Every finding on record at The Green House Cottages of Walnut Ridge

Based on observations, interviews, record review and facility policy review, it was determined that the facility failed to provide the resident with needed medical services for one (Resident #24) of one resident reviewed. Specifically, the facility failed to enter a treatment order on the Treatment Administration Record (TAR), which resulted in an open wound to Resident #24's chest not being treated or assessed for one month. The findings include: Review of Resident #24's admission Record revealed the facility admitted Resident #24 on 01/19/2026 with diagnoses which included heart failure, muscle weakness, diabetes, protein calorie malnutrition, muscle wasting and atrophy, reduced mobility. Review of Resident #24's Care Plan initiated on 05/11/2026 revealed the resident had a skin tear/potential for skin tear of the right chest and the right elbow. Interventions included if a skin tear occurred to obtain an order, staff were to treat the skin tear as ordered and identify causative factors. Review of an Office of Long-Term Care (OLTC) Incident and accident (I&A) Report initiated on 04/30/2026 revealed Resident #24's family member made the facility staff aware that an outdated bandage was found on Resident #24's chest at the time of transfer to the local hospital on [DATE]. Review of images observed from Resident #24's family member revealed a dressing dated 03/29/2026 with the initials of Licensed Practical Nurse (LPN) #8 that was found on Resident #24 when being admitted to the hospital on [DATE]. The images show Resident #24's face, allowing the resident to be identified, as well as the initials of LPN #8 and date of 03/29/2026. Review of an OLTC Witness Statement Form, completed on 05/01/2026, revealed LPN #5 indicated that on 03/25/2026 she was training LPN #8 when Resident #24 returned to the facility. LPN #5 and LPN #8 completed the readmission body audit and removed the dressing from the hospital. Assessed that Resident #24 had a skin tear to the right chest area. LPN #5 then informed LPN #8 they would be using standing orders per facility protocol for treating Resident #24's wound. A dressing was applied to the wound on Resident #24's chest by LPN #5 and LPN #8. Review of an OLTC Witness Statement Form completed on 05/01/2026, revealed RN #9 documented she performed the body audit with the resident sitting in the chair, I pulled up [Resident #24's] shirt .I did not see any patch on [Resident #24's] front, possibly due to me bunching up [the resident's] shirt when I pulled it up Review of the facility's TAR dated March 2026 revealed Resident #24 had a treatment order for a skin tear to the right forearm, but no treatment order for the skin tear to the chest. Review of the facility's TAR dated April 2026 revealed Resident #24 had a treatment order for a skin tear to the right forearm, but no treatment order for the skin tear to the chest. Review of Resident #24's Progress Notes revealed Resident #24 returned to the facility on [DATE] from the hospital. A skin tear to the chest was documented. The Progress Note also revealed that yes there were new areas of concern, and no documentation was included of a treatment or dressing change being completed by LPN #5 to the chest. Review of a facility document titled re-admission Evaluation dated 03/25/2026 and signed by LPN #5, revealed Resident #24 returned to the facility from the hospital on [DATE]. The re-admission Evaluation also revealed Resident #24 had a skin tear to the chest measuring 2.5 centimeters (cm) by 1 cm. Review of a facility document titled Follow-up Question Report dated from 03/03/2026 through 04/29/2029, revealed Resident #24 had showers on the following dates:-03/27/2026 by Certified Nursing Assistant (CNA) #6.-03/31/2026 by CNA #7.-04/05/2026 by CNA #6.-04/08/2026 by CNA #6.-04/12/2026 by CNA #7-04/15/2026 by CNA #7.-04/20/2026 by CNA #7.-04/29/2026by CNA #6.A total of 8 showers were documented from 03/25/2026 until 04/29/2026, all administered by CNA #6 and CNA #7. Review of facility documents titled Body Audit for Resident #24 revealed the following:-03/27/2026 completed by RN #8 front torso was clear. -04/03/2026 completed by LPN #10 front torso was clear. -04/10/2026 completed by the Treatment Nurse (TN) revealed front torso was clear. -04/17/2026 completed by the TN revealed front torso was clear.-04/24/2026 completed by the TN revealed front torso was clear.-05/03/2026 completed by the TN revealed Resident #24 had discoloration to upper front torso, open area on the right side of the chest, signs of healing are shown. During an interview on 05/13/2026 at 1:21 PM, CNA #6 stated that Resident #24 was a two-person assist for showers so there always had to be two staff present for showers. CNA #6 stated that shower days were easy, and he and CNA #7 or another staff member completed the showers together. CNA #6 stated he, had never seen any dressings at all on Resident #24. CNA #6 stated he did not assist the nurses with body audits unless it was to assist the resident to bed. During an interview on 05/13/2026 at 1:37 PM, LPN #5 stated that standing orders were orders the doctor had already approved the nurses to use for all residents. LPN #5 stated all standing orders were entered into the Medication Administration Record (MAR) or TAR. LPN #5 stated she was training LPN #8 on 03/25/2026 when Resident #24 returned to the facility. LPN #5 and LPN #8 completed a full body audit and noted a skin tear to Resident #24's right chest. LPN #5 stated that she and LPN #8 put the dressing on Resident #24's chest. LPN #5 recalled telling LPN #8 they would need to enter the orders into the TAR for Resident #24. LPN #5 stated, I think I put it in. It would still be there if I did it correctly. LPN #5 accessed the electronic medical record for Resident #24. LPN #5 confirmed that no treatment orders were present for the chest wound on the Resident #24's for March 2026 or April 2026 . LPN #5 stated that if a treatment order was not placed on the TAR the other nurses would not know a treatment was needed and it would not get done. During an interview on 05/13/2026 at 2:12 PM, the Assistant Director of Nursing (ADON) stated that even if a standing order was used for treatment of a wound, it would have to be put on the TAR. The ADON stated that orders were to be entered before, you ever even do the treatment and then documentation of the completed task was recorded on the TAR as well. The ADON stated there should not have been a dressing placed on any resident without an entered order or the documentation to follow. The ADON stated if an area was marked clear then there was nothing abnormal there. The ADON stated, I do not think the body audit was done thoroughly if there was documentation the area was clear but there was an actual dressing in place on the body. The ADON stated potential outcomes of a dressing going unchanged could be skin damage, skin deterioration and infection. During an interview on 05/13/2026 at 3:00 PM, the TN stated body audits on Resident #24 were hard. The TN stated Resident #24 would lift their shirt for her to assess and that she did not get a clear view of [Resident #24]. She stated she would ask staff such as CNA's and other nurses if any residents had any issues as well. The TN stated No, that is not a complete skin assessment if I did not look under Resident #24's shirt. I missed the dressing on Resident #24's right upper chest. The TN stated, there should always be an order entered for a dressing change because that is where you document it and that is how the other nurses know that treatment is due. During an interview on 05/13/2026 at 3:25 PM, the Director of Nursing (DON) stated, a report was made that the facility potentially missed a 'patch' on a resident. The DON stated that the nurses that completed the body audits did not see the patch and the CNA's reported not seeing a patch either. The DON confirmed no orders we placed on the TAR. The DON stated, the initials on the patch were LPN #8's initials and it was dated 03/29/2026. The DON confirmed that LPN #8 had been precepting under LPN #5 on 03/29/2026. The DON stated, LPN #5 was responsible for documenting the dressing change. The DON stated, They would not be able to identify that there was a treatment needed if it were not entered on their body audits or the TAR. During an interview on 05/13/2026 at 10:15 PM, LPN #8 stated LPN #5 was her preceptor during that time, and she was shown how to put the treatment order in the system, and the order was placed in the system for Resident #24. LPN #8 indicated she did not recall if the dressing change had been documented but that she knew she changed the dressing on 03/27/2026, so she knew a dressing change was due. LPN #8 stated it had not been changed since I changed it last on 3/27/2026. LPN #8 reported changing the dressing on 03/29/2026 and initialing and dating the dressing. During an interview on 05/14/2026 at 11:40 AM, the Administrator stated she expected all body audits to be done completely by removing all clothing. The Administrator stated when Resident #24 returned to the facility there was a standing order given and the area to Resident #24's upper chest was applied by LPN #5 and the precepting LPN #8. She stated all orders were to be placed in the TAR. The Administrator stated, LPN #5 and LPN #8 stated they put an order in but there must have been a glitch in the system. Review of an OLTC I&A Report revealed in-person in-services were conducted by the DON on 04/30/2026 on Abuse/Neglect, Charting, Body Audits, Admissions, Treatments, and Skin Concerns. -The Skin and Wound in-service dated 04/30/2026 revealed New Admits/Re-Admits will receive a complete body audit within 4/HRS of admitting any wounds, skin tears, bruises, abrasions, or pressure ulcers, with description/measurement. Any resident with a wound will have a care plan identifying wounds and interventions for resolving. The in-service also indicated, New treatment orders will be monitored daily, to ensure all components of order are present and TARs will be reviewed daily for compliance.The in-service on Shower Completion dated 04/30/2026 revealed CNAs were required to complete a shower form, and all skin concerns and observations must be reported to the charge nurse. Review of a facility undated policy titled Abuse, Neglect and Maltreatment Investigating and reporting revealed, This facility will endeavor to protect residents from maltreatment, which means adult abuse, exploitation, neglect, physical abuse, sexual abuse and misappropriation of property. Review of a facility undated policy titled Care and Prevention of Pressure Ulcers and Skin Condition indicated its purpose was to prevent and treat further breakdown of pressure sores; to promote healing of pressure sores that are present; and to identify and treat other skin conditions.

Based on observation, interviews, record reviews and facility policy review, it was determined that the facility failed to notify staff that a resident who had a Peripherally Inserted Central Catheter (PICC) line in place was on Enhanced Barrier Precautions (EBP), resulting in a staff member transferring the resident without appropriate Personal Protective Equipment, and to ensure staff followed EBP when the requirement was posted for one (Resident #99) of one resident reviewed. The findings include: Review of Resident #99's admission Record revealed the resident was admitted by the facility on 04/08/2026 with an open wound to the lower left leg. Review of Resident #99's admission Minimum Data Set (MDS) with an Assessment Reference Date of 04/09/2026, revealed Resident #99 had a Brief Interview for Mental Status score of 10, which indicated Resident #99 had moderate cognitive impairment. The MDS also revealed that Resident #99 received intravenous (IV) medications and antibiotics via midline IV access.Review of Resident #99's Care Plan initiated 04/09/2026, revealed Resident #99 received IV antibiotic therapy with an intervention for EBP precautions due to PICC line. Review of Resident #99's Medication Administration Record (MAR) dated 05/01/2026 - 05/31/2026, revealed an order for EBP every shift with a start date of 04/10/2026. Review of Resident #99's Physician Order dated 04/10/2026, revealed an order for an IV antibiotic two times a day, until 05/16/2026. Review of Resident #99's Clinical Physician Orders dated 04/10/2026, revealed an order for EBP every shift with a start date of 04/10/2026 and end date of 05/12/2026. Review of Resident #99's Progress Notes for May 2026, revealed indicated Resident had a PICC line on 05/01/2026-05/12/2026. During an interview on 05/11/2026 at 1:25 PM, Resident #99 stated they received antibiotics through an IV port because they had a wound on their foot. Resident #99 stated they were to be discharged home after they completed their IV antibiotics. Resident stated the antibiotics would be completed on Saturday and then the resident would be discharged on Sunday. An IV pump was observed sitting in Resident #99's room. While Resident #99 was being interviewed, an identified staff member entered Resident #99's room and put on a pair of gloves, then took the resident's urinal to the bathroom. A few minutes later the staff member entered the resident's room, wearing a pair of gloves and no other form of PPE, and transferred the resident from their bed to their wheelchair. Resident #99's door did not have signage or supplies hanging on the door or in the hallway outside the resident's door that notified staff, visitors, or other residents that Resident #99 was on EBP. During an observation on 05/12/2026 at 3:30 PM, there was no signage for EBP noted on Resident #99's door or outside the room and no PPE was noted hanging on Resident #99's door or in the hallway just outside the door. During an interview on 05/12/2026 at 3:31 PM, Certified Nursing Assistant (CNA) #1 stated they had worked at the facility for seven years. CNA #1 stated, EBP was what we use when a resident has an infection, it was [Personal Protective Equipment]PPE stuff, like gowns, mask and gloves we dress out before going into the resident's room. CNA #1 stated, I am responsible for the residents residing on 600 Hall, on which Resident #99 resided. CNA #1 stated there were no residents on the hall on EBP. CNA #1 stated if a resident was on EBP, the facility's method of informing staff included signage on the door that the resident was on EBP, and the supplies would be hanging in a caddy on the resident's door. CNA #1 stated EBP was to protect the resident, visitors and staff. CNA #1 stated, it was important that the signage be in place, so everyone knew something was going on with the resident. CNA #1 stated urinary tract infections (UTIs), shingles, something in the resident's urine or blood, and wounds would require EBP. During an interview on 05/12/2026 at 3:47 PM, CNA #2 stated they had worked at the facility for almost 4 years. CNA #2 stated, EBP was where you wear gloves, PPE, sanitize your hands and clean. CNA #2 stated a resident was placed on EBP precautions if they had an infection like a UTI or something in their urine or stool. CNA #2 stated, they [the facility] put a sign on the resident's door telling us if a resident was on EBP and they put the supplies outside the door in a container that has drawers for the gowns, gloves, eye wear, shoe booties, or any other thing we need to use for the isolation. CNA #2 stated they were working Resident #99's hall and they did not have a resident on this hallway on EBP. During an interview on 05/12/2026 at 3:56 PM, Registered Nurse (RN) #3 stated they had been working at the facility since December 24, 2025. RN #3 stated they had received training on EBP, and EBP was for the protection of the patient from us and things we could bring in. RN #3 stated the facility would post a sign on the resident's door and hang a caddy over the resident's door with PPE supplies such as masks, gowns, gloves and things needed to care for the resident. RN #3 stated it was important to let staff know and identify who was on EBP because they were at higher risk of infections and you don't want to bring something from outside into them. RN #3 stated Resident #99 was on EBP due to the resident having a PICC line access. During an interview on 05/12/2026 at 4:07 PM, the Director of Nursing (DON) stated the Assistant Director of Nursing (ADON)/Infection Control Preventionist (ICP) was the designated person that trained staff on EBP. The DON stated EBP was used when a resident had an indwelling medical device, PICC lines, catheters, any indwelling device, or feeding tube. The DON stated the staff knew when a resident was placed on EBP because it was in the resident's Care Plan and the facility also put signage on the resident's door and put EBP supplies in a caddy over the door or at the doorway. The DON stated it was important that staff were aware if someone was on EBP to try to cut down on infections in the facility and to let the staff know the resident had an infection in their body; to protect them and others. The DON stated they had a list of all residents who were on EBP in their IP module in the electronic record. The DON also stated that the department heads monitor assigned hallways to ensure the EBP was in place for residents on the department heads assigned hall. Review of an undated facility EBP List revealed Resident #99 was not listed as being on EBP. During an interview on 05/12/2026 at 4:15 PM, the ADON/ICP stated, it was important to identify a resident who required EBP because the facility was trying to cut down on infections and if a resident had an infection in their body, EBP was to protect them and protect others. The ADON/ICP stated it was best practice, and it was pushed out through the Centers for Disease Control (CDC). The ADON/ICP stated they help maintain the program and make sure the facility was effective in making sure that nothing goes from one resident to another. The ADON/ICP stated all staff were trained the same on EBP whether they work in the cottages or in the traditional nursing home setting. The ADON/ICP stated staff were trained upon hire and quarterly on EBP and if the staff seemed to be struggling then they will work with that staff 1 to 1 followed by a teach back method to ensure they understand. The ADON/ICP reviewed the electronic record and stated Resident #99 was on EBP related to wounds. The ADON/ICP stated Resident #99 also had a PICC line. During an interview on 05/12/2026 at 4:19 PM, the Administrator stated it was important to ensure staff were aware of EBP because it kept germs from spreading around to other residents and staff members. The Administrator stated staff were aware of who was on EBP by signs posted on the residents' door and the PPE supplies were in the hangers over the outside of the resident's door. The Administrator stated staff were trained upon hire and quarterly on EBP to ensure staff understood when and where they should wear PPE. On 05/12/2026 at 4:32 PM, the Administrator, ADON/ICP and DON walked to Resident #99's room with this surveyor and verified Resident #99's room was not set up for EBP, no signage or PPE supplies were in place. The ADON/ICP stated they would get the signage and supplies put into place. During an observation on 05/13/2026 at 12:15 PM, LPN #4 did not put on PPE before administering an IV antibiotic through Resident #99's PICC line. EBP signage was noted on Resident 99's door with PPE hanging on the residents' door. LPN #4 stated I should have put on a gown before using the PICC line. During an interview on 05/14/2026 at 8:54 AM, Physician Assistant (PA) stated they were at the facility every day Monday-Friday. The PA stated the ADON/ICP monitored the infection control procedures in the facility and if they had any questions they will bring their concerns to me. The PA stated if they see a lot of UTIs, or other issues, in a specific cottage they would bring it to the ADON/ICP's attention and see if there was an infection control problem. The PA stated, a resident should be placed on EBP if they had something like multi-resistant staphylococcus aureus (MRSA), an infection that was easily spreadable, anything that had increased infectious contact, UTIs, if a resident had a catheter, to prevent sources into the body and other devices that provide an extra route that could cause an infection concern needed to be on EBP. The PA stated the facility would post signs outside the resident's door along with any PPE in a cart that was needed for EBP. The PA stated it was important to ensure the staff were aware of a resident being on EBP because they did not want to cause any extra infections, or harm to the patient. The PA stated a resident should be placed on EBP if they come to the facility with a device such as a catheter, PICC line, a new order and certain infections. The PA stated the resident should be placed on EBP as soon as the facility was notified, for example if a lab notified the facility or when the resident came back from a procedure such as getting PICC line EBP should be set up for them. Review of facility Policy Enhanced Barrier Precautions dated 2022, revealed Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident activities for residents know to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). The policy also revealed clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure CNAs thoroughly washed their hands before handling clean equipment, and 1 of 1 ice machine in the main building was maintained in clean and sanitary condition for 2 of 2 meals observed. The findings are: 1. On 12/16/24 at 11:13 AM, Certified Nursing Assistant (CNA) #1, who was preparing lunch meal in Cottage #1 ' s kitchen, placed a serving of strawberry cake into a blender, added whole milk and two tablespoons of thickener, and pureed. At 11:20 AM, CNA #1 picked up a spatula that was resting on top of a coffee pot inside the dirty side of the food preparation sink waiting to be washed, which had been in contact with food residue, and used it to scrape pureed strawberry cake into a bowl to be served to the resident on the pureed diet, there by contaminating the food. CNA #1 immediately was interviewed and was asked should a spatula in contact with the coffee pot inside the dirty sink be used in food. CNA #1 confirmed she should not have used dirty spatula in food. 2. On 12/16/24 at 11:20 AM, Certified Nursing Assistant (CNA) #2 walked into the kitchen in Cottage #2, putting on her apron and hair net, then sanitized her hands with hand sanitizer, without properly washing her hands with soap and water, she removed a spoon from the drawer by grabbing the tip that would touch the food and used it to place a serving of chicken and dumpling into a blender and pureed to be served to the resident on a pureed diet for lunch meal. CNA #2 was interviewed, and was asked what she should have done after touching dirty objects before handling clean equipment. She stated she should have washed her hands. 3. On 12/16/24 at 11:24 AM, CNA #2 turned on the sink and washed the blender, pureed food and poured it into a divided plate. CNA #2 turned on the sink and washed the blender lid, bowl, and blade with hot water and soap, but did not sanitizer them before assembling them for use, 0n 12/17/24 at 2:27, when the Dietary Manager was interviewed and was asked who what was would happen if the equipment was not properly sanitized before being used to puree food, she stated it will contaminate the food. 4. On 12/17/24 at 11:39 AM, CNA #2 turned on the hand washing sink faucet and washed her hands. Without washing her hands, CNA #2 picked up a blade and attached it to the base on the blender to be used in pureeing food items to be served to the resident on a puree diet. 5. On 12/16/24 at 12:31 PM, inside the opening wall of the ice machine in a room on 400-Hall in the area where ice forms before dropping in to the ice collection had a buildup of wet black residue on it. The surveyor asked the Dietary Manager if she could wipe the area where wet black residue was observed. She did so, solid black residue easily transferred to the tissue. The surveyor asked the Dietary Manager if she could describe what she saw on the opening wall of the ice machine. She stated it was wet black residue. The Dietary Manager was interviewed and was asked how often the ice machine is cleaned and who uses the ice from the ice machine. She stated it is cleaned by the maintenance man once a month. The kitchen staff use it to fill beverages served to the residents at mealtimes. The Certified Nursing Assistant (CNA) use it to for the water pitchers in the residents' rooms. 6. A review of facility policy titled, Hand washing, undated, provided by the Dietary Manager indicated hands should be washed entering the kitchen at the start of a shift and after engaging in other activities that contaminate the hands.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for 1 of 1 meal observed. The findings are: 1. On 12/16/24 at 11:20 AM, Certified Nursing Assistant (CNA) #2 used a 6 ounce spoon to place a serving of chicken and dumplings into a blender, pureed, and poured in a divided plate to serve to residents. The texture of the pureed chicken and dumpling was too thick. 2. On 12/16/24 at 12:26 PM, CNA #2 used a regular spoon to place 2 servings of cut green beans into a blender, pureed and poured it in a divide plate. The texture of the pureed cut green beans was not smooth, not form, water was separated from the vegetables and there were noticeable pieces of stringy beans in the mixture. 3. On 12/16/24 at 11: 35 AM, CNA #2 placed a serving of cornbread into a blender, added milk, and pureed. CNA #2 poured the pureed cornbread into a divided plate. The texture of the pureed cornbread was too thick. 4. On 12/16/24 at 12:28 PM, CNA #2 was interviewed and was asked if she could describe the texture of the pureed food items prepared and served to the resident on a puree diet. She stated pureed cut green beans were stringy and was hard to puree. Pureed cornbread and pureed chicken and dumpling were too thick. CNA #2 was asked if residents on pureed diets would be able to eat those pureed food items. CNA #2 confirmed the pureed cornbread and dumplings would be hard for the resident on pureed diet to eat.

Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program [QAPI] Committee developed and implemented appropriate plans of action to prevent repeated deficiencies for (689) preventing accident and hazards. These failed practices had the potential to affect 8 residents residing in Cottage 1. The findings are: 1. A Recertification survey was conducted on 12/18/23 at the facility. During this survey, F689 was cited for facility failure to ensure an oxygen cannister was stored securely to prevent accidents and hazards in Cottage One. The review of the facility' s Plan of Correction, with a correction date of 12/14/22 indicated: This Plan of Correction and the individual responses are submitted as a Credible Allegation of Compliance solely to meet the requirements of continued certification in the Medicare and Medicaid Programs. These responses do not constitute an admission by the Provider of the truth of the facts alleged or the conclusions set for in the CMS-2567. Step #1: Corrective Action: Upon notification of the deficient practice on 9/21/2022 the administrator immediately ensured all elders safety by performing a perimeter check in all cottages and main building. The administrator ensured all door codes were changed immediately and working properly. Resident #126 was immediately transferred to the hospital for a psychiatric evaluation and did not return to the facility. On 9/21/2022 in order to ensure elders safety the MDS ( Minimum Date Set) coordinator updated resident #5's wander assessment which indicated the resident is low risk at a score of 2, the residents care plan was updated on 10/06/2022 to reflect ability to sit and enjoy the outside on the front porch. Resident #30 was moved into the main building of the facility on 9/13/2022 where each door has a keycode to enter and exit the facility to ensure elders safety. Step #2: Identification of others with the potential of being affected. On 9/21/2022 the MDS coordinator immediately completed wander/elopement assessments on all elders within the facility to identify at risk and high-risk elders. Care plans were updated immediately of any elder at risk or high-risk to show change. Identified elders in the facility's cottages were moved into the main building to ensure safety. Step #3: To ensure deficient practice does not recur: To ensure deficient practice does not recur DON(Director of Nursing) /designee will audit new admissions for elopement risk and ensure appropriate interventions are in place. The DON/designee will audit completed MDS s to ensure the care plan reflects needs/concerns identified in the CAAS. New hires will receive education on wandering, elopement, and resident safety by DON/designee upon initial orientation. All door codes in the main building will be periodically changed to ensure elders safety by the maintenance Director/designee. Staff will be re-in serviced to report change of condition that places elders at risk for elopement. Charge nurse to report the change of condition to supervisor immediately, the care plan will then be updated by the charge nurse/designee with the new interventions to reflect elopement risk and the changes will be communicated to all staff. The facility will educate family members and staff on the importance of not sharing the access code to any resident. A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project was implemented to review and interpret audit findings. Direct care staff in-serviced on 09/21/2022 on facility Elopement Policy to ensure problem does not recur. Step #4: Monitoring Maintenance director/designee will monitor all doors within the main building and cottages 5x weekly for 4 weeks to ensure proper functioning and weekly thereafter. DON/Designee will monitor the 24-hour report daily 5 x a week ongoing and report any elopement activity to the Administrator immediately. The weekend supervisor will review on weekends and report any elopement activity immediately to the DON/Administrator. Any identified concern will be addressed immediately by the DON/Administrator. Step #5: QA Maintenance director/DON/Designee will present all findings to the monthly QA committee for further review and recommendations. On 12/21/23 at 11:15 AM, the Administrator was interviewed: How does the QAA Committee know when an issue arises in any department? The Administrator said the department managers, staff, and verbal reports. We also go over dashboard in facility's computer software daily. The Surveyor asked: How does the QAA Committee know when a deviation from performance or a negative trend is occurring? The Administrator said track and trend through the facility's computer software do root cause analysis and do an action plan to get it back on track. The Administrator was asked: How does the QAA Committee decided which issues to work on? The Administrator said track and trending, and the issues that are most significant that affect the elders, we discuss as a team. The Surveyor asked: How long will the QAA Committee monitor an issue that has been corrected? The Administrator said we will monitor it for monthly and quarterly meetings. The Administrator was asked: Is the QAA Committee aware of repeated survey deficiencies? The Administrator said no. A QAPI policy titled 2023 Quality Assurance & Performance Improvement (QAPA) Plan for The Green House Cottages of Walnut Ridge provided by the administrator on 12/18/23 upon the surveyors entry documented .Performance Improvement Projects .The QAPI team .will review our sources of information to determine if gaps or patterns exist in our systems of care that could result in quality problems .Potential areas to consider when reviewing data include: .State survey results and plans of correction . Step #4: Monitoring Maintenance director/designee will monitor all doors within the main building and cottages 5x weekly for 4 weeks to ensure proper functioning and weekly thereafter. DON/Designee will monitor the 24-hour report daily 5 x a week ongoing and report any elopement activity to the Administrator immediately. The weekend supervisor will review on weekends and report any elopement activity immediately to the DON/Administrator. Any identified concern will be addressed immediately by the DON/Administrator. Step #5: QA Maintenance director/DON/Designee will present all findings to the monthly QA committee for further review and recommendations. On 12/21/23 at 11:15 am The administrator [admin] was interviewed: How does the QAA Committee know when an issues arises in any department? The administrator said The department managers, staff, and verbal reports. We also go over dashboard in Point Click Care [PCC] daily. The surveyor asks: How does the QAA Committee know when a deviation from performance or a negative trend is occurring? The admin said track and trend through PCC and do root cause analysis, and do an action plan to get it back on track. The admin was asks: How does the QAA Committee decided which issues to work on? Admin said track and trending, and the issues that are most significant that affect the elders, we discuss as a team. The surveyor asks: How long will the QAA Committee monitor an issue that has been corrected? The admin said We will monitor it for monthly and quarterly meetings. The admin was asks: Is the QAA Committee aware of repeated survey deficiencies? The admin said no. A QAPI policy titled 2023 Quality Assurance & Performance Improvement (QAPA) Plan for The Green House Cottages of Walnut Ridge provided by the administrator on 12/18/23 upon the surveyors entry documented .Performance Improvement Projects The QAPI team .will review our sources of information to determine if gaps or patterns exist in our systems of care that could result in quality problems .Potential areas to consider when reviewing data include: .State survey results and plans of correction .

Based on observation and interview, the facility failed to ensure medications in a medication cart was used within date in accordance with accepted principles of pharmacy laws and regulations for 1 med cart. It had the potential to affect 4 Residents (#18, #28, #29, and #43) sampled residents who received insulin, and was stored in the med cart for 100 and 600 hall. The findings are: a. On 12/20/23 at 9:03AM, the medication cart for 100 & 600 halls was checked for expired medications. There were 4 vials of Novolog insulin with written date open on them. Novolog insulin for Resident # 29 had an opened date of 11/17/23. Novolog insulin for Resident #28 had an opened date of 11/12/23, Novolog insulin for Resident #43 had an opened date of 11/10/23 and Novolog insulin for Resident #18 had an opened date of 11/05/23. Licensed Practical Nurse (LPN) #2 was asks how long is insulin good for after being opened? She stated, 4 weeks. b. On 12/20/23 at 9:04 AM, the Surveyor asked LPN #2 how often do you check for expired medications? LPN #2 stated, The night nurses are responsible for checking the med carts, but I try to check the medication before I give it. The Surveyor asked LPN #2 how long is insulin good for after being opened? She stated, 4 weeks. c. On 12/21/23 at 10:46 AM, the Surveyor asked the Director of Nurses [DON] how often are med carts checked for expired medications? The DON stated, Well, the night nurses are supposed to check them every night, and then the weekend supervisor is supposed to check them every week. The pharmacy consultant also checks them monthly. The Surveyor asked the DON do you ever check the medication carts for expired medications? The DON stated, I do random checks but I guess I'm going to start checking them. The Surveyor asked how many days can Insulin be used after it is opened? The DON stated, It's 28 days on short acting insulin. d. A facility policy titled Pharmaceutical Services . provided by the DON on 12/21/23 at 09:13 am documented b. Checking the medication storage facilities at least monthly, for proper storage of medications .

Based on observation and interview the facility failed to ensure an oxygen cannister was stored securely to prevent accidents and hazards in Cottage One. The failed practice had the ability to affect all 8 residents who reside in the cottage. The findings are: 12/20/23 11:05 AM 9:40 AM, the medication closet in Cottage 1 was observed to contain a small number of supplies. OTC (Over the Counter) meds were observed to be within the use by the window. Tubing and supplies were also observed to be in date. At 9:42 AM, upon opening the double doors to the medication closet, an oxygen cannister was observed standing in the corner. The cannister was not secured in a rack. The Nurse Consultant immediately instructed the nurse to get a holder to secure the oxygen tank.

Based on observation and interview, the facility failed to ensure the call light was within reach for one Resident (Resident #73) in cottage 4. This failed practice endangers the health and safety of residents and had the potential to affect 11 residents that utilize call lights. The findings are: a. On 12/18/23 at 2:29 PM, Resident # 73 was lying in a specialty bed in high position. Resident #73 was awake and wearing a neck pillow, and glasses. The Surveyor observed the call light on the floor and under bed out of reach. b. On 12/18/23 at 3:04 PM, the Surveyor observed the call light in Resident #73's room in the same position, on the floor under the bed, and out of reach. The Surveyor asked Resident #73 if he could reach his call light and if he knew where it was. Resident # 73 answered, No to both questions. c. On 12/18/23 at 3:14 PM, the Surveyor asked CNA (Certified Nursing Assistant) if Resident #73's call light was within the Resident's reach. The CNA answered, No it's in the floor. We normally lay it across the bed across his lap because the clip is broken. The Surveyor asked the CNA how long the clip had been broken. The CNA stated I don't know. The Surveyor asked how often residents are checked to make sure call lights are within reach. The CNA stated, We usually do 2-hour rounds, but he hollers out at us. He has done that a few times. The Surveyor asked Resident #73 how often staff comes in to see if needs are being met. Resident #73 stated Less now, then in the past. d. On 12/20/23 at 12:25 PM, Resident #73 was sitting up in bed. Surveyor observed call light under covers, and asked Resident #73 if call light could be reached. Resident #73 stated, Nope, I can't reach it. It was on the floor earlier. The Surveyor prompted Resident #73 telling where the call light was observed, and asked if call light could be pushed. Resident reached under covers, found the call light attached to his brief, and pushed it. The Surveyor waited 8 minutes and the call light did not work. e. On 12/20/23 at 12:33 PM, the Surveyor asked the Assistant Administrator where the call lights signaled after being pushed by residents. The Assistant Administrator stated, We have a CNA that wears a beeper that beeps when they push their call lights. The Surveyor asked the CNA #2 (wearing the beeper) if Resident #73's call light had signaled on her beeper. CNA #2 stated, No, I don't see it flashing or showing as she looked at the beeper. The Surveyor accompanied the Assistant Administrator and CNA #2 to Resident #73's room and asked the Resident to push the call light. The call light did not signal the beeper. The Surveyor asked how long the call light had been broken. CNA #2 stated, It was working yesterday just fine. The Assistant Administrator answered, I will have our Maintenance man come and look at it. f. On 12/20/23 12:43 PM, the Assistant Administrator brought a cow bell into #73's room to use until call light could be repaired. g. On 12/20/23 1:36 PM, the Surveyor asked the DON for policy on call lights. h. On 12/20/23 2:58 PM, the Administrator informed Surveyor there was no facility policy for answering call lights.

Based on observation, interview and record review, the facility failed to ensure that a Bi Pap (Bilevel Positive Airway Pressure) mask was stored properly to prevent cross contamination for 1 Resident (R #343) of two (#18 and #343) sampled residents who have physician's orders for a Bi pap machine. The findings are: On 12/18/23 at 11:45 AM, Resident #343 mask and bi-pap machine were on top of a hard plastic, 3 drawer storage unit. The mask was observed to be open to air, not stored in a bag to prevent cross contamination. On 12/20/23 at 9:30 AM, Resident #343's bi-pap mask was observed to be lying beside the bi-pap machine on top of the hard plastic, 3 drawer storage unit. The mask is open to air, not stored in a bag to prevent cross contamination. On 12/21/23 at 9:00 AM, Resident #343's bi pap mask was observed to be in the same location, where it had been observed all week. On 12/21/23 at 9:15 AM the Surveyor asked the Director of Nursing (DON) to view the resident's mask laying exposed to air and contaminants. The DON was asked how the Resident's mask should be stored. She stated, That should be in a bag. The Surveyor asked the DON due to Resident #343's post heart transplant, would a clean mask be especially important. The DON stated, Yes it would, I'll have them do that right now. On 12/21/23 at 9:15 AM the Director of Nursing (DON) was asked to view the resident's mask laying exposed to air and contaminants. DON was asked how the resident's mask should be stored. She replied, that should be in a bag. DON was asked if the fact that R #343 was post heart transplant, would a clean mask be especially important. DON stated, yes it would, I'll have them do that right now.

Based on observation, record review, and interview, the facility failed to ensure adequate supervision was provided to prevent elopement for 1 (Residents #30) of 3(Resident #30, #48, #126) sampled residents who were at high risk for elopement. This failed practices resulted in past immediate jeopardy that caused or was likely to cause serious harm, injury, or death to Resident #30 who eloped from the facility. The Administrator, Director of Nursing (DON), and Consultant were informed of the past Immediate Jeopardy on 9/20/22 at 12:30 p.m. and the current on 9/21/22 at 3:21 p.m. and The facility failed to ensure adequate supervision was provided to prevent elopement for 1 (Resident #126) of 3 sampled residents (Residents #30, #48, #126). This failed practice resulted in immediate jeopardy that caused or was likely to cause serious harm, injury, or death to Resident #126 who eloped from the facility and Resident #5 who exited the front door but did not leave the front porch. The Administrator, Director of Nursing (DON), and Consultant were informed of the Immediate Jeopardy on 9/21/22 at 3:21 p.m. These failed practices had the potential to affect 8 residents who were an elopement risk per the list provided by the Administrator on 9/22/22 at 12:40 p.m. The findings are: 1. Resident #30 was admitted to facility on 7/15/22 with diagnosis of [CONDITION(S)] not having achieved remission, Chronic Diastolic (Congestive) Heart Failure, Hypertensive Heart Disease with Heart Failure and Anxiety Disorder. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/22/22 documented resident scored 11 (8-12 indicates moderate impairment) on the Brief Interview for Mental Status (BIMS) and independent with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. a. On 8/16/22 Resident #30 left the cottage to go to the main building to look for her nurse. The resident went to the end of 200 hall in the afternoon to look for her nurse. b. The 8/17/22 at 2:30 p.m. Nursing Note documented, Note Text: Resident has been wandering and walking around facility for most of the shift resident has been more confused than normal as well, resident showing signs and symptoms (s/s) of increased anxiety/anxiousness, resident is worried that staff is out to get her, resident called daughter and daughter came to visit with resident, daughter stated that she needs her anxiety medication, this nurse call Advanced Practice Registered Nurse (APRN) who stated okay to give One time only dose of [MEDICATION(S)] 0.5 Mg [milligrams] 2 tablets PO [By Month], and to obtain a UA (urinalysis) with C&S [culture and sensitivity] on resident, Orders processed by this nurse, will continue to monitor. c. The 9/6/22 at 11:32 p.m. Nursing Note documented, Note Text: Elder stated (I have been thinking about kill myself, and that scares me. I don't want to kill myself. But I can stop thinking about it) After talking with her, she does not have a plain, for suicide. Reported to [Name] APN (Advanced Practice Nurse). d. The 9/7/22 at 7:51 p.m. Nursing Note documented, Note Text: Resident is currently on 15 min (minute) safety checks r/t [related to] stating she wants to kill herself. Stated she did not have a plan. Resident was also attempting to elope today. Resident called 911 twice earlier today stating that there was people painting on her antique tables and she wanted them out of her house. She has been stating that we need to get all the children and people who do not belong there out of her house. She has been pacing and crying all shift. PRNs [As needed] administered and noted effective at this time. Resident is currently resting in bed. Respirations even and unlabored. Will continue to monitor and make note of any changes. e. An Office of Long-Term Care (OLTC) Witness Statement Form dated 9/12/22 at 3:45 p.m. and signed by Certified Nursing Assistant (CNA) #4 documented, Witness Full Name [Name] Job Title [CNA] .I, [Name] was leaving [Business name] after my shift and seen [Resident name] behind the cottages walking. By the time I was able to turn around she had already made it almost to [Business name] I pulled into [Business name], got out of my ear and tried to redirect her. She wasn't having it. I asked if anyone knew she had left, she said no. She got into [Business name] and held the door shut so I couldn't get in. Once I got in another CNA got there to help. [Resident name] was telling [Business name] staff that her chest was hurting. Our administrator got there and also tried to talk to her and redirect her. Our administrator had to call her family. [Resident name] was my eyesight the whole time. I watched her leave from our facility ground to [Business name]. f. An OLTC Witness Statement form dated 9/12/22 at 4:05 p.m. and signed by the Certified Nursing Assistant (CNA) #6 documented, Witness Full Name [Name] Job Title [CNA] . I was vacuuming, and CNA #7 was in the kitchen I looked up and I remember her standing by the island by the TV, but I never heard the door open or close because of the vacuum. But we never thought she would run away because she likes to sit outside and read but [DON Name] and [ADON name] came over to let us know what was going on. g. The 9/12/22 at 7:49 p.m. Nursing Note documented, Note Text: [Name], CNA (Certified Nursing Assistant) came into DON office and stated that [Name], CNA had just called her and stated that resident, [Resident name] was seen by [name] going around the fence between our facility and [Business name] parking lot. [Name] states that when she saw the resident, she was still on facility grounds, and she had the resident in her sight. Administrator called [name], resident's daughter, to help assist returning resident safely to the facility. Once safely returned to facility resident assessed with temp, 98.4, in normal limits and no negative findings noted. Resident's family member is to stay with resident tonight. Resident to be transitioned to main traditional home tomorrow. Hospice notified of situation. [Name], APRN notified via telephone. h. An OLTC Witness Statement form dated 9/13/22 at 10:00a.m. and signed by Resident #30 documented, Witness Full Name [Name Resident #30] Job Title [None listed] .Relation to Resident (if Any) Self .I was running away, because I was afraid. Because I was in a business of what, I can't remember. i. An OLTC Witness Statement form dated 9/12/22 and signed by Licensed Practical Nurse (LPN) #1 documented, Witness Full Name [Name] Job Title [CNA] . I was passing medication on 200 hall in main building during the time of resident wandering from cottage 2. j. The Care Plan initiated on 9/13/22 documented, . [Name] scored 4 on Wandering Risk scale, she is not a risk for elopement at this time. 9/12/22 Elopement attempt was made 9/13/22 Moved to main building . k. On 9/19/22 at 1:38 p.m. The resident's family notified the surveyor, One night mom had to come over to the building from the cottage to get some medication because the nurse was in the main building and not the cottage. l. An OLTC Witness Statement form dated 9/16/22 at 9:20 a.m. and signed by the Certified Nursing Assistant (CNA) #7 documented, Witness Full Name [Name] Job Title [CNA] On 9/12/22 I had been in the kitchen cooking and went to answer the call light in room 2-3. When walking past the window I seen [Resident name] outside walking on the porch. She would walk around on the porch off and on during the day. When I came out of room 2-3, I had learned then that [Resident name] had wandered off. m. On 9/20/22 at 8:19 a.m. The Surveyor asked the Certified Nursing Assistant (CNA) #4, Can you tell me what information you have regarding [Resident name] going over to [Business Name]? CNA #4 stated, I was off work. I got off at 2:00 p.m. I went to get my kids when they got out of school. I had to go to [Business name] to get my children some prescriptions. I was leaving [Business name] and I seen her walking from Cottage 2 over to Cottage 1. I tried to keep an eye on her as I was leaving. She was on the curb trying to cross over to the other side of the drive. I pulled turned left onto the highway and then turned left into the facility to turn around. When I got back over, she was at [Business name] in the grassy part in front of the building. I met up with her and told my kids to stay in the car. When I got out, I was trying to talk to her and asked if she told anyone she was gone. She stated, no I didn't but I probably should have. I was walking with her to the [Business name] door and I was on the phone with CNA #5. I asked CNA #5 if anyone knew [Resident name] was in [Business name]. I called the ADON and then I seen the Administrator's trying to get to his truck. I turned around for one second and [Resident] went into the [Business name] and closed the doors. She held the doors closed shut and I could not get in. I finally made my way into [Business name] and another CNA was in the building as well. That was when the Administrator pulled up. The Administrator took over everything from there and I came back to the facility and wrote my witness statement. The Surveyor asked, Do you know what time this occurred? CNA #4 stated, 3:30-3:45pm. The Surveyor asked CNA #4, Has the resident ever done something like this before? CNA #4 stated, No she would always set outside on the front porch or walk around the cottages, but she has never left before. n. On 9/20/22 at 8:33 a.m., The Surveyor asked CNA #5, Can you tell me what information you have regarding [Resident name} going over to [Business name]? CNA #5 stated, I was on the phone with [CNA #4] and I was leaving work. My children get off the school bus here. They were already with me, and I was leaving, and CNA #4 stated, [Resident name] was in the parking lot of [Business name]. I turned back into the facility, and I ran in and told DON and ADON. They jumped up and ran to the Cottages. CNA #4 stayed with the resident until the Administrator got there. I went over to the cottage to help the staff check on the residents then I left because, I had my kids with me. o. On 9/20/2022 at 11:02 a.m., an Inservice was provided by the facility, with 36 staff signatures completed on 9/12/22. It documented, .Elopement/Elopement attempts/ Exit seeking or shaking the door ., If any of the above has occurred or occurring, you should immediately do these steps every time: Inservice staff on elopements after any elopement attempt immediately after ensuring all other elders are accounted for and the missing elder is back in the home ., 1. Do a head count/census count to ensure al are accounted for and are safe? ., 2. Do a perimeter check to insure all elders are accounted for and are safe and are not outside ., 3. Search every office, closet, supply closet, locked doors, refrigerators, every nook and cranny to ensure all elders are accounted for and or safe ., 4. Do door checks on every exit door to ensure all exit doors are secured and alarms are functional ., 5. Do an elopement assessment on all elders and ensure the assessment is correct. Do not use old scores. If all post elopement assessments were completed within 30 minutes, there is something wrong ., 6. Ensure that the elopement binder at the nurse's station is up to date. Any elder that exit seeks, attempts to elope or shakes the doors should have a up to date picture that shows their entire body. If they ambulate-the picture needs to show them standing with whatever device is in use. If a Wheelchair is in use, the picture should include that .,7. An elopement assessment should be completed on every elopement attempt, even if unsuccessful. Any time an exit seeker shakes the door, one should be completed ., 8. Care plans should address any elopement a score of 5 or higher. If their score is above 5, but doesn't exit seek, doesn't express a desire to go home, then the care plan needs to address that the elopement score if high because they are on numerous medications. 1 point is given for every medications that is checked .,9. Every exit door should have some type of alarm on it. If there isn't one, obtain a smart alarm from Walmart or closest store available as soon as possible and place it on the exit door .,10. All staff needs to in serviced on elopements, attempted elopements, exit seeking behavior and any resident that shakes the door are considered to be an elopement risk and should be treated as such ., 11. All staff need to be in serviced on responding immediately to an alarming door ., 12. The administrator, DON [director of nursing] and or ADON [assistant director of nursing] should be notified immediately ., 13. Follow your specific missing resident/elopement protocols in notifying police, family, etc. [etcetera] or as otherwise instructed by the administrator ., 14. Review every admission/readmission assessment for their elopement score and any that have expresses desire to go home and /or exits seeks; initiates steps immediately to prevent elopement from occurring . p. On 9/20/22 at 11:19 a.m. The DON provided a statement and it documented, On September 12, 2022, at approximately 1600 (4:00 PM, I, [Name] RN/DON [Registered nurse/Director of Nursing] and [Name] LPN/ADON [Licensed Practical Nurse/Assistant Director of Nursing] pulled a complete census report we rounded on all elders in the cottages and checked the cottage doors for proper locking and alarm functions as well as a perimeter check. Next, I, [Name] RN/DON [Registered nurse/Director of Nursing] completed rounds on all elders in the traditional building while checking doors for proper locking and alarm functions as well as a perimeter check. q. On 9/20/22 at 3:54p.m., The Surveyor asked the DON [Director of Nursing], Are you aware of the resident coming over here during a rainstorm one night looking for her nurse? DON stated, No, I have never heard of that. The Surveyor asked, Are you aware of a day when the resident walked over to the building from the cottage to get medication from her nurse? DON stated, I do know she come over to the building looking for her nurse. She would walk around the cottages yard and would set outside a lot of the time. The Surveyor asked, Can you tell me what occurred that day on 8/16/22 that the resident walked over to the building looking for her nurse? The Surveyor asked, What was done to prevent resident from leaving the cottage and returning to the traditional building? DON stated. I educated the resident and the Nurse. The Surveyor asked the DON, Can I see the documentation you have for the education? DON stated, I done the education verbally and there was no documentation. The Surveyor asked, Do your nurses work the cottages and building at the same time? DON stated, Yes. r. Review of Resident #30's medical chart showed no documentation of the occurrence. 2. Resident # 126 was admitted on [DATE] with diagnoses of Malignant Neoplasm of Esophagus, Unspecified, Adult Failure to Thrive, Malignant Neoplasm of Upper Third of Esophagus, Barrett's Esophagus with High Grade [CONDITION(S)] and Severe Protein-Calorie Malnutrition. The Admission Minimum Data Set (MDS) has not been completed. A Brief Interview for Mental Status (BIMS) was completed on 9/14/22 and resident scored 15 (13-15 indicates cognitively intact). The Admission Evaluation dated 9/13/22 documented resident was independent with bed mobility, eating, ambulation, toileting, and required supervision with dressing and personal hygiene. a. On 9/13/22 The Admission Evaluation documented, .B. Wandering Risk Scale .1. The resident is comatose, and/or dependent on Activity of Daily Living (ADL)S and cannot move without assistance, and/or is stuporous b. no. Mental Status 2. The resident: 1. Can follow instructions. Mobility 3. The resident: 3. Is ambulatory Speech Patterns 4. The resident: 0. Can communicate History of Wandering 5. The resident: 0. Has no history of wandering. Diagnosis 6. The resident has: 0. NO diagnosis of dementia/cognitive impairment; diagnosis impacting gait/mobility or strength .Wandering Risk Sale Score 4.0 . b. The Care Plan initiated on 9/19/22 documented, . [Resident name] scored 4 on Wandering Risk Scale, she is not at risk to elope at this time .Wandering risk Assessment as indicated, observe for any changes in mobility, exit seeking or wandering behaviors .Ambulation: Resident #126 is independent with ambulation .LOCOMOTION: Resident #126 is independent with locomotion .9/18/22 Observe for unsafe practices, cue for safety as needed. Encourage her to wear appropriate footwear, assist as needed. c. The 9/20/22 at 3:45 pm, Nursing Note documented, Nature/Description of Incident: CNA (Certified Nursing Assistant) reported that she was sitting at the table near the front door and witnessed resident walking to the door from the front porch pulling her wheelchair behind her and as resident was approaching the door, the CNA got up to meet her, and residents wheelchair began to roll backwards and resident grabbed her wheelchair and sat slowly to the ground in a crisscross legged fashion without hitting her head. Staff stated that resident's right buttocks touched the ground first and resident was continuously asking CNA not to report incident. CNA reported that she told resident that the incident had to be reported. As the nurse approached the resident outside at the front door, she was sitting on the ground holding on to the left side arm rest of her wheelchair with her right hand. Resident was assisted to a standing position and was resistive when this nurse and CNA was attempting to help her into her wheelchair. This nurse assisted resident to her room and observed resident for injuries with CNA at side. When this nurse asked resident what happened, she responded My wheelchair rolled backwards, and I couldn't grab it so I sat down. Resident stated that she sat down and did not fall. No new s/sx (signs/symptoms) of injuries from current fall. There was no redness noted and she denied pain . d. The 9/20/22 at 10:30 pm Nursing Note documented, Note Text: CNA reported to me. Resident was trying to leave the facility, when trying redirect resident. She stated If you don't leave me alone you will have to call the ambulance for yourself. Because I'm going to hurt you bad. e. The 9/21/22 at 6:41 am Nursing Note documented, Note Text: CNA reported elder was demanding to go to the Kitchen. When CNA explained the kitchen was closed and locked. She stated, I can go anywhere I want, and if you try to stop me, I will break the door down. f. The 9/21/22 at 9:00 am, Nursing Note documented, Note Text: Elder noted to be up stumbling around in her room. This nurse asked elder to please sit down and use her wheelchair (w/c) for mobility until she is stronger. Elder has had multiple falls and staff do not want her to get hurt. Elder was also asked to continue working with therapy to build her strength. Elder stated I am not crazy. Elder reassured that no one had said she was crazy, and she was asked to use the w/c because she is still weak and needs to build her strength up. Elder's room noted to have things strewn all over as well as liquid in the floor. Staff attempted to clean it up but elder was uncooperative. g. On 9/21/22 at 11:07am the Administrator was walking quickly down 200 Hallway pushing a wheelchair. The Billing Office Manager (BOM) swiftly walked back into the building. This Surveyor looked out the front door and observed a police car in the road with flashing lights and traffic was backed up. The Surveyor walked out the front door to the grass area between the road and the building and met the Administrator. The Surveyor asked the Administrator, What is going on? The Administrator stated, The Director of Nursing (DON) is on the phone calling for [Ambulance Service Name] to transfer her out for a psych (psychological) eval (evaluation). The Surveyor asked the Administrator, How did she get out? The Administrator stated, She [Resident] knows the code to the building and now she [Resident] is refusing to come back in. h. On 9/21/22 at 11:15am, the Resident was sitting in the back of a police car with her legs out the door and her feet on the road talking with Bystander #2 and the police refusing to come back into the facility. i. On 9/21/22 at 11:16am, Bystander #1 walked up to the Surveyor and stated, I am with the television stations and was leaving the reception and she [Resident] was just standing in the middle of the road. I saw Bystander #2 get out of her vehicle and walk up to the resident. Then a person came out of the building walking toward the resident and the resident started saying I am scared and would not let the employee come close to her. j. On 9/21/22 at 11:19 am, the Resident was loaded into the back of an ambulance by Emergency Personnel. k. On 9/21/22 at 11:20 am, Bystander #2 stated, I was driving down the road and I see this lady standing in the middle of the road. I went up to her and asked her if she was ok. The police stopped and we just started talking to her and was able to get her to set down in the car. She would not let anyone get close to her. l. On 9/21/22 at 11:24am, The Surveyor asked Certified Nursing Assistant (CNA) #3, Can you tell me what happened with Resident #126? CNA #3 stated, The BOM came out her office and said [Resident name] is outside. I darted outside and the police were already out there with her. The Surveyor asked CNA #3, Do you know how she got out? CNA #3 stated, She knows the code by her room so she must have gone out that door because she did not come through the front. m. On 9/21/22 at 11:25am, The Surveyor asked the BOM, Can you tell me what happened with Resident #126? The BOM stated, I got a phone call and the person said, Hey, I think one of your residents is out in the road trying to touch cars. I asked [CNA #3] is that [Resident #126] outside. She looked outside and said yes as she went out the front door. [Resident #126] was standing in the road and people were coming up to her [resident] and I started calling administration. n. On 9/21/22 at 11:30am, Nursing Incident and Accident report documented, Nature/Description of Incident: BOM ran to DON/ADON [Director of Nursing/Assistant Director of Nursing] office and stated that resident was on the highway trying to touch cars. DON, ADON, & Administrator immediately ran outside to resident where she was standing with a police officer, bystander, and CNA near the police officers' car in the turning lane in the middle of the road in front of the facility. Staff attempted to redirect resident back to facility, and she refused. She told the police officer she wanted to get in his car and refused for staff to come near her. Resident refused to speak to staff and stated to the police officer, Please I don't want to go back there. I want to stay with you. I want to get in your car. Let me stay with you please. The DON immediately called APRN [Advanced Practice Registered Nurse] and received STAT [Without delay] telephone order to send resident out to ER [emergency room ] for eval and treatment. Description of Injuries: Resident refused to talk to staff or allow staff to come near her, unable to observe for injuries or pain. Immediate Actions Taken: Sent to [Hospital Name] ER for evaluation and treatment o. The 9/21/22 at 11:31am Nursing Note documented, Note Text: At 11:26, resident was transported to (Named Facility) emergency room (ER) for eval and treatment via (Named Ambulance Company) accompanied by 2 EMS personnel.,(Named) mother, was notified of incident and transfer. She stated she lived a couple hours away and was unsure if she would be able to make it to the hospital and thanked this nurse for calling. p. The 9/21/22 at 12:30pm Nursing Note documented, Note Text: Last night at approximately 1915, resident was noted to be yelling [Name]. Resident was noted to be in her wheelchair at her room doorway. Enquired who [Name] was and she stated my friend up there, referring to another resident. Resident stated that she had fell and no one was taking care of her. Explained to resident that we were taking care of her and that is why we were checking her vitals and neuros (neurological status). Resident's neuros noted to be WNL [Within normal limits]. Also explained to resident that we had contacted [Name], APRN [Advanced Practice Registered Nurse] and had received order to send her to the ER [emergency room ] for evaluation. She responded that we were taking too long and asked if she needed to call 911. She said, I want [Name] to call all my doctors to check this place out. Explained that we were calling the ambulance to come get her. [Resident name] was then escorted via wheelchair to DON office while report was being called to [Hospital Name] ED [Emergency Department] and [Ambulance Service Name] per [ADON Name]. [ADON name] asked resident if there was anyone that she would like for us to call and she said [Name]. [ADON] attempted to call [Name] without success x2 attempts. Asked resident if there was anyone else, she would like to notify and she said her mother. Her mother was called at approximately 1921 [7:21p.m.]and resident yelled to put her on speaker phone while ADON was attempting to explain situation. Resident stated, My room is inhumane, but you know how nasty I am. Mom I am confused at this place. Mother, [Mother Name], replied to resident you don't think properly when you need to get some rest. After phone call resident was mumbling to herself repeatedly I am so sorry ya'll are not taking care of me. Asked what we are not doing to take care of you, and she replied everything. Asked to explain what she meant, and she would only reply everything. [Ambulance Service Name] arrived at office at 1930 [7:30p.m.] Resident's PEG [Percutaneous Endoscopic Gastrostomy] was flushed and disconnected from continuous feeding. She was assisted onto the stretcher, and she was telling [Ambulance Service Name] that we don't take care of people here. Female paramedic was noted to stated that she has only seen us take care of people and we were nice. Resident in care of [Ambulance Service Name] x2 and exited facility at 1943 (7:43p.m.). q. The 9/21/22 at 1:42pm note documented, Note Text: At approximately 0820 this morning spoke with [Name] APRN regarding information obtained from resident's parents during phone call last evening regarding resident's past behavioral issues, her attention seeking behaviors, and past drug abuse. No new orders received at this time. The 9/21/22 at 9:12PM Nursing Note documented, Note Text: Spoke with RN at (Named Hospital) and resident was admitted to (Named unit) for weakness and elevated troponin. r. An Office of Long-Term Care (OLTC) Witness Statement form dated 9/21/22 and signed by the Certified Nursing Assistant [CNA] documented, Witness Full Name [Name] Job Title [CNA] .Did my 15 minutes at 11:00am safety check on [Resident name], she was still in her bed. I came to relief [Name] at the door. Name BOM, came and told me [Resident name] was outside in the road. I ran out the door to be with her until nurse or department head could arrive on scene. s. An OLTC Witness Statement form dated 9/21/22 at 11:50a.m. and signed by the BOM documented, Witness Full Name [Employee name] Job Title [Billing Office Manager] .I received a phone call on facility phone around 11:05am. Caller stated, I think one of ya'll resident is out in the highway trying to touch cars. I said, Thank you. I ran outside to look but couldn't quite tell. I came back to the door and asked [name] to look, which she did, and she said it was her. She went on out to the road, and I ran in to the DON [Director of Nursing] office to tell Administrator, DON, and ADON who then rushed outside. t. On 9/21/22 at 5:13pm, the plan of removal was accepted. u. On 9/23/22 at 8:25am, The Surveyor asked the DON, Were there any revisions made to [Resident Name] care plan on Tuesday after her verbalizing wanting to leave the facility? DON stated, I would have to look at her care plan. The Surveyor asked, When do you revise your facility care plans? DON stated, They are done after our morning meetings. The Surveyor asked, Who is responsible for revising care plan? DON stated, The MDS [Minimum Data Set] Coordinator. v. On 9/23/22 at 8:47am, The Surveyor asked MDS Coordinator #1, Did you make any revisions to [Resident name] following her verbalizing wanting to leave the facility on Tuesday? MDS Coordinator #1 stated, No, I did not. The Surveyor asked MDS coordinator #1, When do you revise care plans? MDS Coordinator #1 stated, Usually after morning meeting and we are able to go over everything. That Wednesday morning, I was working a medication cart on the floor so I would not have made any changes to the care plan. MDS Coordinator pulled up the resident's care plan on her computer and stated, Sometime that day after she eloped, it looks like I update her care plan after they completed a new wandering risk assessment. w. On 9/23/22 at 8:52am, The Surveyor asked MDS Coordinator #2, Did you make any revisions to [Resident name] following her verbalizing wanting to leave the facility on Tuesday? MDS Coordinator #2 stated, No, I did not The Surveyor asked, When do you revise care plans? MDS Coordinator #2 stated, The same as her. After we go over things in the morning meeting or I will change it throughout the day as the orders change. The Surveyor asked, Were there changes to [Resident name] care plans that needed to be made? MDS Coordinator #2 stated, I am not even sure we had a morning meeting on Wednesday. The Plan Of Removal for Resident #126 was provided by the Administrator on 09/21/22 at 4:59 PM reads as follow: Preperation and/or execution of this plan do not constitute admission or agreement by the provider thta immediate jeopardy exists. This response is also not to be construed as an admission of fault by the facility, its empoyees, agents or other individuals who draft or may be discussed in this response and immediate jeopardy removal plan. This immediate jeopardy removal plan is submitted as the facility's immediate actionable plan to remove the likelihood that serious harm to a resident will occur, or reocur. 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 9/21/2022) Residents directly involved in this deficient practice had their care plan reviewed and updated by the DON or designee and updated to reflect current wandering and elpement risk. The MDS Coordinator reveiwed Section E of the MDS and associated CAA for all residents. Care Plans were reviewed and updated to ensure they reflect audit findings, Concerns were not identified. MDS Coordinator/Designee re-evaluated residents at risk for wandering using an wander risk assessment tool. All nursing staff currently shiftswill be educated on wandering, elopement, and resident safety from the DON and designee(s). Any staff on leave will receive education on their next scheduled work day. 2. Actions to Prevent Occurence/Reoccurence: The facility took the following actions to prevent an adverse outcome from reoccuring. (Completion Date: 9/21/22) Elopement and wandering resident's policy was reviewed. The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place. The DON or designee will audit compleded MDS's to ensure the care plan reflects needs/concerns identified in the CAAs. New hires will receive education on wandering, elopement, and resident safety by the DON or designee(s) upon initial orientation. Administrator or designee(s) called upon the Fire/Alarm Security Team to evaluate maglock on front door and changed all keypad codes to each door withn the facility on 9/21/2022. Saff will be re-in-serviced to report a change of conditi [TRUNCATED]

Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; failed to ensure food items stored in dry goods area were sealed, labeled, and dated; failed to ensure 1 of 4 ice machines were maintained in sanitary condition, failed to ensure hot foods on the steam table were maintained at or above 135 degrees Fahrenheit to prevent potential food borne illness for residents who received meals from 1 (main Kitchen) of 4 out of the kitchens; foods were dated when received to assure first in first out usage to prevent potential for food bone illness. The failed practices had the potential to affect 10 who received meals from Cottage #2, 39 residents who received meals and ice from the main kitchen (total census: 76), as documented on a list provided by Dietary Employee ---. The findings are: 1.On 9/19/22 at 10:54 PM(AM?), a tour of the main Kitchen with Dietary Employee #2 showed, the section of the ice machine where ice formed before it dropped had an accumulation of wet, red, and black residue on it. The panel of the ice machine had a wet black residue on it. The Surveyor asked Dietary Employee #2 to wipe the residue off the panel and the section of the ice machine where ice formed, the wet, red, and black residue easily transferred to the tissue. The Surveyor asked Dietary Employee #2 to describe what transferred to the tissue, There was black and red residue. The Surveyor asked, Who used the ice from the ice machine and how often do you clean the ice machine? She stated, CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms and we use it to fill beverages served to the residents at meals. The Maintenance Employee cleans it. a. On 09/19/22 At 4:06 PM, The Surveyor asked the Maintenance Employee, how often do you clean the ice machine? He stated, I clean it out every month. I empty it out and clean it. 2. On 9/19/22 at 11:06 AM, the following were in the storage room: a. An opened bag of tortilla chips was stored on a shelf, the bag was not sealed. b. An opened bag of toasted oats was stored on a shelf, the bag was not sealed. 3. On 9/19/22 at 11:08 AM, the following spices in the kitchen cabinet of Cottage 2 were not dated when they were received or opened: a. A container of onion powder. b. Container of celery salt. c. Container of garlic powder. d. A container of ground black pepper. e. One container of all spice [NAME] flakes. f. One container of cinnamon g. One bottle of soy sauce h. One container of Italian seasoning and a tub of syrup. 4. On 9/19/22 at 11:17 AM, a bag of wheat bread and a bag of (brand name) bread stored on the counter had no received or opened date. 5. On 9/19/22 at 11:55 AM, Dietary Employee #2 touched her mask, without washing her hands, she picked up clean cups by the rims and poured tea to serve to the residents for lunch. 6. On 9/19/22 at 11:59 AM, the Certified Nursing Assistant tested and read the temperature of the following food items: a. Pureed chicken enchilada 98 degrees Fahrenheit and pureed refried beans 99.4 degrees Fahrenheit. 7. On 9/19/22 at 12:09 PM, Dietary Employee #2 picked up the water hose with her bare hands, used it to spray off leftover food items from the blender bowl contaminated her hands, placed dishes in the dirty rack and pushed them into the dish washing machine to wash. When the dishes stopped washing, Dietary Employee #2 moved to the clean side in the dishwasher area and without washing her hands picked up a clean blade from the dish rack and attached it to the base of the blender to puree food items for the residents who received pureed diets for the lunch meal. The Surveyor immediately asked Dietary Employee #2 was, What should you have done after touching dirty objects and before handling clean equipment or food items? She stated, I should have washed my hands 8. On 9/19/22 at 12:16 PM, Dietary Employee #3 was wearing gloves; she removed a bag of flour tortillas from the shelf in the storage room and placed it on the counter. She removed a bag of shredded cheese from the refrigerator and placed it on the counter. She picked up a sauce pan and placed it on the stove. She then turned on the stove. Without removing gloves and washing her hands, she removed flour tortillas from the bag and placed them in the saucepan, removed shredded cheese from the bag, placed it on top of the flour tortillas and made cheese quesadillas for the residents who did not like chicken enchiladas. The Surveyor asked Dietary Employee #3 What should you have done after touching dirty objects and before handling clean equipment objects? She stated, Washed my hands. 9. On 9/20/22 at 2:23 PM, The facility's policy on hand washing documented, Wash hands before beginning a different task.

Based on interview and record review the facility failed ensure Medicaid recipient residents were notified when the amount in their trust account was within $200 of the Supplemental Security Income (SSI) resource limit. (R#2, R #10, R#31, R#45, R#50). The failed practice had the potential to affect the 51 residents who had a trust account managed by the facility according to a list provided by the Business Office Manager (BOM) on 9/20/22 at 10:55 AM. The findings are: On 09/20/22 at 10:55 AM, The BOM provided a list of residents who had a trust account managed by the facility. Of the 60 accounts listed, three accounts were within $200 of the resource limit. Two of the accounts were over the $2,000 limit. The Surveyor asked the Business Office Manager if the resident's or their families/representatives were notified of their balances. The Business Office Manager stated, .we send out monthly statements . The Surveyor asked if a letter was sent out specifically to notify families of their proximity to the $2,000 limit and the repercussions of going over the limit. The BOM stated, .I've been here eight and a half years and I have never sent out a letter .

Based on record review and interview, the facility failed to ensure the State Ombudsman was notified in writing of transfers to the hospital, to protect resident rights for 2 (Residents #34 and #55) of 8 (Residents #28, #29, #34, #48, #55, #62, #70, #72) sampled residents who were transferred to the hospital in the last twelve months. A list of discharges and transfers was provided by the Business Office Manager (BOM) on 9/22/22 at 11:05 AM. The findings are: 1. Resident #34 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/17/22 the resident received a score of 11 (8-12 moderately impaired) on the Brief Interview for Mental Status (BIMS. The list of transfers and discharges showed, Resident #34 was transferred to the hospital on 9/6/22. 2. Resident #55 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the MDS with an ARD of 8/8/22, the resident received a score of 15 (13-15 Cognitively Intact) on the BIMS. The resident requires extensive assistance with bed mobility, transfer & dressing. Limited Assistance is required for hygiene and toileting. Eating requires supervision. The list of transfers and discharges showed, Resident #55 was transferred to the hospital on 9/18/22. 3. On 9/20/22 at 10:30 AM, the BOM provided the Notice of Transfer/Discharge/LOA with Bed Hold Policy -V7. It states that the Resident (regardless of payment type) will be transferred, discharged or on leave of absence with expected turn to the facility, Method of notification hand delivered to the resident, and a notice must be hand delivered to the representative. The Surveyor asked the BOM, who was responsible for sending the Notice of Transfer out to the family or representative. She stated, .I do that . The Surveyor asked the BOM who was responsible for the notification of the state Ombudsman. She stated, .I'm not sure who is doing that. At one time I think the Assistant Director of Nursing (ADON) did that. Let me check and get back to you . The BOM returned and stated, .I was right it hasn't been done . On 9/23/22 at 9:50 AM, the Surveyor asked the BOM to confirm the length of time since the Ombudsman was notified and she stated, .it's probably been a year, but I can guarantee she will be now .

Based interview and record review the facility failed to ensure the resident's plan of care was updated to reflect an acute change in resident's elopement/wandering status for 1 (Resident #126) of 8 residents identified as high risk for elopement according to the list provided by the Administrator on 9/22/22 at 12:40pm. These failed practices resulted in Immediate Jeopardy that caused or was likely to cause serious harm, injury, or death to Resident #126 who eloped from the facility on 9/21/22 at 11:07am. The Administrator, Director of Nursing (DON), and Consultant were informed of the Immediate Jeopardy on 9/21/22 at 3:21 p.m. The findings are: Resident #126 was admitted on [DATE] with diagnoses of Malignant Neoplasm of Esophagus, Unspecified, Adult Failure to Thrive, Malignant Neoplasm of Upper Third of Esophagus, Barrett's Esophagus with High Grade [CONDITION(S)] and Severe Protein-Calorie Malnutrition. The Admission Minimum Data Set (MDS) has not been completed. A Brief Interview for Mental Status (BIMS) was completed on 9/14/22 and resident scored 15 (13-15 indicates cognitively intact). The Admission Evaluation dated 9/13/22 documented resident was independent with bed mobility, eating, ambulation, toileting, and required supervision with dressing and personal hygiene. 1. On 9/13/22 The Admission Evaluation documented, .B. Wandering Risk Scale .1. The resident is comatose, and/or dependent on Activity of Daily Living (ADL)S and cannot move without assistance, and/or is stuporous b. no. Mental Status 2. The resident: 1. Can follow instructions. Mobility 3. The resident: 3. Is ambulatory. Speech Patterns 4. The resident: 0. Can communicate. History of Wandering 5. The resident: 0. Has no history of wandering. Diagnosis 6. The resident has: 0. No diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. The Care Plan initiated on 9/19/22 documented, . [Resident name] scored 4 on Wandering Risk Scale, she is not at risk to elope at this time .Wandering risk Assessment as indicated, observe for any changes in mobility, exit seeking or wandering behaviors .Ambulation: Resident #126 is independent with ambulation .LOCOMOTION: Resident #126 is independent with locomotion .9/18/22 Observe for unsafe practices, cue for safety as needed. Encourage her to wear appropriate footwear, assist as needed. 3. The 9/20/22 at 3:45 pm Nursing Note documented, Nature/Description of Incident: CNA (Certified Nursing Assistant) reported that she was sitting at the table near the front door and witnessed Resident #126 walking to the door from the front porch pulling her wheelchair behind her and as resident was approaching the door, the CNA got up to meet her, and residents wheelchair began to roll backwards and resident grabbed her wheelchair and sat slowly to the ground in a crisscross legged fashion without hitting her head. Staff stated that residents' right buttocks touched the ground first and resident was continuously asking CNA not to report incident. CNA reported that she told resident that the incident had to be reported. As the nurse approached the resident outside at the front door, she was sitting on the ground holding on to the left side arm rest of her wheelchair with her right hand. Resident was assisted to a standing position and was resistive when this nurse and CNA was attempting to help her into her wheelchair. This nurse assisted resident to her room and observed resident for injuries with CNA at side. When this nurse asked resident what happened, she responded My wheelchair rolled backwards, and I couldn't grab it so I sat down. Resident stated that she sat down and did not fall. No new s/sx (signs/symptoms) of injuries from current fall. There was no redness noted and she denied pain . 4. The 9/20/22 at 10:30 pm Nursing Note documented, Note Text: CNA reported to me. Resident was trying to leave the facility, when trying redirect resident. She stated If you don't leave me alone you will have to call the ambulance for yourself. Because I'm going to hurt you bad. 5. The 9/21/22 at 6:41 am Nursing Note documented, Note Text: CNA reported elder was demanding to go to the Kitchen. When CNA explained the kitchen was closed and locked. She stated, I can go anywhere I want, and if you try to stop me, I will break the door down. 6. The 9/21/22 at 9:00 am Nursing Note documented, Note Text: Elder noted to be up stumbling around in her room. This nurse asked elder to please sit down and use her wheelchair (w/c) for mobility until she is stronger. Elder has had multiple falls and staff do not want her to get hurt. Elder was also asked to continue working with therapy to build her strength. Elder stated I am not crazy. Elder reassured that no one had said she was crazy, and she was asked to use the w/c because she is still weak and needs to build her strength up. Elder's room noted to have things strewn all over as well as liquid in the floor. Staff attempted to clean it up but elder was uncooperative. 7. On 9/21/22 at 11:07 am The Administrator quickly pushed a wheelchair down the 200 Hallway. The Billing Office Manager (BOM) walked back into the building swiftly. The Surveyor looked out the front door and observed a police car in the road with flashing lights, traffic was backed up. The Surveyor walked out the front door to the grass area between the road and the building and met the Administrator. The Surveyor asked the Administrator, What is going on? The Administrator stated, The Director of Nursing (DON) is on the phone calling for [Ambulance Service Name] to transfer her out for a psych (physcological) eval (evaluation). The Surveyor asked the Administrator, How did she get out? Administrator stated, She [Resident #126] knows the code to the building and now she [Resident #126] is refusing to come back in. 8. On 9/21/22 at 11:15am, Resident #126 was in the back of a police car with her legs out the door and her feet on the road, talked with Bystander #2 and the police, refused to come back into the facility. 9. On 9/21/22 at 11:16am, Bystander #1 walked up to the Surveyor and stated, I am with the television stations and was leaving the reception and she [Resident] was just standing in the middle of the road. I saw Bystander #2 get out of her vehicle and walk up to the resident. Then a person came out of the building walking toward the resident and the resident started saying I am scared and would not let the employee come close to her. 10. On 9/21/22 at 11:19 am, Resident #126 was loaded into the back of an ambulance by Emergency Personnel. 11. On 9/21/22 at 11:20 am, Bystander #2 stated, I was driving down the road and I see this lady standing in the middle of the road. I went up to her and asked her if she was ok. The police stopped and we just started talking to her and was able to get her to set down in the car. She would not let anyone get close to her. 12. On 9/21/22 at 11:24am, The Surveyor asked Certified Nursing Assistant (CNA) #3, Can you tell me what happened with Resident #126? CNA #3 stated, The BOM came out her office and said [Resident name] is outside. I darted outside and the police were already out there with her. The Surveyor asked CNA #3, Do you know how she got out? CNA #3 stated, She knows the code by her room so she must have gone out that door because she did not come through the front. 13. On 9/21/22 at 11:25am, The Surveyor asked the BOM, Can you tell me what happened with Resident #126? BOM stated, I got a phone call and the person said, Hey, I think one of your residents is out in the road trying to touch cars. I asked CNA #3 is that [Resident name] outside. She looked outside and said yes as she went out the front door. [Resident name] was standing in the road and people were coming up to her [resident] and I started calling administration. 14. On 9/21/22 at 11:30am, Nursing Incident and Accident report documented, Nature/Description of Incident: BOM ran to DON/ADON [Director of Nursing/Assistant Director of Nursing] office and stated that resident was on the highway trying to touch cars. DON, ADON, & Administrator immediately ran outside to resident where she was standing with a police officer, bystander, and CNA near the police officers' car in the turning lane in the middle of the road in front of the facility. Staff attempted to redirect resident back to facility, and she refused. She told the police officer she wanted to get in his car and refused for staff to come near her. Resident refused to speak to staff and stated to the police officer, Please I don't want to go back there. I want to stay with you. I want to get in your car. Let me stay with you please. The DON immediately called APRN [Advanced Practice Registered Nurse] and received STAT [Without delay] telephone order to send resident out to ER [emergency room ] for eval and treatment. Description of Injuries: Resident refused to talk to staff or allow staff to come near her, unable to observe for injuries or pain. Immediate Actions Taken: Sent to [Hospital Name] ER for evaluation and treatment 15. The 9/21/22 at 11:31am Nursing Note documented, Note Text: At 11:26, resident was transported to (Named) emergency room (ER) for eval and treatment via Medic One (Named Ambulance Company) accompanied by 2 EMS personnel. mother, was notified of incident and transfer. She stated she lived a couple hours away and was unsure if she would be able to make it to the hospital and thanked this nurse for calling. 16. The 9/21/22 at 12:30pm Nursing Note documented, Note Text: Last night at approximately 1915, resident was noted to be yelling [Name]. Resident was noted to be in her wheelchair at her room doorway. Enquired who [Name] was and she stated my friend up there, referring to another resident. Resident stated that she had fell and no one was taking care of her. Explained to resident that we were taking care of her and that is why we were checking her vitals and neuros (neurological status). Resident's neuros noted to be WNL [Within normal limits]. Also explained to resident that we had contacted [Name], APRN [Advanced Practice Registered Nurse] and had received order to send her to the ER [emergency room ] for evaluation. She responded that we were taking too long and asked if she needed to call 911. She said I want [Name] to call all my doctors to check this place out. Explained that we were calling the ambulance to come get her. [Resident name] was then escorted via wheelchair to DON office while report was being called to [Hospital Name] ED [Emergency Department] and [Ambulance Service Name] per [ADON Name]. [ADON name] asked resident if there was anyone that she would like for us to call and she said [Name]. [ADON] attempted to call [Name] without success x2 attempts. Asked resident if there was anyone else, she would like to notify and she said her mother. Her mother was called at approximately 1921 [7:21p.m.] and resident yelled to put her on speaker phone while ADON was attempting to explain situation. Resident stated, My room is inhumane, but you know how nasty I am. Mom I am confused at this place. Mother, [Mother Name], replied to resident you don't think properly when you need to get some rest. After phone call resident was mumbling to herself repeatedly I am so sorry ya'll are not taking care of me. Asked what we are not doing to take care of you, and she replied everything. Asked to explain what she meant, and she would only reply everything. [Ambulance Service Name] arrived at office at 1930 [7:30p.m.] Resident's PEG [percutaneous Endoscopic Gastrostomy] was flushed and disconnected from continuous feeding. She was assisted onto the stretcher, and she was telling [Ambulance Service Name] that we don't take care of people here. Female paramedic was noted to stated that she has only seen us take care of people and we were nice. Resident in care of [Ambulance Service Name] x2 and exited facility at 1943 (7:43p.m.). 17. The 9/21/22 at 1:42pm note documented, Note Text: At approximately 0820 this morning spoke with [Name] APRN regarding information obtained from resident's parents during phone call last evening regarding resident's past behavioral issues, her attention seeking behaviors, and past drug abuse. No new orders received at this time. The 9/21/22 at 9:12PM Nursing Note documented, Note Text: Spoke with Named) RN at (Named) and resident was admitted to 2 East for weakness and elevated troponin. 18. An Office of Long-Term Care (OLTC) Witness Statement form dated 9/21/22 and signed by the Certified Nursing Assistant [CNA] documented, Witness Full Name [Name] Job Title [CNA] .Did my 15 minutes at 11:00am safety check on [Resident name], she was still in her bed. I came to relief [Name] at the door. Name BOM, came and told me [Resident name] was outside in the road. I ran out the door to be with her until nurse or department head could arrive on scene. 19. An OLTC Witness Statement form dated 9/21/22 at 11:50a.m. and signed by the BOM documented, Witness Full Name [Employee name] Job Title [Billing Office Manager] .I received a phone call on facility phone around 11:05am. Caller stated, I think one of ya'll resident is out in the highway trying to touch cars. I said, Thank you. I ran outside to look but couldn't quite tell. I came back to the door and asked [name] to look, which she did, and she said it was her. She went on out to the road, and I ran in to the DON office to tell Administrator, DON, and ADON who then rushed outside. 20. On 9/21/22 at 5:13pm, the plan of removal was accepted. 21. On 9/23/22 at 8:25am, The Surveyor asked the DON, Were there any revisions made to [Resident Name] care plan on Tuesday after her verbalizing wanting to leave the facility? DON stated, I would have to look at her care plan. The Surveyor asked, When do you revise your facility care plans? DON stated, They are done after our morning meetings. The Surveyor asked, Who is responsible for revising care plan? DON stated, The MDS [Minimum Data Set] Coordinator. 22. On 9/23/22 at 8:47am, The Surveyor asked MDS Coordinator #1, Did you make any revisions to [Resident name] following her verbalizing wanting to leave the facility on Tuesday? MDS Coordinator #1 stated, No, I did not. The Surveyor asked MDS coordinator #1, When do you revise care plans? MDS Coordinator #1 stated, Usually after morning meeting and we are able to go over everything. That Wednesday morning, I was working a medication cart on the floor so I would not have made any changes to the care plan. MDS Coordinator pulled up the resident's care plan on her computer and stated, Sometime that day after she eloped, it looks like I update her care plan after they completed a new wandering risk assessment. 23. On 9/23/22 at 8:52am, The Surveyor asked MDS Coordinator #2, Did you make any revisions to [Resident name] following her verbalizing wanting to leave the facility on Tuesday? MDS Coordinator #2 stated, No, I did not. The Surveyor asked, When do you revise care plans? MDS Coordinator #2 stated, The same as her. After we go over things in the morning meeting or I will change it throughout the day as the orders change. The Surveyor asked, Were there changes to [Resident name] care plans that needed to be made? MDS Coordinator #2 stated, I am not even sure we had a morning meeting on Wednesday.

Based on observation, record review, and interview the facility failed to ensure meals were prepared and served in accordance with the planned written menu to meet the nutritional needs of the residents for 1 of 2 meals observed. These failed practices had the potential to affect 3 residents who received mechanical soft diets and 1 resident who received pureed diets in cottage #2, one resident who received puree diet and 3 residents who received mechanical soft diets in cottage #3 according to a list provided by the Dietary Supervisor. The findings are: 1. The 9/19/22 Spring/Summer Lunch Meal Menu documented residents who received regular diets were to receive 2 oz. (ounces) of tortilla chips, residents on mechanical soft diets were to receive tortilla bread one each, residents on pureed diets were to receive an #8 scoop (2/3 cup) of pureed chicken enchilada and a #16 scoop (1/4 cup) of pureed tortilla bread. 2. The following observations were made during the noon meal preparation and meal service in Cottage #2: a. On 9/19/22 at 11:31 AM, CNA #1 used a #8 scoop (1/2 cup) to place one serving of chicken enchilada casserole into a blender, instead of a #6 scoop (2/3 cup). She pureed the chicken enchilada. At 11:33 AM, she poured the pureed chicken enchilada in a divided plate, covered the plate with foil and placed it in a warmer. b. On 9/19/22 at 11:44 AM, CNA #1 used a #10 scoop (1/3 cup) and placed one serving of refried beans into a blender and pureed, instead of a #8 scoop (1/2 cup) of pureed refried beans as per the menu. c. On 9/19/22 at 12:35 PM, the residents that were on regular diets were not served tortilla chips, residents on mechanical soft diets did not receive tortilla bread and the resident on a pureed diet was not served pureed tortilla bread. d. On 9/19/22 at 12:36 PM, The Surveyor asked CNA #1, how many servings of Chicken enchilada did you prepare for a puree diet? She stated, I did one serving. The Surveyor asked, what scoop size did you use to serve pureed chicken enchilada? She stated, I used #8 scoop and gave one serving. e. On 9/20/22 at 11:03 AM, the Surveyor asked Certified Nursing Assistant #1 the reason residents on regular diets were not served chips, residents on mechanical soft diets did not receive tortilla bread and the resident on a pureed diet did not receive tortilla bread. She stated, It was my fault. 3. On 9/19/22 at 12:25 PM, the following observations were made during the meal service in Cottage #3: a. A resident on a pureed diet was served pureed refried beans, pureed chicken enchilada and pureed green beans. There was no bread served to the resident with her lunch meal. The menu specified a #16 scoop (1/4 cup) of pureed tortilla bread for each resident on pureed diets. b. Residents on regular diets, were not served tortilla chips. c. Residents on mechanical soft diets did not receive tortilla bread. d. The resident on a pureed diet was not served tortilla bread. e. On 9/19/22 11:10 AM, the Surveyor asked CNA #2 the reason residents on regular diets were not served chips, residents on mechanical soft diets did not receive tortilla bread and the resident on a pureed diet did not receive tortilla bread. She stated, I should have given it to them.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect one resident who received a pureed diet in cottage #2 and one resident who received a pureed diet in cottage #3 as documented on the Diet List provided by the Dietary Supervisor. The findings are: 1. On 9/19/22 at 11:37 AM, Certified Nursing Assistant #1 used a #12 scoop to place 3 servings of brownie into a blender, added milk and pureed. At 11:43 AM, She poured the pureed brownie into a pan and placed it on a shelf in the refrigerator. The consistency of the puree brownie was runny, not smooth. 2. On 9/19/22 at 12:25 PM, The following observations were made during the noon meal service in cottage #3: a. A resident on a pureed diet was served pureed refried beans, pureed chicken enchilada and pureed green beans. i. The consistency of the pureed refried beans was chunky, not smooth, pieces of beans were visible in the mixture. ii. The consistency of the pureed chicken enchilada was chunky, not smooth, pieces of chicken were visible in the mixture. iii. On 9/19/22 at 12:27 PM, the Surveyor asked Certified Nursing Assistant #2 to describe the consistency of the pureed beans and pureed chicken enchilada. She stated, They were both chunky. We try our best with what we have. b. On 9/20/22 at 7:44 AM, a pan of pureed bread and a pan of pureed sausage were on the steam table. The consistency of the pureed bread was thick, not smooth; the consistency of the pureed sausage was gritty, not smooth. The Surveyor asked Dietary Employee to describe the consistency of the pureed diets. She stated, Pureed sausage was gritty. Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items; to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen, failed to ensure food items stored in dry goods area were sealed, labeled, and dated ; failed to ensure 1 of 4 ice machines were maintained in sanitary condition and hot foods were maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service, to prevent potential food borne illness for residents who received meals from 1 of 4 kitchens. foods were dated as when received to assure first in first out usage to prevent potential for food bone illness ;The failed practices had the potential to affect 10 who received meals from Cottage #2, 39 residents who received meals and ice from the main kitchen (total census: 76), as documented on a list provided by Dietary Employee ---.and the findings are: 1. On 9/19/22 at 10: 54 PM The section of the ice machine where ice forms before dropping ice collector had accumulation of wet, red, and black residue on it. The panel of the ice machine had wet black residue on it. The Dietary Employee [NAME] Davis was asked to wipe the residue on the panel on the section of the ice machine where ice forms and the panel with a tissue She did, and the wet, red, and black residue easily transferred to the tissue. She was asked to describe the contents within the ice machine panel and the section where ice forms She stated, There were black and red residue. -She was asked Who used the ice from the ice machine and how often do you clean ice machine. She stated, CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms and weuse it to fill beverages served to the residents at meals. The maintenance man cleans. It. At 4:06 PM The maintenance man was asked how often do you clean the ice machine? He stated, I clean it out every month. I emptied it out and clean it. 2. On 9/19/22 at 11:06 AM The following observations were made in the storage room: a. An opened bag of tortilla chips was stored on a shelf in the storage room. The bag was not sealed. b. An opened bag of toasted oats was stored on the shelf in the storage room. The bag was not sealed. 3. On 9/19/2022 at 11:08 AM The following observations were made in the species in the kitchen cabinet on cottage 2, there were no dates when species were received or opened. 1. A container of onion powder. 2. Container of celery salt. 3. Container of garlic powder. 4. A container of ground black pepper. 5. One container of all spice [NAME] flakes. 6. One container of cinnamon. 7. one bottle of soy sauce. 8 One container of Italian seasoning and a tub of syrup. 4. On 9/19/22 at 11:17 AM A bag of wheat bread and a bag of sunbeam bread stored on the counter had no date when there were opened and received. 5. On 9/19/22 at 11:55 AM Dietary Employee #2 touched her mask and without washing her hands, she picked up clean cups by the rims and poured tea to serve to the residents for lunch. 6. On 9/19/22 at 11:59 AM The temperature of the food items when tested and read by Certified Nursing Assistant #1 were with the following results: a. Pureed chicken enchilada 98 degrees Fahrenheit and pureed refried bean 99.4 degrees Fahrenheit. 7. On 9/19/22 12:09 PM AM Dietary Employee #2 picked up the water hose with her bare hand, used it to spray off leftover food items from the blender bowl contaminating her hands. Placed dishes in the dirty rack and pushed them into the dish washing machine to wash and after the dishes stopped washing. Dietary Employee, moved to the clean side in dishwasher area and without washing her hands picked up clean blade from the dish rack and attached it to the base of the blender to be used in pureeing food items to be served to the residents who received pureed diets for the lunch meal. On 9/19/22 PM Dietary Employee #2 immediately was asked was asked, What should you have done after touching dirty objects and before handling clean equipment or food items? She stated, I should have washed my hands. At 12:48 PM Dietary Employee #2 was asked what should you have done after touching dirty objects and before handling clean equipment objects? She stated, I should have changed washed my hands. 8. On 9/19/22 at 12:16 PM Dietary Employee #3 was wearing gloves on her hands; she took out a bag of flour tortilla from the shelf in the storage room and placed it on the counter. She removed a bag of shredded cheese from the refrigerator and placed it on the counter. She picked up a sauce pan and placed it on the stove. She then turned on the stove. Without removing gloves and washing her hands, she removed flour tortilla from the bag and placed them on the saucepan, removed shredded cheese from the bag and placed on top of the flour tortilla and made cheese [NAME] for the residents who do not like chicken enchilada. Dietary Employee #3 was asked what should you have done after touching dirty objects and before handling clean equipment objects? She stated, Washed my hands. 9. On 9/20/2022 The facility's policy on hand washing documented, Wash hands before beginning a different task.

Based on observation, interview, and record review the facility failed to ensure that fingernails were cleaned and trimmed to promote good personal hygiene and grooming for one resident (#64) of 6 (#5, #25, #28, #29, #64, and #68) sampled residents who require assistance with nail care according to a list provided by the Administrator on 9/23/22 at 8:25 AM. Resident #64 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the minimum data set (MDS) with an Assessment Reference Date (ARD) of 08/31/22 the resident received a score of 15 (13-15 cognitively intact). The resident required extensive assistance with bed mobility, transfers, toileting, dressing and personal hygiene. Eating was accomplished with supervision only. a. On 09/19/22 at 11:40 AM, Resident #64 was sitting up in her bed. Her nails were long, extended from the base of the finger by up to an inch. The underside of the nails were stained and discolored, several with debris under them. Her nails were covered in polish which was chipped and streaked. The Surveyor asked the Resident if she enjoyed her nails being long. She stated, .yes, but just not this long . Resident #64 continued to describe that a nurse had to cut her nails because she was diabetic. She stated, .they say they will return to cut them and never do . b. On 09/20/22 at 10:44 AM, Resident #64's nails remained long and discolored with dark colored debris under them. The nail on the index finger of the right hand was broken off even with the finger. Resident stated, .yeah, I did that last night . When they get so long, if you hit one they will break I'm surprised it didn't bleed . It is sore . The Surveyor asked the Resident to confirm that she had requested that her nails be cut. She stated, .I have, but I know they are busy. c. On 09/22/22 at approximately 2:00 PM, Resident #64was sitting up in her bed. Her nails remained unchanged. The Director of Nursing (DON) was shown the resident's nails. Resident #64 displayed the nail that was broken off two evenings prior and described how her finger was still sore. The Surveyor asked the if resident's nails should be trimmed. She stated, .I know she likes them long, but yes those need to be trimmed . A nurse must trim the nails of someone who is diabetic . d. On 9/22/22 at 3:00 PM, The Administrator provided Diabetic Nail Care Guideline. The guideline stated that nursing licensed staff were to do diabetic nail care weekly and as needed.

Based on record review and interview, the facility failed to ensure documentation regarding education on the risk versus benefits of not receiving the COVID-19 vaccine and refusal was obtained and provided to staff members. This failed practice had the potential to affect 6 staff members who were unvaccinated according to the list provided by the Director of Nursing (DON) on 7/29/21. The findings are: 1. On 7/28/21 at 10:00 a.m., documentation of five COVID-19 unvaccinated staff members was requested from the DON to review for documentation of education, refusal, and immunization. The DON stated, I do not have any, I do for the residents. 2. On 7/28/21 at 11:19 a.m., the DON was asked, Where the employees offered the COVID-19 vaccination? She stated, Yes, on 1/4/21, 2/1/21 and 3/1/21 [Name] Pharmacy came and administered the vaccines. She was asked, Has the staff been educated on the benefits and potential side effects of the COVID-19 vaccine? She replied, Yes, the staff that received the vaccines have been. She was asked, Do you have any documentation where the staff was educated regarding the benefits and potential side effects of the COVID-19 vaccine? The DON stated, No, but they were handed the Fact Sheet for the [Vaccine Name] when they received their vaccination. She was asked, Do you have any documentation where the staff that refused the COVID-19 vaccine was educated regarding the benefits and potential side effects? She replied, No. She was asked, Do you have any documentation on the staff members that did not receive the vaccine due to refusal, prior vaccination or contraindication to having the COVID-19 vaccine? She stated, No, I do not.

Based on observation, interview and record review, the facility failed to ensure staff washed their hands before handling clean equipment or food items failed to ensure food item stored in the freezer and dry storage areas were covered, sealed and dated; failed to ensure the kitchen floor, dry storage area floors, dish washing room, and walls were free of debris, dirt, grease, grime, stains and standing water and kitchen appliances (toaster, shelves where pans, pots and water pitchers were stored) were cleaned and free of stains; and expired food item was promptly removed/ discarded by the expiration or use by dates to prevent potential for cross contamination and/or food bone illness. These failed practices had the potential to affect 42 residents who received meals from the kitchen (total census: 50), as documented on a list provided by the Dietary Supervisor on [DATE]. The findings are: 1. On [DATE] at 10:34 a.m., the following observations were made in the kitchen: a. A bag of shredded carrots was in the small refrigerator in the kitchen. No date was located on the bag of carrots. b. Lids were placed on the pitchers of unsweetened and regular tea in a manner that left an opening at the spout which left the liquid open to air. 2. On [DATE] at 10:38 a.m., the followings observations were made on the food preparation counter: a. A four slotted toaster was sitting on a tray on a worktable in the kitchen. The toaster was corroded with a coating of dried breadcrumbs, black and brown in color, all along the top surface at the bread slot areas. b. A tray containing 28 slices of toasted bread and 16 slices of untoasted bread was on the worktable beside the toaster. The bread was not completely covered leaving the bread exposed. Dietary Employee #2 stated, We were going to use the bread for lunch. 3. On [DATE] at 10:39 a.m., the following observations were made on the shelf above the food preparation counter: a. A bag of brown sugar was open and not placed in a closed container. b. A bag of gravy mix was open. c. A bag of powdered sugar and a bag of chocolate pudding were both open and in the same large zip lock bag, that was left open. d. A cardboard carton of instant mashed potatoes was opened and was not in a sealed zip lock bag. e. A container of Old Bay seasoning was open to air. f. A box of cream of wheat was open to air. 4. On [DATE] at 10:43 a.m., one box of waffles was stored on a shelf in the freezer in the storage room. The box had been opened. Inside the box the plastic bag containing the waffles was not sealed. 5. On [DATE] at 10:47 a.m., one box of milk was stored in the milk crate located in the milk cooler in the storage room. The carton had an expiration date of [DATE]. 6. On [DATE] at 10:51 a.m., the wall in the dish room was covered with a dark substance. The vent in the dish-room ceiling was covered with rust. One fluorescent light fixture was missing a cover. The second light fixture had a broken cover which had one large piece that was sagging and appeared about to fall. The floor in the dish room and throughout the kitchen had cracked and missing tiles. In the dish room there was exposed concrete and areas of standing water on the floor. 7. On [DATE] at 10:57 a.m., a shelf above the three compartments sink where three pots were stored face down had and accumulation of grease and food crumbs. 8. On [DATE] at 10:58 a.m., the shelf below the steam table contained rust, where 13 pans were stored top down. The floor in front of the steam table was chipped. The front of the steam table was covered with rust. 9. On [DATE] at 11:00 a.m., a large plastic container sitting on a metal tray was housed on the top shelf over the stove. The container was filled with oil and covered in oil. Dietary Employee #2 stated, That's our leftover oil that we use if someone wants something fried. She was asked how long container/oil had been used. She stated, I think we used it yesterday. Dietary Employee #2 could not provide menu or any other type of documentation concerning when the use of the oil was initiated. No date was on the container. 10. On [DATE] at 11:04 a.m., Dietary Employee #1 lifted the cover off the serving window into the dining room and spoke to a resident. She went to the storage room and picked up a bag that contained lids and placed them on the counter. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used to pureed food. Immediately Dietary Employee #1 was asked what should you have done after touching dirty objects and before handling clean equipment. She stated, Wash my hands. 11. On [DATE] at 3:49 p.m., one open bottle of lemon juice was stored on a shelf in the storage room. Some of the juice had been used. The label on the bottle documented, 'Refrigerate after opening. 12. On [DATE] at 3:50 p.m., a box of Grey Poupon mustard containing 12 jars was on the shelf in the storage room. The jars had an expiration date of [DATE]. 13. The facility hand washing policy key concept provided by the Dietary Manager on [DATE] at 12:36 p.m. documented, Wash hands before food preparation, touching clean equipment or utensils, switching to another food prep task and after cleaning duties.

Based on observation and interview, the facility failed to ensure maintenance services were provided to ensure a wall was intact and free of holes for the resident to have a safe, clean and comfortable environment for 1 (Room #205) of 10 (Rooms 200 thru 209) on the 200 Hall. The findings are: a. On 06/21/21 at 10:34 am, in room #205 there was a large hole approximately 1 foot in diameter in the wall beside an electrical outlet. There was sheetrock tape hanging out of the hole and the resident's bed frame shoved up in it. b. On 06/24/21 at 02:15 pm, a Maintenance Employee measured the hole to be 11 inches wide, 12 inches long and approximately 4 ½ inches deep from sheetrock to sheetrock. The Maintenance Employee stated, I wasn't aware of the hole but will fix it right away. c. On 06/25/21 at 08:40 am, Registered Nurse (RN) #1 was asked what he would do if he noticed something in a resident's room that required maintenance. He stated, If it put the resident in immediate danger, then the resident would be moved to another room and maintenance would be notified immediately. If it was something that just needs repaired, then I would fill out a Maintenance Request form. He was asked if he ever saw the hole in the wall in Room #205 and he stated, No, I never seen a hole. The RN was shown a picture and he stated, Wow, I never seen that! . d. On 06/25/21 at 08:45 am, Certified Nursing Assistant (CNA) #3 was ask what she would do if she noticed something in a residents' room that required maintenance. She stated. I would fill out a maintenance request form. She was asked if she ever saw the hole in the wall in Room #205 and she stated, No. I usually work on 400-hall so I never seen it. e. On 06/25/21 at 08:52 am, the Maintenance Employee brought his Maintenance Request Form book and showed the surveyor what staff filled out when maintenance service is needed. He was asked if he had a request form for that room. He stated, No, before yesterday, I didn't know it was there.

Based on observation, record review, and interview the facility failed to ensure a resident who was at high risk for elopement and wore a wander guard transmitter was properly monitored and resulted in an elopement for 1 (Resident #4) resident and failed to accurately assess and determine elopement risk for 1 (Residents #5) residents of 2 (Residents #4, and #5) sampled residents. These failed practices resulted in immediate jeopardy that caused or was likely to cause serious harm, injury, or death to Resident #4 who eloped from the facility and Resident #5 who exited the front door but did not leave the front porch and had the potential to affect 11 residents who were an elopement risk per the list provided by the Assistant Director of Nursing (ADON) on [DATE] at 12:32 p.m. The Administrator, Director of Nursing (DON), and Consultant were informed of the Immediate Jeopardy on [DATE] at 4:54 p.m. The findings are: 1. Resident #4 had diagnoses of Alzheimer's Disease Unspecified, Unspecified Dementia with Behavioral Disturbance, Post-Traumatic Stress Disorder, Chronic and Major Depressive Disorder. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] documented the resident scored 15 (,d+[DATE] indicates cognitively intact) on a Brief Interview for Mental Status (BIMS); required supervision with bed mobility, transfers, walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, eating, toilet use, and personal hygiene; and did not have a Wander/Elopement Alarm. a. On [DATE], the Elopement Risk Assessment documented, . Elopement Risk Score 9 .A. Instructions: a. Assessment to be completed on admission, with Significant Change in condition and quarterly if applicable. B. Scoring: A score of less than 5 = Low Risk for Elopement. Score of 5 or greater = High Risk for Elopement. B. 1. Cognition/Mental Status/Memory b) Moderately impaired .3. Ambulation: Choose one option below a) Able to ambulate independently 4. Able to transfer independently a) Yes 5. History of wandering prior to nursing home placement a) Yes 6. Resistant to nursing placement a) Yes 7. Expresses desire to go home a) Yes 8. Exit Seeking a) Yes .11. Medication - choose all that are appropriate c. Antidepressant e. Antihypertensive . Comments/Notes/Additional Information: continue current care plan of frequent observation . b. A Physician's Order dated [DATE] documented, Wanderguard to (specify) to alert staff of attempts to exit facility unsupervised. Check placement [Brand name] exp [expires] ,d+[DATE] on left lower leg guard ID [number] every shift for elopement risk. Check function on ,d+[DATE] [11:00 a.m. - 7:00 a.m.]. c. The Care Plan initiated on [DATE] documented, . [Resident #4] is at risk for elopement attempts, and at risk for injury related to wander guard placed to left ankle .Observe for proper working of wanderguard. Report problems promptly, observe his whereabouts, intervene, and redirect as needed . d. On [DATE], the Elopement Risk Assessment documented, .Elopement Risk Score 9 .A. Instructions: a. Assessment to be completed on admission, with Significant Change in condition and quarterly if applicable. B. Scoring: A score of less than 5 = Low Risk for Elopement. Score of 5 or greater = High Risk for Elopement. B. 1. Cognition/Mental Status/Memory b) Moderately impaired .3. Ambulation: Choose one option below a) Able to ambulate independently 4. Able to transfer independently a) Yes 5. History of wandering prior to nursing home placement a) Yes 6. Resistant to nursing placement a) Yes 7. Expresses desire to go home a) Yes 8. Exit Seeking a) Yes .11. Medication - choose all that are appropriate c. Antidepressant e. Antihypertensive . Comments/Notes/Additional Information: continue current plan of care, continue use of wanderguard to ensure resident safety . e. On [DATE], the Elopement Risk Assessment documented, .Elopement Risk Score 8 .A. Instructions: a. Assessment to be completed on admission, with Significant Change in condition and quarterly if applicable. B. Scoring: A score of less than 5 = Low Risk for Elopement. Score of 5 or greater = High Risk for Elopement. B. 1. Cognition/Mental Status/Memory a) Intact .3. Ambulation: Choose one option below a) Able to ambulate independently 4. Able to transfer independently a) Yes 5. History of wandering prior to nursing home placement a) Yes 6. Resistant to nursing placement a) Yes 7. Expresses desire to go home a) Yes 8. Exit Seeking a) Yes .11. Medication - choose all that are appropriate c. Antidepressant e. Antihypertensive . f. An Office of Long Term Care (OLTC) Incident and Accident Report (I&A) documented, Date and Time Submitted (if known): [DATE] 1912 [7:12 pm] Date & Time of Discovery: [DATE] 1827 [6:27 pm] .Summary of Incident Received phone call from Dietary Manager at 1827 [6:27 pm] that resident had eloped. Resident stated that he was on the way to go visit his friend. Resident stated that he just held down the door until it released. Timeline revealed that resident was seen in his room at 1800 [6:00 pm]. Wanderguard was on and working properly. The door that resident exited did not have wanderguard sensor. The front door and 400 hall doors are the ones with sensors. Staff heard the door alarm at 1810 [6:10pm]. Staff went to check on the door and there was another resident [Resident #7] shaking on the door and they thought that was what sounded it. Resident was brought back to the building by dietary manager. Body Audit immediately performed with no injuries. 15 minute safety checks to prevent reoccurrence. Family, Police, and APRN [Advanced Practice Registered Nurse] notified. Facility will do full investigation. g. An OLTC Witness Statement form dated [DATE] at 6:27 p.m. and signed by the Dietary Manager documented, Witness Full Name [Dietary Manager] Job Title [Dietary Manager] .I was leaving Walmart to go fishing. I saw resident walking on side of the road. I stopped, got out of my truck, and asked [Resident #4] if he would get in my truck and go back to the nursing home. He got in truck. I called DON [Director of Nursing] at 6:27 [p.m.] on my way back to the building. h. On [DATE], the Elopement Risk Assessment documented, .Elopement Risk Score 7 .A. Instructions: a. Assessment to be completed on admission, with Significant Change in condition and quarterly if applicable. B. Scoring: A score of less than 5 = Low Risk for Elopement. Score of 5 or greater = High Risk for Elopement. B. 1. Cognition/Mental Status/Memory a) Intact .3. Ambulation: Choose one option below a) Able to ambulate independently 4. Able to transfer independently a) Yes 5. History of wandering prior to nursing home placement a) Yes 6. Resistant to nursing placement a) No 7. Expresses desire to go home a) Yes 8. Exit Seeking a) Yes . 10. Evidences Shadowing behavior (follows staff, peers, strangers) Yes11. Medication - choose all that are appropriate c. Antidepressant . i. An OLTC Witness Statement form dated [DATE] at 6:45 p.m. and signed by CNA (Certified Nursing Assistant) #2 documented, Witness Full Name [CNA #2] Job Title [CNA] .Shift 2 .I picked up trays at 6:00 pm. [Resident #4] was in his door way standing. At 6:10 pm the 200 hall backdoor alarm went off. [Nurse] and I went down and shut the alarm off. [Dietary Manager] found him in front of [a facility name] and brought [Resident] back at 6:30 pm. j. An OLTC Witness Statement form dated [DATE] at 1846 (6:47pm) and signed by LPN (Licensed Practical Nurse) documented, Witness Full Name [Nurse Name] Job Title [LPN] .Shift 7a-7p .@ [at] 1810 [6:10pm] 200 hall emergency exit alarm was going off this nurse and CNA [CNA #2] went to assess the situation. This nurse and CNA was able to silence the alarm. Resident's alarm was still secured to his ankle at time of incident. This nurse did not hear ankle alarm sound because of the 200 hall door had no sensor. k. An OLTC Witness Statement form dated [DATE] at 7:00 pm and signed by LPN documented, Witness Full Name [LPN #1] Job Title [LPN] .Shift 7a-7p .@ 1810 [6:10 pm] I heard 200 hall door go off. I was in the bathroom, as I came out [nurse] and [CNA #2] was at doors. Resident was brought back at @ 1830 [6:30 pm] by [Dietary Manager] Resident was assessed with no injuries and foot alarm was intact on leg, but alarm did not go off with door alarm because there was not a wanderguard sensor on that door. Another resident [Resident #7] was also noted to be playing with the door during that time but stated she was looking outside. l. On [DATE] at 8:30 a.m., informed Administrator of the new complaint received from the office. Administrator stated, That resident will be moving to another facility with a secure unit. The resident is being transferred to [Facility name]. Resident had previously resided there before being transferred to this facility. [Resident #4] went out the door on the end of 200 hall. 200 hall had previously been a secure unit and did not require a wander guard sensor in place because it was enclosed by a privacy fence. The fence was blown away last week during the severe [NAME] that occurred here. Sometime approximately [DATE] we did away with the secure unit because we only had two male residents that required it and we decided to put wander guards on those two residents. One resident has since expired and [Resident #4] was the other resident. [Resident #4] is the only resident in the facility with a wander guard in place. m. On [DATE] at 8:47 a.m., the Surveyor and Maintenance Director went and checked every door to the outside in the facility. The 200 hall door worked appropriately but does not have a wanderguard sensor. The 300 hall door worked appropriately but does not have a wanderguard sensor. The 400 hall door worked appropriately and had a wanderguard sensor. The 500 hall door is the secure unit and worked appropriately. The 500 hall door exited to a fenced in area. The dining room door to the outside does not have an emergency release and does not have a wanderguard sensor. n. On [DATE] at 9:16 a.m., the Maintenance Director was asked, What did you do about the door on the 200 hall not having a wanderguard sensor in place? The Maintenance Director stated, I called [name] company this morning and they will be coming sometime this week or next to install wanderguard sensors on the doors that don't have one. Currently, the front door and the 400 hall are the only two halls with wander guard sensors. The Maintenance Director was asked, How did the resident get out of the 200 hall door? The Maintenance Director stated, He just held the door bar down and after 15 seconds it released, and he walked out. I came in Monday morning and checked the door and checked his wanderguard to make sure it was working, and it was. o. On [DATE] at 12:04 p.m., the Director of Nursing (DON) was asked, What constitutes someone to be an elopement risk? The DON stated, We have an elopement assessment and he [Resident #4] had previously eloped in [DATE]. The DON was asked, Is that why he had a wanderguard on because he had previously eloped? The DON stated, Yes. The DON was asked, When do you complete elopement assessments? The DON stated, The MDS [Minimum Data Set] girl completes them quarterly and the nurse will complete it after someone elopes. The DON was asked, What is the time frame for completing elopement assessments after an elopement? The DON stated, I don't believe there is a time frame, but we did complete them immediately. They were all completed yesterday. The DON was asked, Did you complete elopement assessments on all the residents after [Resident #4] eloped? The DON stated, Only on him that night. The rest were completed yesterday. The DON was asked, Why did you not complete an elopement assessment on everyone in the facility that night? The DON stated, Because he was the only one that eloped. The DON was asked, Should everyone have had an elopement assessment after an elopement? The DON stated, We did do one on everyone in the facility yesterday and updated the elopement binder. The DON was asked, Who was identified as an elopement risk? The DON stated, He was the only one identified. The DON was asked, When did you start the elopement assessments after [Resident #4] eloped? The DON stated, They were started yesterday morning. The DON was asked, Who completed the elopement assessments yesterday? The DON stated, MDS girl, [Name]. p. On [DATE] at 12:09 p.m., the MDS Coordinator was asked, Did you complete the elopement risk assessments yesterday? The MDS Coordinator stated, Yes. The MDS Coordinator was asked, Did you complete one on everyone in the facility? The MDS Coordinator stated, Yes, except for [Resident #4] because his was completed the night before when he eloped. The MDS Coordinator was asked, What constitutes someone to be at risk for elopement? The MDS Coordinator stated, They are alert or confused and able to ambulate and transfer on their own, different medications and polypharmacy. The MDS Coordinator was asked, How do you complete the assessments? The MDS Coordinator stated, I go look at the progress notes, what was completed on the last elopement assessment and their current medications. The MDS Coordinator was asked, Do you get up and observe the residents? The MDS Coordinator stated, Sometimes, but most of the time I look in their chart. The MDS Coordinator was asked, What constitutes someone to be put in the elopement risk binder? The MDS Coordinator stated, If they have a 5 or above on their assessment. q. On [DATE] at 12:36 p.m., the facility provided a copy of the list of residents that were identified as an elopement risk which documented one resident, Resident #4. r. On [DATE] at 4:08 p.m., CNA #1 was asked, Did you see [Resident #4] trying to leave the facility? CNA #1 stated, No, I have never seen him attempt to go out the doors. He does go look out the doors a lot of the time but has never tried to leave. CNA #1 was asked, After he returned to the facility, were you given any special instructions by the nurses or the DON? CNA #1 stated, Yes, keep a close watch on him because he had got out. s. On [DATE] at 4:15 p.m., CNA #2 was asked, Can you tell me what happened on Sunday night with [Resident #4] getting out of the facility? CNA #2 stated, I heard the alarm going off and I went to the door. I didn't know the code to the door to stop the alarm. I pushed on the door and it came right open. I looked outside but did not see anyone. One of the nurses had to come down to me and use the key to turn the alarm off because I don't have a key. CNA #2 was asked, Was anyone around the door when you went to it? CNA #2 stated, No, ma'am there was no one around the door. CNA #2 was asked, Did you know the resident had got out of the facility? CNA #2 stated, No. CNA #2 was asked, When did you find out he was out of the building? CNA #2 stated, Honestly, I didn't know he was gone until [Dietary Manager] brought him back. CNA #2 was asked, Did you receive any special instructions after he returned to the facility? CNA #2 stated, No, only to do 15 minute checks and if he is not in his room to find out where he is at and locate him. t. On [DATE] at 4:36 p.m., LPN #1 was asked via telephone interview, Can you tell me what happened on Sunday night? LPN #1 stated, I was in the restroom when I heard the door alarm go off. When I came out of the restroom a nurse and CNA were at the door trying to get the alarm off. LPN #1 was asked, Did you know that [Resident #4] had exited the building? LPN #1 stated, No, I did not until he was brought back to the facility. LPN #1 was asked, Did you receive any special instructions when he returned? LPN #1 stated, Yes, he was put on 15 minute safety checks and I checked his wanderguard and it was intact. You know, I did not know that 400 hall and the front door were the only doors with a sensor for the wanderguard. So, the wanderguard does not protect him on 200 hall because it does not have a sensor. u. A Missing Residents policy provided by the Administrator on [DATE] at 12:17 p.m. documented, Purpose: The purpose of a Missing Resident Policy and Procedure is to ensure that all necessary steps are taken in the event that a resident wanders away from the facility .10. After a Resident is located, the charge nurse will notify all involved that the resident has been found: a. Family b. Physician .11. Document incident including all notifications, condition of resident upon return, and strategies utilized to prevent recurrence .Elopement-Wandering Resident Incident .13. When completing your incident report/nursing documentation on this event, please include the following: a. Time the resident was discovered; b. Time the resident was last seen; .14. Care plan updated with diversional approaches, modifications, appropriately timed goals that are specific to the resident's individual wandering habits . 2. Resident #5 had diagnoses of [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] Disorder, Unspecified Convulsions, Anxiety disorder and Heart Failure. The Quarterly MDS with ARD of [DATE] documented the resident scored 15 (,d+[DATE] indicates cognitively intact) on a BIMS and required supervision for bed mobility, transfers, walking, eating, and toilet use and limited assistance for personal hygiene and dressing. a. The Care Plan documented, . [Resident #5] is at risk for decline in mood and behaviors as well as increased anxiety, diagnosis of [CONDITION(S)], [CONDITION(S)] disorder, mood disorder, and depression .[Resident #5] has diagnosis of [CONDITION(S)] and is ordered anti-psychotic drug . [Resident #5] has a diagnosis of Seizures and is at risk for [CONDITION(S)] activity . [Resident#5] has a diagnosis of [CONDITION(S)] and is ordered anti-psychotic medication. She is at risk for target behaviors such as but not limited to Hallucinations (God and the devil speaking to her) and delusions (all sickness of others being her fault and messing everything up) . Date Initiated: [DATE] . is at risk for attempts of elopement . Date Initiated: [DATE] .15 min safety checks in progress . Date Initiated: [DATE] . b. On [DATE], the Elopement Risk Assessment documented, .Elopement Risk Score 6 A. Instructions: a. Assessment to be completed on admission, with Significant Change in condition and quarterly if applicable. B. Scoring: A score of less than 5 = Low Risk for Elopement. Score of 5 or greater = High Risk for Elopement. B. 1. Cognition/Mental Status/Memory a) Intact .3. Ambulation: Choose one option below b) Able to ambulate using cane, quad cane, walker or rolling walker 4. Able to transfer independently a) Yes .11. Medication - choose all that are appropriate c. Antidepressant e. Antihypertensive . f. Antiseizure . c. A Nursing Note dated [DATE] at 6:22 a.m. documented, Describe Behavior: Attempting to elope, went out alarmed door at the end of 100 hall, staff tried to stop her, but were unable, so they went out with her. Non-pharmacological interventions: Redirected to come back in the building, nurse attempted to calm her down. Effect: continuing to cry, and scream. PRN [as needed] medication: Outcome: currently lying in her bed, 15 min safety checks put in place. d. A Nursing Note dated [DATE] at 11:21 p.m. documented, Describe Behavior: Resident noted agitated and resident noted yelling demanding to leave facility without a place to stay or a way to go anywhere. Resident became very confrontational to staff members. Non-pharmacological interventions: Redirect resident with [restaurant] because resident c/o [complains of] being hungry Effect: Resident noted calmer but continues behaviors PRN medication: [MEDICATION(S)] 5mg [milligrams] IM [intramuscular] one time dose Outcome: Resident lying in bed with eyes closed. No behaviors noted at this time. e. On [DATE], the Elopement Risk Assessment documented, .Elopement Risk Score 7 A. Instructions: a. Assessment to be completed on admission, with Significant Change in condition and quarterly if applicable. B. Scoring: A score of less than 5 = Low Risk for Elopement. Score of 5 or greater = High Risk for Elopement. B. 1. Cognition/Mental Status/Memory a) Moderately impaired .3. Ambulation: Choose one option below b) Able to ambulate using cane, quad cane, walker or rolling walker 4. Able to transfer independently a) Yes .11. Medication - choose all that are appropriate c. Antidepressant e. Antihypertensive f. Antiseizure . f. A Nursing Note dated [DATE] at 8:24 a.m., documented, Note Text: resident is in socials office, sharing delusions she has about her being rich, having lots of properties and houses, and about other personalities [name] and [name]. resident says she's going on vacation to [City] and then she will be discharging from facility to one of the properties she supposedly owns in [City]. g. A Nursing Note dated [DATE] at 2:16 p.m., documented, Note Text: Resident ambulated to Medical Records office to visit with staff. After sitting on her rolling walker, resident began to talk about the land she owns in [City] and [City] areas. Resident continued to talk about owning this nursing facility, about going on vacation with a special credit card that God gave her. Resident stated it requires a special scanner that she invented. Per resident statement, her vacation will be in [City, State] and her boyfriend will be so surprised because she has a friend that owns a limousine service. Resident also reported that she would love to stay but plans to leave facility by 3 this afternoon. Resident was asked how she planned to leave, resident responded with I have a friend with a car that is coming to get me. Resident continued talking with staff and stated I have money in a secret account. I don't need my stimulus money. They can keep it! Resident then stood with difficulty, stated, Well, I have to go. It's time to make the fruit pizza. Resident then began exiting the medical records office. Resident suddenly yelled Ouch!, I just ran over my own toes. I will be glad when they get my new walker in. At that time, resident continued out of the office to attend the afternoon activity. h. On [DATE] at 14:35 (2:35pm), the Elopement Risk Assessment documented, .Elopement Risk Score 8 A. Instructions: a. Assessment to be completed on admission, with Significant Change in condition and quarterly if applicable. B. Scoring: A score of less than 5 = Low Risk for Elopement. Score of 5 or greater = High Risk for Elopement. B. 1. Cognition/Mental Status/Memory a) Moderately impaired .3. Ambulation: Choose one option below a) Able to ambulate independently 4. Able to transfer independently a) Yes .11. Medication - choose all that are appropriate c. Antidepressant e. Antihypertensive f. Antiseizure .Comments/Notes/Additional Information: resident is not an elopement risk at present time. Triggered due to medications i. A Nursing Note dated [DATE] at 5:21 a.m., documented, Note Text: Resident noted calling cab company, but cab company informed resident that she needs full amount of money which resident stated she did not. She asked a CNA if he could loan her the money or give her a ride somewhere. CNA informed resident that he could not. Resident became agitated and noted cursing at staff. Resident stated I'm gonna call the police and they're gonna answer and I'm gonna tell them that it's not an emergency, I just can't find a ride and I want to go. Resident did not call 911 but got on tablet and been listening to music calmly. j. On [DATE] at 9:16 a.m., the Maintenance Director informed surveyor while checking facility doors he changed the code to the front door last night ([DATE]) at 8:50 p.m. due to a resident knowing the code to the front door. The Maintenance Director was asked, Why did you have to change the code to the front door only? The Maintenance Director stated, A resident had watched and learned how to open the front door, so it was the only one I changed. The Maintenance Director was asked, Did the resident go out the front door requiring the need to change the code? The Maintenance Director stated, I don't know. I just got a call from [CNA #3] stating I need to come and change the code to the front door. k. On [DATE] at 10:42 a.m., the DON was asked, Why was the code to the front door changed at 8:50 p.m. last night? The DON stated, [Resident #5] has [CONDITION(S)] and went out the front door under the carport area waiting on a cab to come pick her up that her boyfriend had called. The nurse told [Resident #5] a storm was coming and if a cab came to pick her up, she could go out on a leave then. The DON was asked, Did [Resident #5] let herself out? The DON stated, Yes, she found out the code. l. An OLTC Witness Statement form dated [DATE] at 10:52 a.m., and signed by the DON documented, Witness Full Name [DON] Job Title [RN (Registered Nurse), DON] .Shift ,d+[DATE]:30 .Received phone call from [Nurse name] that resident [Resident #5] learned the code to the front door and was sitting outside on front porch waiting for a cab. Instructed LPN [Licensed Practical Nurse] to go speak with her and tell her that the weather was bad if she would please come sit inside and wait. Resident came back inside. Maintenance changed code to front door. Resident goes on LOA [leave of absence] at times with her boyfriend. Elopement assessment was completed on [DATE] and is not at risk for elopement at this time. m. On [DATE] at 1:10 p.m., the DON was asked, What time did [Resident #5] go outside? The DON stated, [CNA #3] called me at 8:41 p.m. [[DATE]] and the resident was back in the building by 8:53 p.m. I was on the phone with her the whole time while they tried talking her into coming back in the building. The DON was asked, Do you know how long she was outside? The DON stated, I am not sure. Staff were outside with the smokers, so she was in the line of sight at all times. The DON was asked, Did you complete an I&A [Incident and Accident] on [Resident #5] going out the door last night by herself? The DON stated, No, because it was not an elopement. [CNA #3] called me, and they were outside trying to get her to come back into the facility. n. On [DATE] at 2:03 p.m., CNA #3 was asked, Can you tell me what happened last night with [Resident #5] going outside? CNA #3 stated, I was told at supper that she knew the code to get out of the building. [CNA #2] told me the resident knew the code and had let herself out of the building and was under the car port area with her bags. The Maintenance Director came up here and changed the code. She was never outside by herself. [CNA #2] was out with the smokers and she was out there at that time as well. I called [DON] to let her know what was going on and I was on the phone with her outside while the nurses tried getting her to come back inside the building. o. On [DATE] at 2:31 p.m., the DON was asked, Why was [Resident #5] not considered an elopement risk? The DON stated, She has never tried to elope before and her assessment triggered for medications only. The DON was asked, Does she routinely go outside unsupervised? The DON stated, She does go set out on the front porch and she will set out there with other residents as well. p. On [DATE] at 2:24 p.m., the DON was asked, How do you identify residents that are at risk for elopement? The DON stated, Risk assessments are completed, we ask the questions on the risk assessment, mental status changes, changes in condition, and exit seeking behaviors. The DON was asked, Did the MDS Coordinator assist you in making the list of residents that you currently have identified as an elopement risk that have been placed on the elopement risk list? The DON stated, We printed all the risk assessments from every resident that was completed. We discussed them then decided everyone on 500 hall, the secure until would be an elopement risk and we discussed [Resident #5]. The DON was asked, On the elopement risk assessment, it gives you a score. Do you use that score to determine who is at risk for elopement? DON stated, There is a legend of 5 or greater being an elopement risk. We do not use that score all the time because some residents can score a 5 or greater but aren't able to get out of bed so we feel those numbers aren't accurate. We are going to be looking at every resident individually to determine if they are truly a risk. The DON was asked, So basically, you don't used the risk assessment score to determine who is at risk for elopement, you are going to base it off what you are seeing the residents do in the facility? The DON stated, Yes, that is right. We aren't using the score. 3.The Immediate Jeopardy was removed on [DATE] at 9:04 a.m. and the scope and severity reduced to E when the following Plan of Removal was implemented. a. Resident was discharged from the facility on [DATE] at 1545 [3:45pm] transfer process started on [DATE] at 9:36 a.m. and elder was placed on 15 min [minute] safety checks on [DATE] until discharged from facility. b. Elopement assessments were performed on all residents in the facility on [DATE] and care plans updated as needed per MDS Coordinator and 11 other residents have been identified as high risk for elopement at this time. The Administrator and DON will review elopement assessments to ensure they reflect resident's current behaviors. c. In services regarding elopement initiated by ADON on [DATE] and elopement binder was checked and updated to make sure all elders have photos in the binder. Staff will be inserviced and trained on monitoring doors until sensors are in placed starting [DATE]. d. Maintenance Director assessed all exit doors on [DATE] and will complete weekly to ensure the alarms are working properly and contacted alarm service to get a quote for applying wanderguard system to all exit doors, quote has been sent and awaiting for approval. e. Resident with wanderguard was walked to exits with wanderguard system in place and all are working properly, the alarm sounded when elder in range. No other residents in building with wanderguard in use. f. Effective now any further elopements or attempts of elopement staff will initiate 15 min [minute] safety checks for resident and exits to ensure proper working condition. In service initiated on [DATE]. g. Pink stop sign placed on 200 hall exit door on [DATE] to help redirect residents from trying to exit facility.

A. Based on observation, record review and interview, the facility failed to ensure Resident #5 received necessary treatment and services to promote healing of existing pressure ulcers and prevent the development of new pressure ulcers, as evidenced by a failure to ensure repositioning was provided at least every two hours for 1 (Resident #5) of 2 (Residents #2 and #5) case mix residents with pressure ulcers. This failed practice resulted in actual harm to Resident #1, who developed a new Stage II pressure ulcer and experienced deterioration of an existing pressure ulcer, and had the potential to cause more than minimal harm for 3 residents who had pressure ulcers and 10 residents who were at risk for developing pressure ulcers, according to lists provided by the Director of Nursing (DON) on 2/22/13 at 9:55 a.m. The findings are: Resident #5 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/5/12 documented the resident was severely impaired in cognitive skills for daily decision-making per staff assessment for mental status, required extensive physical assistance of two people for transfers, was incontinent of bowel and bladder, was at risk for the development of pressure ulcers and had one Stage II Pressure Ulcer. a. The Plan of Care last updated 2/12/13 documented, "Problem Onset: 9/12/12 ...(Resident #5) is at high risk for skin breakdown due to immobility and incontinence, disease process and history of skin breakdown... Assist to ensure that (Resident #5) is making frequent and significant position changes, both in bed and chairs to relieve / reduce pressure... 2/12/13... (Resident #5) has a Stage 2 pressure area to his right buttock, he is at risk for worsening of area." b. The Pressue Ulcer Evaluation dated 2/14/13 documented, "...Evaluation Type... Weekly Note... Wound Information... Acquired... In-house... Location... Right buttock... Stage... Stage 2... Measurements Length (in cm (centimeter)) 1.0... Width (in cm) ... 1.0... Depth (in cm) 0.1... Treatment... Turning and repositioning every 2 hours, date initiated: since admission..." c. On 2/19/13 at 8:30 a.m., 10:00 a.m. and 10:35 a.m., the resident was up in his high back wheelchair, in the dining room, on the secure wing. d. On 2/19/13 at 10:45 a.m., the Activity Director pushed the resident to his room. Certified Nursing Assistant (CNA) #1 and the Activity Director attempted to scoot his buttocks over in the chair. The resident stated, "No, No." They pushed the resident back to the dining room. CNA #1 was asked, "What time did you come to work?" She stated, "At 7:00 a.m." She was then asked, "Was everyone up in their chairs when you got here this morning?" She replied, "Yes, they were." She was then asked, "Has this resident (Resident #5) been repositioned since you came to work?" She replied, "No, I'm waiting on my partner." e. On 2/19/13 at 11:00 a.m., CNA #1 left the hall to go to lunch. The Assistant Director of Nursing (ADON) remained on the secure wing. f. On 2/19/13 at 11:30 a.m., the resident remained up in his wheelchair in the dining room on the secure wing. g. On 2/19/13 at 11:33 a.m., CNA #1 stated the ADON was going to get some help to lie the resident down. h. On 2/19/13 at 11:45 a.m., CNA #1 and CNA #2 transferred the resident to the bed with a lift. When they removed his pants, his brief was saturated with urine. There were 2-inch by 2-inch purple indentations on his buttocks and upper, posterior thighs from the RoHo cushion in his chair. When the resident was turned to his left side there was [MEDICATION NAME] dated 2/18/13 on the right buttocks. The Treatment Nurse removed the [MEDICATION NAME] and measured the open area as 1.5 centimeter (cm) by 0.5 cm. There was a new open area to the scrotum that measured 0.8 cm by 0.5 cm and was beefy red. At 12:10 p.m., the imprint of the cushion remained on the resident's buttocks and upper back thighs. i. A Nurses note dated 2/19/13 at 1:03 p.m. documented, "Pressure area to the right buttock is now 1.5 by .5 cm with very scant drainage however, the outer dimensions are larger. Resident has a new open area directly on the bottom of his scrotum. (Name of physician) notified of both issues." j. On 2/20/13 at 11:05 a.m., the Treatment Nurse stated that if the resident had not been up so long on 2/19/13 he probably would not have developed a new pressure ulcer. B. Based on observation and record review, the facility failed to ensure heels were off loaded to decrease the potential for skin breakdown for 3 (Residents #2, #4 and #6 ) of 5 (Residents #2, #4, #5, #6 and #12) case mix residents identified to be at risk for pressure ulcer development. These failed practices had the potential to affect 3 residents with pressure ulcers and 10 residents at risk for pressure ulcer development, according to lists provided by the DON on 2/22/13 at 9:55 a.m. The findings are: 1. Resident #2 had a [DIAGNOSES REDACTED]. upper extremity and one lower extremity. a. The Plan of Care late updated 2/8/13 documented, "(Resident #2) is at risk for altered skin integrity related to impaired mobility... history of decubs (Decubitus), incontinence..." There were no documented interventions related to off-loading of the resident's feet. b. On 2/18/13 at 12:10 p.m., during initial tour, the resident was lying in bed with her feet directly on the bed. c. On 2/19/13 at 8:15 a.m., 10:50 a.m., 2:00 p.m. and 4:20 p.m., the resident was lying in bed with her feet were directly on the bed. 2. Resident #6 had a [DIAGNOSES REDACTED]. a. The Plan of Care last updated 2/11/13 documented, "Problem Onset: 1/14/13... Potential for skin breakdown ...Observe and assure position changes frequently. Provide assistance as needed. Ensure placement of pressure reducing mattress on bed..." b. The Skin Risk assessment dated [DATE] documented, "Sensory perception - Slight limited... Moisture: Occasionally Moist ...Activity ...Chairfast ...Mobility: Very Limited: ...Nutrition: Very Poor ...Friction (and) Shear: Problem... Addendum: Resident at risk this week as behavior, cognition, physical ability, communication and appetite have declined. Resident at high risk for the first time since admit... Grand Total 12 (Score 10 - 12 High Risk)." c. On 2/19/13 at 8:22 a.m., 9:13 a.m., 10:00 a.m. and 2:22 p.m., the resident was in bed with her heels resting on the mattress. 3. Resident #4 had [DIAGNOSES REDACTED]. The Significant Change MDS with an ARD of 12/13/12 documented the resident scored 2 (0-7 indicates severe cognitive impairment) on the BIMS, required extensive physical assistance of two-plus people for bed mobility, had limitation in range of motion of both lower extremities, was incontinent of bowel and bladder and was at risk for pressure ulcer development. a. The Plan of Care dated 7/24/12 documented, "(Resident #4) is at risk for skin breakdown due to impaired mobility and cognition, poor intake, dry skin, picking and scratching at skin, incontinence, and history of decub... Assist (Resident #4) to make frequent and significant position changes, both in bed and wheelchair..." b. The Skin Risk assessment dated [DATE] at 11:44 a.m. documented, "Sensory Perception: Very Limited ...Moisture: Very Moist ...Activity: Chairfast ...Mobility: Very Limited ...Nutrition: Very Poor ...Friction (and) Shear: Problem ...Addendum: ...Resident is highly incontinent, highly immobile, highly confused, verbal but not related to need, poor nutrition and hydration, history of previously healed decubs, dx (diagnosis) of failure to thrive. Resident is laid down after meals, turned side to side while in bed to relieve pressure to her backside, no skin on skin. Three in one creme to the buttocks and coccyx every day and as needed for protection. Thus for these interventions have been sufficient to prevent skin breakdown at this time. Group total 10 (Score 10 - 12 high risk)." c. On 2/19/13 at 8:20 a.m., 9:12 a.m., 10:00 a.m., 12:13 p.m., 2:19 p.m. and 4:12 p.m., the resident was lying in bed with her heels resting on the mattress. 4. On 2/20/13 at 10:17 a.m., the Treatment Nurse was asked, "If a resident is at risk for pressure ulcers, are they supposed to have their heels off-loaded? The nurse stated, "Yes... they are in bed, heels should be off-loaded."