base, fluid filled. Review of the physician's orders [REDACTED]. The 7/3/2014 physician's orders [REDACTED]. On 7/15/2014 the physician's orders [REDACTED]. The 6/24/14 care plan noted that Resident #10 had the "potential for pressure ulcer development r/t (related to) decreased mobility secondary to fx hip with repair, and bowel and bladder incontinence. Interventions placed at the time of admission included body audits as scheduled, encourage 75-100% of meals and fluid intake and ensure resident is repositioned during rounds and as needed. On 7/1/2014 the resident was noted by the Nurse Practitioner with bilateral heel ulcers the care plan was updated on 7/1/2014 to include a new treatment; skin prep to the left and off loading boot to the left heel as tolerated, remove for hygiene and body audits. The update noted treatment to right heel with no specifics. The care plan on 7/3/2014 indicated offloading boot to the right heel; apply offloading boot to right heel as tolerated, may remove during hygiene and bathing, check skin integrity to right foot each shift. On 7/4/2014 a new problem area was added "Alteration in skin integrity AEB two unstageable PU (pressure ulcers)"; interventions included "Monitor for s/sx (signs/symptom) of new pressure ulcer and non-responding current pressure ulcers." The CNA care plan and documentation were unavailable for review. There was no access to Point of Care: Resident Detail information (CNA care plan) because "The system has archived all data relating to the documentation..." There was no evidence in the medical record to verify that a comprehensive prevention program, including turning and positioning and off-loading, had been followed prior to development of pressure ulcers on the heels. During an interview on 12/18/14 at approximately 11:00 AM, the Wound Care Nurse stated, "On 7/1/14, the Nurse Practitioner saw the resident's heels with intact blisters with no drainage from them. Skin prep was ordered to the heels and an off-loading boot was also ordered to the left heel. We have only one boot in the facility at a time. I ordered another boot on 7/1/14. I applied the one off loading boot to the worse heel (left) on 7/1/14. The right heel boot came in on 7/3/14 and an order was written to put it on the right heel. The order was not written for the right heel boot until 7/3/14, until the boot came in and was available in the facility." The Wound Care Nurse confirmed that the skin prep was discontinued by the NP on 7-15-14 and a new treatment ordered due to the wounds' worsening condition. The Wound Care Nurse stated, "S/he would pull her socks off and dig her heels in the bed approximately 2 times a day. S/he really did not get out of bed and refused to do so." Review of the care plan revealed this information had not been included.

Based on record review and interview, the facility failed to prevent the development of pressure ulcers for 1 of 3 residents reviewed for pressure ulcers. Although admitted without open areas and assessed at low risk for pressure ulcers, Resident #10 developed blisters on both heels after admission to the facility which were incorrectly staged and worsened prior to discharge. There was no evidence that a comprehensive prevention program was followed prior to development of pressure ulcers on the heels. The findings included: Cross refer to F-279 as it relates to the failure of the facility to develop a comprehensive care plan for Resident #10 to meet the his/her needs related to pressure ulcers. There was no evidence that a comprehensive care plan to include off loading of the heels was in place prior to the development of pressure ulcers on his/her heels. The facility admitted Resident #10 with current [DIAGNOSES REDACTED]. Review of the 6-24-14 admission skin assessment on 12-16-14 at approximately 9:00 AM revealed no pressure ulcers. Section M of the 7-1-14 Admission Minimum Data Set (MDS) Assessment noted no pressure ulcers. No skin issues were noted on the 6-29-14 Licensed Nurse Weekly Summary. The Braden Scales completed on 6-25-14, 7-2-14, and 7-9-14 noted the resident at low risk for development of pressure ulcers. Review of Progress Notes revealed that on 7/1/14, the Nurse Practitioner (NP) "Noted blisters to bil(ateral) heels. Left heel covers entire heel, non-blanchable. Right heel quarter size and non-blanchable." On 7-15-14, the NP documented "Right heel 3.9?8.0. 75% wound granulated tissue with mild drainage-no odor. Small necrotic area to center of wound where initial non-blanchable area was. Left heel 6.7?8.0 intact blister with purple discoloration at base, fluid filled." The treatment plan included: "Skin prep right and left heel BID, off loading boot to bil LE (lower extremities)." Review of the Treatment Administration Record on 12-16-14 at approximately 9:00 AM revealed that treatment to the left and right heel was started on 7/1/14 with skin prep to bilateral heels. An off loading boot to the left heel was started on 7-1-14. On 7/3/14 an off loading boot to the right heel was implemented. Also, there was an order on 7-1-14 to check the skin integrity for each foot every shift. Review of the Weekly Wound Documentation Progress Sheets on 12-16-14 at approximately 9:15 AM confirmed that the new pressure ulcers on the heels were acquired on 7/1/14: An "unstageable" area on the right heel measured 3.8 centimeters (cm) x 3.3 cm x 0 cm and an "unstageable" area on the left heel measured 6.0 cm x 7.8 cm x 0 cm. On 7/9/14, the right heel measured 5.3 cm x 7.2 cm x 0 cm and the left heel measured 6.4 cm x 7.3 cm x 0 cm. Each of the areas was described as "an intact fluid filled blister with purple discoloration beneath fluid." Based on review of the Weekly Wound Documentation Progress Sheet, a Stage II pressure ulcer may "present as an intact or open/ruptured serum-filled blister." An unstageable wound is described as "Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed." The 6/24/14 care plan noted that Resident #10 had the "potential for pressure ulcer development r/t (related to) decreased mobility secondary to fx hip with repair, and bowel and bladder incontinence." Interventions for this focus area included body audits as scheduled (non-specific frequency), encourage food/fluid intake, and reposition during rounds and as necessary (non-specific frequency). Interventions for the [MEDICAL CONDITION] focus area included to "Offer toileting...peri and or incontinent care during rounds and PRN (as needed)." The care plan dated 6/24/14 failed to address off loading of the resident's heels. Bilateral pressure ulcers were identified on 7/1/14 and off loading of the left heel using a boot was identified; the right heel was not off loaded until 7/3/14 when another boot was obtained by the facility. Review of the medical record failed to show that off loading of Resident #10's heels were addressed prior to 7/3/14 when boots were applied to both heels. During an interview on 12/18/14 at approximately 11:00 AM, the Wound Care Nurse stated, "There was no indication of the heel wounds on admission." S/he verified that the admission body audit noted no pressure ulcers. The Wound Care Nurse related, "On 7/1/14, the Nurse Practitioner saw the resident's heels with intact blisters with no drainage from them. Skin prep was ordered to the heels and an off-loading boot was also ordered to the left heel. We have only one boot in the facility at a time. I ordered another boot on 7/1/14. I applied the one off loading boot to the worse heel (left) on 7/1/14. The right heel boot came in on 7/3/14 and an order was written to put it on the right heel. The order was not written for the right heel boot until 7/3/14, until the boot came in and was available in the facility." The Wound Care Nurse confirmed that the skin prep was discontinued by the NP on 7-15-14 and a new treatment ordered due to the wounds' worsening condition. The Wound Care Nurse stated, "S/he would pull her socks off and dig her heels in the bed approximately 2 times a day. S/he really did not get out of bed and refused to do so." Review of the care plan revealed this information had not been included.