Every finding on record at The Greens at Pinehurst Rehabilitation & Living Ce

Based on record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of medications for 2 of 5 residents who were reviewed for unnecessary medication (Residents #93 and #13). The findings included: 1. Resident #93 was admitted to the facility on [DATE] with diagnoses that included dysfunction of the bladder, and retention of urine. A review of the Medication Administration Record (MAR) for Resident #93 from 12/24/25 to 12/30/25 revealed she did not receive an antibiotic medication. A quarterly MDS assessment dated [DATE] indicated Resident #93 had severely impaired cognition and was coded for an antibiotic during the seven-day assessment period. On 3/18/26 at 3:01 PM, an interview occurred with MDS Coordinator #2. She reviewed the 12/30/25 MDS and Resident #93's December 2025 MAR. MDS Coordinator #2 confirmed Resident #93 did not receive an antibiotic from 12/24/25 to 12/30/25 and that the antibiotic was coded in error on the MDS assessment. During an interview on 3/19/26 at 11:00 AM, the Director of Nursing indicated it was her expectation for the MDS assessment to be coded accurately. 2. Resident #13 was admitted to the facility on [DATE] with diagnoses of dementia with psychotic disturbance and post traumatic stress disorder (PTSD). Physician orders dated 4/3/25 included an order for Hydroxyzine 25 milligrams (mg) tablets, to give 1/2 tablet (12.5 mg) twice daily for anxiety. A review of Resident #13's Medication Administration Record (MAR) for January 2026 revealed he received Hydroxyzine 12.5 mg twice daily throughout the month. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], completed by MDS Nurse #2, documented that Resident #13 was receiving medications from the antianxiety drug classification. The assessment also included documented indications for the use of antianxiety medications. During an interview with MDS Nurse #2 on 3/19/26 at 10:43 AM, she stated Resident #13 was not ordered any medications that belonged to the antianxiety drug classification. She reported she had coded the resident as receiving antianxiety medications based on the Hydroxyzine order. She further stated she was unsure of the drug classification for Hydroxyzine. After reviewing the medication information, MDS Nurse #2 confirmed Hydroxyzine is classified as an antihistamine. She acknowledged that coding Resident #13 as receiving an antianxiety medication on the MDS was an error. The Director of Nursing was interviewed on 3/19/26 at 11:05 AM. She stated she expected MDS assessments to be coded accurately.

Based on record review and staff interviews, the facility failed to obtain a Level II Preadmission Screening and Resident Review (PASRR) evaluation after the initial approval for nursing home placement expired for 1 of 1 resident reviewed for PASRR (Resident #3).The findings included: Resident #3 was admitted on [DATE] with diagnoses that included major depressive disorder, generalized anxiety disorder, and post traumatic stress disorder.Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had not been evaluated by a Level II PASRR and determined to have a serious mental illness, intellectual disability, or other related condition.Review of the admission record revealed Resident #3 was admitted with a Level II PASRR for short term admission that was issued on [DATE] and expired on [DATE]. There was no evidence within the medical record to indicate the facility had submitted a referral for another Level II PASRR evaluation to extend approval past the [DATE] expiration date.During an interview with the Social Worker on [DATE] at 1:30 PM, she confirmed Resident #3's Level II PASRR for short term admission had expired on [DATE] and she had not submitted a request for another Level II PASRR evaluation. She stated that Resident #3's expired Level II PASRR was an oversight that had fallen through the cracks, and a new Level II PASRR evaluation should have been requested before the temporary one expired.During an interview on [DATE] at 1:22 PM, the Administrator stated she expected PASRR evaluations to be monitored and up to date. She stated a review for Resident #3 should have been requested before the expiration date.

Based on record reviews, observations, and interviews with resident representatives, resident and staff, the facility failed to provide resident representatives and/or residents with the opportunity to participate in the care planning process for 2 of 3 residents reviewed for care plan participation (Residents #77 and #13). The findings included: 1.) Resident #77 was admitted to the facility on [DATE]. A review of Resident #77's 5-day Minimum Data Set (MDS) assessment dated [DATE] indicated he was cognitively intact. Review of Resident #77's electronic health record indicated neither he nor his Resident Representative were included as attendees during care plan meetings conducted on 10/17/25, 1/13/26 and 3/2/26. An interview with Resident #77 on 3/16/26 at 12:14 PM revealed he had not been invited to a care plan meeting since residing at the facility. Resident #77 stated he was unaware the facility held care plan meetings until he heard others talking about them recently. Resident #77 indicated he would like to have attended care plan meetings with his daughter so he could have been actively involved in his care plan at the facility. The Social Worker (SW) was interviewed on 3/19/26 at 12:38 PM and stated she had not sent invitations to Resident #77 to attend care planning meetings. The SW indicated she was responsible for organizing and scheduling care plan meetings but had only been sending invitations for the 72-hour care plan meeting for new admissions or if families had expressed care concerns to her in person or via email. She stated she was unaware she should be inviting residents and/or resident representatives to care plan meetings on a regular basis. She stated that she was informed yesterday, 3/18/26, that she should be scheduling care plan meetings with residents and/or resident representatives based off the MDS calendar that was provided to her monthly by the MDS Coordinator. She indicated that she should be scheduling the care plan meeting, completing the care plan invitation, delivering to residents if applicable and providing the completed invitation to the receptionist to be mailed to the resident representative. The SW confirmed she had not been completing quarterly or annual care plan meetings with residents and/or resident representatives. An interview was conducted with the Administrator on 3/19/26 at 1:57 PM who stated she was unaware of residents and/or resident representatives not being invited to care plan meetings, and she would expect them to have the opportunity to be involved in person or by phone. 2. Resident #13 was admitted to the facility on [DATE] with diagnoses of dementia with psychotic disturbance, post traumatic stress disorder (PTSD), abnormal weight loss, failure to thrive, and anemia. Minimum Data Set (MDS) assessments were completed for Resident #13 on the following dates: 2/11/25 – Quarterly 5/13/25 – Quarterly 8/11/25 – Comprehensive 11/11/25 – Quarterly 1/7/26 – Quarterly Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had severe cognitive impairment. Review of care plan conference invitation letters provided by the Social Worker (SW) showed Resident #13's Representative had been mailed one invitation letter. The letter was dated 11/7/25 and invited the Resident Representative to a quarterly care conference with the facility's Interdisciplinary Team (IDT) to review Resident #13's care plan. The meeting was scheduled to be held in person on 11/17/25 at 1:00 PM. Review of Resident #13's medical record revealed a care plan conference was held on 11/17/25 that included the Resident Representative. There were no other care plan conferences documented in the medical record. During an interview on 3/18/26 at 12:29 PM Resident #13's Representative stated they had only been notified of and invited to attend one care plan conference since Resident #13's admission. The Representative confirmed the meeting they attended occurred in November 2025 and stated they were unaware that routine care plan conferences should have occurred. During an interview on 3/18/26 at 1:30 PM the SW stated she had only been sending invitations and holding care meetings for the 72 hour post admission residents or for residents or families who expressed concerns. She stated she was unaware she should have been inviting all residents and/or resident representatives to care plan meetings on a routine basis. The SW reported that she was informed today that she should have been scheduling care plan meetings based on the MDS calendar. The SW confirmed she had not completed quarterly or annual care plan meetings with all residents and/or resident representatives because she was not aware it was her responsibility. She stated the previous SW who trained her did not inform her of that. During an interview on 3/19/26 at 1:22 PM the Administrator stated that she had been made aware that annual and quarterly care plan meetings had not been completed for all residents, and residents and/or resident representatives were not invited to attend care planning meetings. The Administrator stated it was her expectation that the plan of care for all residents be reviewed quarterly and as needed with the resident and/or resident representative.

Based on record review, and interviews with the Medical Director and staff, the facility failed to administer scheduled medications as ordered by the physician for 1 of 6 residents reviewed for medication administration (Resident #12).The findings included:Resident #12 was admitted to the facility on [DATE] with diagnoses that included hypertension and constipation.A review of Resident #12's active physician orders for March 2026 revealed the following:An order dated 2/17/26 for Metoprolol Tartrate 25 mg. Give one tablet via G-tube two times a day for hypertension. Hold for heart rate less than 65 or systolic blood pressure less than 100.An order dated 2/17/26 for MiraLax 17 gm/scoop (grams per scoop) via G-tube two times a day for constipation.A review of the March 2026 Medication Administration Record (MAR) for Resident #12 revealed the following:Metoprolol Tartrate 25 mg was scheduled for 9:00 AM. Nurse #2 administered the medication at 12:07 PM on 3/16/26.MiraLax 17 gm/scoop was scheduled for 9:00 AM. Nurse #2 administered the medication at 12:07 PM on 3/16/26.An interview with Nurse #2 on 3/16/26 at 3:10 PM revealed he was an agency nurse who worked at the facility intermittently. Nurse #2 stated he fell behind on morning medication administration on 3/16/26 and did not administer Resident #12's scheduled morning medications until 12:00 PM. He reported he did not request assistance to ensure medications were given on time.The Director of Nursing was interviewed on 3/19/26 at 10:29 AM and stated Resident #12's medications were required to be administered on time. The DON reported Nurse #2 was an agency nurse and that agency staff had been instructed to request assistance if they fell behind with medication administration. The DON stated she did not know why Nurse #2 did not request assistance the morning of 3/16/26 as the medications should have been given one hour before or one hour after their scheduled time to remain in an acceptable timeframe. On 3/19/26 at 1:00 PM, the Medical Director was interviewed. He reviewed Resident #12's medical record and confirmed she experienced no ill effects related to the late administration of her medications on 3/16/26. He stated Resident #12's blood pressure and pulse remained within normal limits and she appeared clinically unaffected. The Medical Director acknowledged the facility's requirement that medications be administered within one hour before or after the scheduled time and stated he expected staff to follow this policy.

Based on observations, record review, and resident and staff interviews, the facility failed to provide nail care for 1 of 2 dependent residents reviewed for activities of daily living (ADL) (Resident #6). The findings included:Resident #6 was admitted to the facility on [DATE] with diagnoses including contracture of unspecified joint (left hand) and reduced mobility.A care plan revised on 1/2/25 indicated Resident #6 had an ADL self-care performance deficit with a goal that read Resident #6 would maintain her current level of function. According to the care plan, the resident was dependent on the assistance of one staff with personal hygiene.The significant change Minimum Data Set (MDS) assessment completed 2/14/26 documented Resident #6 as cognitively intact, without rejection of care behavior, and dependent on others for personal hygiene.Review of the bath skin review sheets for Resident #6 for the dates of 3/10/26, 3/14/26, and 3/17/26 revealed only toenail condition was listed.Resident #6 was observed on 3/16/26 at 9:58 AM. The free edge of Resident #6's fingernails on both hands were either jagged or broken, extended past her fingertips by what appeared to be more than 1/4 inch, or about the width of a pencil eraser, and had a brown substance underneath the free edge of the nail. The fingers on the left hand were noted to be curled inward towards the palm. No wounds were observed in the palm of Resident #6's left hand when she uncurled the fingers with the use of her right hand. A subsequent observation of Resident #6's fingernails on 3/17/26 at 11:37 AM revealed them to be unchanged, and in the same condition as the observation from 3/16/26 at 9:58 AM.An interview conducted with Resident #6 on 3/16/26 at 9:58 AM indicated her preference was to keep her fingernails short, especially on the left hand since it was contracted. The resident stated long fingernails often stabbed into the palm of her left hand and caused her discomfort. Resident #6 stated Nurse Assistants (NA) would sometimes clean underneath her nails, but no one had offered to cut them.NA #4 could not be reached by phone for an interview after multiple attempts.A follow-up interview with Resident #6 on 3/17/26 at 11:37 AM revealed she had received a bath that morning, but the NA did not clean her fingernails.Nursing Assistant (NA) #1, who was assigned to Resident #6 on 3/17/26 for the 7:00 AM to 7:00 PM shift, was interviewed on 3/17/26 at 1:18 PM. NA #1 reported she would typically check the resident's nails every time she bathed someone. However, NA #1 stated she had given Resident #6 a bed bath earlier that morning, but she did not provide nail care or ask the resident if she wanted nail care completed. She did not explain why she failed to provide nail care, but NA #1 indicated she would go back and ask Resident #6 if she wanted nail care completed. An interview was conducted with Nurse #1 on 3/17/26 at 1:47 PM who stated it was ultimately the assigned nurse's responsibility to ensure nail care was provided to all residents on their assignment. Nurse #1 stated the nurses were supposed to complete a nail review during the resident's weekly skin assessment. Nurse #1 indicated she was unsure when Resident #6 was due for a weekly skin assessment.A review of the weekly skin assessments in Resident #6's electronic medical record did not contain documentation regarding the resident's fingernails for the last documented assessment dated [DATE].The Director of Nursing (DON) was interviewed on 3/19/26 at 11:45 AM, and stated she expected the NAs to provide nail care for the residents on the days they received their bath or shower. However, she explained she had also designated an NA to complete nail inspections weekly on all residents and made a list of those who needed nail care. According to the DON, the nurses would provide nail care for the residents or nail care would be completed as an activity for the residents by the Activities Director. The DON stated she was unsure how Resident #6's nail care was missed last week, but she would ensure the resident's fingernails were addressed.

Based on observation, record review, and staff interviews, the facility failed to clean and dry the syringe used to administer medications and water flushes through a gastrostomy tube/G-tube (a tube that delivers liquid nutrition and medications directly to the stomach) before storing it in a dry plastic bag for 1 of 2 residents reviewed for G-tube feeding management (Resident #12). This deficient practice had the potential to cause bacterial growth and contamination.Findings included:Resident #12 was admitted to the facility on [DATE] with diagnoses that included unspecified dysphagia (difficulty swallowing), gastrostomy status, and aphasia (communication impairment) following a cerebral infarction (stroke).An admission Minimum Data Set assessment dated [DATE] indicated Resident #12 was moderately cognitively impaired and received 51% of more of her total calories from enteral feedings. A review of the active orders revealed Resident #12 had an order for a tube feeding formula to be provided at 72/ml/hr. (milliliters/per hour) continuous over 20 hours with water flushes of 110 ml/hr. every 4 hours during feeds.A review of the electronic Medication Administration Record (MAR) dated March 2026 indicated Nurse #1 had administered medication to Resident #12 via the gastrostomy tube (G-tube) at 7:37 AM the morning of 3/17/26.On 3/17/26 at 10:23 AM, an observation revealed Resident #12's G-tube flush syringe stored in a plastic bag hanging from the feeding pump pole and was dated 3/17/26 and 0000, which indicated it had been changed at midnight. The syringe was separated from the plunger. However, the elongated syringe tip contained thick, crusted yellow material, and the lower third of the syringe barrel was coated with the same yellow substance. The plastic bag storing the syringe contained water droplets throughout with pooling at the bottom.An interview with Nurse #1 on 3/17/26 at 1:47 PM revealed she observed Resident #12's tube feeding syringe was discolored when she administered medications and water flushes earlier that morning. Nurse #1 stated some medications could stain the syringes, but she would need to verify which medications could cause discoloration. Nurse #1 reported rinsing the syringe with water after use but stated she had no supplies to scrub it. Nurse #1 indicated she separated the syringe and plunger and placed them in the storage bag after rinsing. Nurse #1 stated she knew the syringe should be stored with the plunger removed but was not aware the syringe and plunger should be allowed to air dry before being placed into a clean, dry bag.An interview was conducted with the Director of Nursing on 3/19/26 at 1:00 PM who revealed Resident #12's G-tube syringe should have been washed and the plunger removed from the syringe to allow it to dry before placing it back into a dry bag to prevent any bacterial growth. However, she explained the observed stained syringe should have been discarded and replaced with a new one. According to the DON, all G-tube syringes were routinely replaced every night shift.

Based on record review and interviews with staff and the Medical Director, the facility failed to prevent a significant medication error when Nurse #2 did not administer scheduled medication as ordered. Resident #12 was prescribed scheduled anti-seizure medications to be administered every morning at 8:00 AM and 9:00 AM and Nurse #2 administered the medications 3 and 4 hours late. This deficient practice had the potential to increase seizure activity and affected 1 of 1 resident reviewed for significant medication error (Resident #12).The findings included:Resident #12 was admitted to the facility on [DATE] with diagnoses that included intractable epilepsy (a seizure disorder that is difficult to manage or treatment-resistant), without status epilepticus (a seizure lasting 5 minutes or multiple seizures occurring close together without the person regaining consciousness in between). An admission Minimum Data Set assessment dated [DATE] indicated Resident #12 had moderately impaired cognition and was coded as receiving anti-seizure medication. Review of Resident #12's revised care plan dated 2/24/26 revealed a focus for anti-seizure medications related to epilepsy with an intervention to give the medication as ordered by the doctor. Review of the active Physician orders for March 2026 revealed the following orders:An order dated 2/17/26 for Lacosamide 150 milligrams (mg). Give one tablet via G-tube (gastrostomy tube) two times a day for seizures.An order dated 2/17/26 for Levetiracetam 1000 mg. Give one tablet via G-tube every morning and at bedtime for seizures.An order dated 2/20/26 for Phenytoin Sodium Extended 100 mg. Give one capsule via G-tube two times a day for seizures.Review of Resident #12's March 2026 Medication Administration Record (MAR) revealed Phenytoin Sodium Extended 200 mg was scheduled to be given at 8:00 AM, Lacosamide 150 mg was scheduled to be given at 9:00 AM and 5:00 PM, and Levetiracetam 1000 mg was scheduled to be given at 9:00 AM and 9:00 PM. The March 2026 MAR documented that Resident #12 did not receive these medications from Nurse #2, as scheduled at 8:00 AM and 9:00 AM until 12:07 PM on 3/16/26.An interview with Nurse #2 on 3/16/26 at 3:10 PM, revealed he was an agency nurse who worked at the facility intermittently. Nurse #2 stated he fell behind on morning medication administration on 3/16/26 and did not administer Resident #12's scheduled morning medications until 12:00 PM. He reported he did not request assistance to ensure medications were given on time.The Director of Nursing (DON) was interviewed on 3/19/26 at 10:29 AM and stated Resident #12's seizure medications were required to be administered on time. The DON reported Nurse #2 was an agency nurse and that agency staff had been instructed to request assistance if they fell behind with medication administration. According to the DON, she was unaware Resident #12 received her morning medications outside the acceptable timeframe. The DON stated she did not know why Nurse #2 did not request assistance the morning of 3/16/26 as the medications should have been given one hour before or one hour after to remain in an acceptable timeframe.On 3/19/26 at 1:00 PM, the Medical Director was interviewed. He reviewed Resident #12's medical record and confirmed the resident did not appear to have suffered any ill effects due to the late administration of her anti-seizure medications on 3/16/26, however it could have increased her risk for seizure activity due to her diagnosis of intractable seizures. The Medical Director stated the resident's blood pressure and pulse remained within normal limits, no seizure activity was documented, and Resident #12 appeared clinically unaffected. The Medical Director acknowledged the facility's requirement that medications should be administered within one hour before or after the scheduled time and stated he expected staff to follow this policy.

Based on observation, record review, and interviews with staff and the Nurse Practitioner, the facility failed to follow its infection control policies and procedures for hand hygiene when the Assistant Director of Nursing failed to change gloves and perform hand hygiene during wound care for Resident #12 and Resident #4. The deficient practice occurred for 1 of 4 staff observed for infection control practices (Assistant Director of Nursing). The findings included:The facility's undated policy titled Infection Control Guidelines for All Nursing Procedures states that alcohol based hand rub (60-95% ethanol or isopropanol) is the preferred method of hand hygiene when hands are not visibly soiled. The policy requires hand hygiene before donning gloves, before handling clean or soiled dressings or gauze, after handling used dressings or contaminated equipment, and after removing gloves. The facility's enhanced barrier precautions protocol states staff are to wear gloves and a gown with high-contact resident activities such as wound care and to perform hand hygiene before and after leaving the resident's room.a.) On 3/18/26 at 1:24 PM, the Assistant Director of Nursing (ADON) was observed performing wound care for Resident #12, who was under enhanced barrier precautions for wounds and an indwelling urinary catheter. The ADON donned a gown and gloves before entering the room and placed a clean towel on the bedside table as a barrier. She placed clean dressing supplies on the towel.The ADON removed the soiled dressing from the resident's right foot and placed the soiled dressing on the clean barrier next to unused supplies. The ADON did not remove gloves or perform hand hygiene before cleaning the right foot wound. Without performing hand hygiene or changing gloves, she opened a collagen package, tore off collagen, applied it to the wound, and applied a bordered dressing to Resident #12's foot.Without removing gloves or performing hand hygiene, the ADON removed the soiled sacral dressing and placed it on the bedside table barrier, cleaned the sacral wound, opened collagen, tore off a piece, and applied collagen and a bordered dressing.After completing both wound treatments, the ADON removed her gown and gloves, washed hands, exited the room, and placed unused supplies taken into the resident's room onto a paper towel on the treatment cart.b.) On 3/18/26 at 1:54 PM, an observation of the Assistant Director of Nursing (ADON) performing wound care for Resident #4 was conducted. Resident #4 had orders for enhanced barrier precautions due to the presence of a wound.The ADON donned a clean gown and gloves without performing hand hygiene before entering Resident #4's room. She placed a clean towel on the bedside table as a barrier and placed clean wound care supplies on top of the towel. The ADON repositioned the resident onto her left side and removed the soiled sacral dressing, leaving the dressing on the bed. She cleaned the sacral wound and placed the used gauze on the towel next to the clean supplies.Without removing gloves or performing hand hygiene, the ADON opened a collagen with silver packet, tore a piece, and placed it into the wound bed. She then applied a silicone bordered dressing. The ADON removed her gloves without performing hand hygiene, exited the resident's room while still wearing the gown, and retrieved tape from the top of the wound cart in the hallway. She reentered the room, did not perform hand hygiene, and don clean gloves.The ADON then removed the soiled dressing from Resident #4's right foot and left the dressing on the bed. She wrapped the resident's foot with a dry dressing without removing gloves or performing hand hygiene between handling soiled items and applying clean dressings.After completing the wound care, the ADON discarded the used dressings and towel, removed her gown and gloves, and washed her hands. She removed unused wound care supplies from the resident's room and placed them on a paper towel on top of the wound care cart.An interview was conducted with the ADON on 3/18/26 at 2:05 PM. She reported she had only worked for the facility for two days and had not previously performed wound care there. The ADON stated she should have performed hand hygiene prior to donning gloves, removed gloves and performed hand hygiene after removing soiled dressings, then donned clean gloves before applying clean dressings. She acknowledged she should not have worn the same gloves throughout the procedure or used the same gloves from one wound to another. The ADON further stated she should have discarded soiled dressings in the trash and should not have placed soiled dressings on the clean barrier next to clean supplies. The ADON also stated she should not have removed unopened supplies from residents' bedside tables or placed them on the wound care cart. She then discarded the unused supplies in the trash and cleaned the top of the wound care cart with disinfecting wipes.On 3/19/26 at 10:29 AM, the Director of Nursing (DON) was interviewed and stated she expected the ADON to follow the facility's infection control policies, including hand hygiene and enhanced barrier precautions. The DON reported the ADON should have performed hand hygiene before wound care, between glove changes, and after completing wound care when removing her gown and gloves. The DON stated the ADON should not have entered the hallway wearing a gown or gloves and indicated the ADON required additional infection control education.The Wound Care Nurse Practitioner (NP) was interviewed on 3/19/26 at 11:13 AM and stated he could not speak to events that occurred when he was not present. He reported he would expect the facility to follow evidence based practice for enhanced barrier precautions and adhere to infection control policies.

Based on record review, observations, and staff interviews, the facility failed to post accurate staffing information as compared to the daily staff scheduled for licensed and unlicensed nursing staff for 7 out of 30 days reviewed (2/16/26, 2/22/26, 2/23/26, 2/25/26, 3/1/26, 3/8/26 and 3/15/26). The facility also failed to post the daily nurse staffing sheet for 1 out of 5 days observed (3/16/26). The findings included: 1. A review of the facility's daily posting for nursing staff for the past 30 days (2/16/26 to 3/16/26) as compared to the daily staffing schedule included an inaccurate total of nursing staff worked, which included the following: a. The nursing schedule for 2/16/26 indicated that 9 Nurse Aides (NAs) worked from 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 2/16/26 documented that 7 NAs worked from 7:00 AM to 3:00 PM. b. The nursing schedule for 2/22/26 indicated that 8 NAs worked from 7:00 AM to 3:00 PM and 7 NAs worked from 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 2/22/26 documented that 7 NAs worked 7:00 AM to 3:00 PM and 8 NAs worked 11:00 PM to 7:00 AM. c. The nursing schedule for 2/23/26 indicated that 6 NAs worked from 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 2/23/26 documented that 5 NAs worked from 11:00 PM to 7:00 AM. d. The nursing schedule for 2/25/26 indicated that 6 NAs worked from 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 2/25/26 documented that 7 NAs worked from 11:00 PM to 7:00 AM. e. The nursing schedule for 3/1/26 indicated that 7 NAs worked from 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 3/1/26 documented that 5 NAs worked from 11:00 PM to 7:00 AM. f. The nursing schedule for 3/8/26 indicated that 6 NAs worked from 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 3/8/26 documented that 7 NAs worked from 11:00 PM to 7:00 AM. g. The nursing schedule for 3/15/26 indicated that 1 Registered Nurse (RN) and 3 Licensed Practical Nurses (LPNs) worked from 7:00 AM to 7:00 PM. The daily posted nurse staffing sheet for 3/15/26 documented that no RN and 4 LPNs worked from 7:00 AM to 7:00 PM. On 3/19/26 at 8:20 AM, an interview occurred with the Staff Scheduler who stated she managed the staffing schedule and daily postings. She was able to review the staffing schedules and daily postings and verified the number of staff working on 2/16/26, 2/22/26, 2/23/26, 2/25/26, 3/1/26, 3/8/26 and 3/15/26 did not match. She stated she failed to update the daily posted nurse staffing sheet when a staff member either called out, was a no-show for work or when a staff member came in to cover a need. The staff scheduler explained that on 3/15/26 she forgot to count the RN that worked on the 7:00 AM to 7:00 PM shift and mistakenly counted her as an LPN. The Administrator was interviewed on 3/19/26 at 11:30 AM and stated that the daily posted nurse staffing sheet and the nursing schedule should match the number of staff worked on any given shift. 2.) During the initial tour of the facility on 3/16/26 at 8:45 AM and a subsequent observation on 3/16/26 at 1:13 PM, the posting of the daily staffing data, located inside a clear plastic stand in the foyer of the reception area, was dated 3/13/26. An interview was conducted with the Scheduler on 3/17/26 at 10:29 AM who stated during the weekdays it was either her responsibility, or the Director of Nursing (DON) would help at times, to post the daily staffing sheets. She indicated she thought the DON had posted the daily staffing sheet the morning of 3/16/26. The Director of Nursing was interviewed on 3/19/26 at 10:29 AM who stated the Scheduler was responsible for posting daily staffing sheets Monday through Friday, and the Receptionists were responsible for posting them on the weekends. However, the DON indicated she had posted the staffing sheet herself Monday morning, 3/16/26, shortly after entering the facility at 6:00 AM. The DON stated she was not sure why the daily staffing sheet was not present when the State entered the building except maybe someone had pulled the sheets for review. She explained the daily staffing sheet should have been posted for 3/16/26. The Administrator was interviewed on 3/19/26 at 1:49 PM who stated the DON told her she had posted the daily staffing sheet on 3/16/26. According to the Administrator, it was possible someone removed the staffing sheet from the folder to review and failed to put it back.

Based on observations and staff interviews, the facility failed to date leftover food items stored for use in the dry goods storage area and in 1 of 1 walk-in coolers. This practice had the potential to affect food served to residents. The findings included: a. An observation on 12/2/24 at 9:35 AM of the dry goods revealed the following concerns: - an open and undated bag of corn flakes placed in transparent wrapping. - an undated bag of leftover brown sugar stored in a plastic bag that was not sealed. b. An observation of the walk-in cooler on 12/2/24 at 9:45 AM revealed the following concerns: - an undated leftover package of sliced cheese stored in transparent wrapping - an undated leftover package of sliced ham stored in transparent wrapping - a stainless-steel container with cooked mixed vegetables that had not been dated An interview with the Dietary Manager on 12/2/24 at 10:00 AM indicated that she was new in the position. She stated she was responsible for making sure food items were dated and stored properly. An interview with [NAME] #2 on 12/3/24 at 11:10 AM revealed that she knew that refrigerated leftover food had to be used within 3 days. She further indicated that all dry goods should be sealed and labeled with an open date and used within 7 days. If not used in 7 days, the dry foods should be thrown out. An interview with Dietary Aide #1 on 12/3/24 at 11:13 AM indicated that food items should be sealed, dated and the expiration or use by date should be checked daily, and thrown out when indicated. An interview with the Administrator on 12/4/24 at 9:30 AM revealed the Dietary Manager was new on the job. He then said that sanitary and safe food was very important, and he would make sure the Dietary manager would have a system in place to monitor food items for proper wrapping and dating of leftover foods.

Based on record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of accidents (Residents #63, #64 and #17). This was for 3 of 22 residents whose MDS assessments were reviewed. The findings included: 1. Resident #63 was admitted to the facility on [DATE] with diagnoses that included vascular dementia. A review of Resident #63's medical record revealed he had a fall on 9/20/24 with a minor injury since the quarterly MDS assessment on 8/9/24. The annual MDS assessment, dated 11/9/24, indicated Resident #63 had severe cognitive impairment and was not coded for any falls since the last assessment. On 12/5/24 at 9:50 AM, an interview occurred with the MDS Coordinator, who reviewed the MDS assessment dated [DATE] as well as Resident #63's medical record. The MDS Coordinator confirmed Resident #63 had a fall since the last assessment on 8/9/24 and should have been coded for a fall with minor injury. She stated it was an oversight. An interview was conducted with the Administrator on 12/5/24 at 10:12 AM and stated it was his expectation for the MDS assessments to be coded accurately in the area of falls. 2. Resident #64 was admitted to the facility on [DATE] with diagnoses that included history of a stroke with left sided weakness and repeated falls. A review of Resident #64's medical record revealed he had falls on 7/5/24 with no injury, 7/25/24 with no injury, 8/3/24 with no injury, 8/7/24 with no injury and another fall on 8/7/24 with minor injury since the annual MDS assessment on 6/15/24. The quarterly MDS assessment, dated 9/15/24, indicated Resident #64 had moderately impaired cognition and was coded with one fall with minor injury since the last assessment. On 12/5/24 at 9:50 AM, an interview was completed with the MDS Coordinator, who reviewed the MDS assessment dated [DATE] as well as Resident #64's medical record. The MDS Coordinator confirmed Resident #64 had four falls without injury since the last assessment on 6/15/24 and should have coded the MDS assessment as 2 or more falls with no injury. She stated it was an oversight. An interview was conducted with the Administrator on 12/5/24 at 10:12 AM and stated it was his expectation for the MDS assessments to be coded accurately in the area of falls. 46095 3. Resident #3 was admitted to the facility on [DATE] with diagnoses that included Dementia. a. A review of Resident #3's medical record revealed she had a fall on 07/24/24 with no injuries. A quarterly Minimum Data Set (MDS) assessment, dated 07/31/24, indicated Resident #63 had moderate cognitive impairment and was not coded for any falls since the last assessment (quarterly dated 6/15/24). b. A review of Resident #3's medical record revealed she had a fall on 08/05/24 with no injuries. A quarterly MDS assessment, dated 09/15/24, indicated Resident #3 had moderate cognitive impairment and was not coded for any falls since the last assessment (quarterly dated 7/31/24). An interview was conducted with the MDS Coordinator on 12/5/24 at 9:55 AM. The MDS Coordinator reviewed the MDS assessment dated [DATE] as well as Resident #3's medical record. The MDS Coordinator confirmed Resident #3 had a fall since the last assessment on 07/24/24 and should have been coded for a fall with no injury. She then reviewed the MDS assessment dated [DATE] as well as Resident #3 ' s medical record. The MDS Coordinator confirmed Resident #3 had a fall since the last assessment on 08/05/24 and should have been coded for a fall with no injury. She stated it was an oversight. An interview was conducted with the Administrator on 12/5/24 at 10:12 AM and stated it was his expectation for the MDS assessments to be coded accurately in the area of falls.

Based on manufacturer's recommendations, observations, record review and staff, and Consultant Pharmacist interviews, the facility failed to discard expired medications in 1 of 2 medication carts (Masters Hall Medication Cart) reviewed for medication storage and labeling. Findings included: An observation was conducted on 12/04/24 at 1:50 PM of the Masters Hall medication cart in the presence of Nurse #1. The observation revealed the following expired medications: a. One opened bottle of Latanoprost eye drops used to treat glaucoma (a condition in which increased pressure in the eye can lead to gradual loss of vision) with an opened date of 09/10/24. The manufacturer's recommendation was to discard 6 weeks after opening. b. One opened bottle of Latanoprost eye drops used to treat glaucoma (a condition in which increased pressure in the eye can lead to gradual loss of vision) with an opened date of 10/16/24. The manufacturer's recommendation was to discard 6 weeks after opening. c. One opened bottle of Latanoprost eye drops used to treat glaucoma (a condition in which increased pressure in the eye can lead to gradual loss of vision) with an opened date of 10/18/24. The manufacturer's recommendation was to discard 6 weeks after opening. An interview was conducted with Nurse #1 on12/04/24 at 1:52 PM. She verified the medications were expired and she removed them from the medication cart and discarded them. She indicated nurses were to check dates on all multi-use medications prior to administration to make sure they were not expired. She then stated she did not realize the medications were expired. She indicated she had not checked the medication cart for expired medications on 12/04/24. An interview was conducted with the Director of Nursing (DON) on 12/05/24 at 10:01 AM. She stated all nurses were responsible for checking dates on multi-use medications prior to administration to verify that they were not expired. She explained that the unit managers could also check the medication carts for expired medications however there was no set days or schedule for them to follow. She then stated the pharmacist should be performing medication cart audits when they were in the building. She expected the nurses to always check dates prior to administration and to remove medications that were expired. A phone interview was conducted with the facility Pharmacist on 12/05/24 at 11:15 AM. She stated she came to the facility every other month and checked the medication carts for dated and expired medications. She explained that she tried to look at all four medication carts while in the facility but that was not always possible, however, she did review at least two of them. She indicated the last time she was at the facility was in October and she checked two medication carts at that time. She did not recall which medication carts that she reviewed in October. The Pharmacist verified the manufacturer's recommendation was to discard Latanoprost eye drops 6 weeks after opening.

Based on record review and staff interview, the facility failed to ensure Nursing Assistants (NAs) received annual Dementia training. This was for 4 (NA #1, NA #2, NA #3 and NA #4) of 5 NAs reviewed for staffing. The findings included: a.NA #1's date of hire was 06/22/10. Review of NA #1's Education/In-services records indicated no record of Dementia training since 06/07/23. b.NA #2's date of hire was 02/02/16. Review of NA #2's Education/In-services records indicated no record of Dementia training since 06/07/23. c.NA #3's date of hire was 12/20/99. Review of NA #3's Education/In-services records indicated no record of Dementia training since 06/06/23. d.NA #4's date of hire was 12/19/22. Review of NA #4's Education/In-services records indicated no record of Dementia training since 06/07/23. An interview was conducted with the Director of Nursing (DON) on12/05/24 at 10:01 AM. She explained the current Staff Development Coordinator (SDC) had been out on medical leave since October 2024 however she had requested to step down from her current position of SDC upon returning. The DON stated Dementia training should be completed yearly, and it was an oversight it wasn't completed within the last year. The DON verified with the previous SDC nurse that it was an oversite that the Dementia training was not completed. An interview was conducted with the Administrator on 12/05/24 at 10:35 AM. He confirmed Dementia training had not been completed since 06/07/23. He stated it was an oversight that the training had not been done. The Administrator stated it was his expectation that the NAs received annual Dementia training.

Based on record reviews and interviews with staff, Physician Assistant (PA), Wound Nurse Practitioner, and Medical Director (MD), the facility failed to implement preventative measures for a resident assessed to be moderate to high risk for development of pressure ulcers. The resident developed a deep tissue injury to the sacrum, 2 deep tissue injuries to the left lateral foot, as well as a deep tissue injury to the left ankle. Deterioration of the sacral wound was not communicated to the MD or the PA. The resident was admitted to the hospital with septic shock for 1 of 8 residents (Resident #178) reviewed for pressure injuries. The findings included: Hospital discharge summary indicated Resident #178 was previously living in an assisted living environment for 100+ days prior to being seen in the Emergency Department on 7/24/2023 for acute onset mental status change thought to be caused by a urinary tract infection. The resident was discharged from the hospital to the skilled nursing facility for short term rehabilitation. Resident #178 was admitted to the facility 8/1/2023 with diagnoses that included type 2 diabetes, coronary artery disease, hypertension (high blood pressure), altered mental status with recent history of urinary tract infection. The resident's admission Minimum Data Set, dated dated dated [DATE] indicated the resident did not have any pressure injuries upon admission. The resident was coded as moderately cognitively impaired and required extensive assistance with bed mobility, eating, dressing, and personal hygiene during the assessment period. The resident was always incontinent of bowel and bladder. The resident's admission care plan dated 8/2/2023 contained a focus for risk of skin impairment related to incontinence and being in bed or geriatric chair. Interventions included; resident needs pressure relieving mattress on bed to protect the skin while in bed. The intervention was dated 8/9/2023. Per Unit Manger #1The resident was provided a pressure relieving mattress on 8/9/2023. On 8/3/2023 the Wound Nurse Practitioner (NP) completed Resident #178's admissions skin assessment. Her progress note indicated the resident's skin was intact and he was moderate to high risk for skin breakdown. The Wound NP recommended moisture barrier creams and turning /repositioning to prevent pressure injuries. The resident's medical record contained the following active orders; Give resident health shake twice daily. The order had a start date of 8/6/2023. The medical record contained a weekly skin assessment completed 8/8/2023. The skin was intact. The resident's medical record contained a progress noted dated 8/13/2023 by Nurse #5 indicated the resident had a new open area on coccyx measuring approx. 4 centimeters (cm) long. She notified the provider on call and received orders to clean and cover the wound with a foam dressing every other day and as needed until the wound could be evaluated by the Wound NP. There was no other description of the wound. Attempts to contact Nurse #5 were not successful. Resident #178's Treatment Administration Record (TAR) for August revealed the resident received wound care per the order given by the provider on 8/13/2023. On 8/15/2023 the Wound NP evaluated Resident #178. The visit summary indicated the resident had the following pressure injuries; Left lateral foot deep tissue injury, length 2.3cm x width 2.5cm x depth 0 Left ankle deep tissue injury, 1.2cm x 1.3cm x 0 Sacrum deep tissue injury, 3cm x 1.8cm x 0.2cm with moderate serosanguinous exudate The Wound NP recommended cleaning and application of skin preparation for the left lateral foot and left ankle, as well as leaving both open to air. She recommended cleaning, medical grade honey, and hydrocolloid, and dressing changes 3 times a week for the sacral deep tissue injury. The resident's medical record contained the following active orders; Cleanse sacral wound with wound cleanser, apply medical grade honey, cover with hydrocolloid three days per week and as needed. The order had a start date of 8/16/2023. Cleanse left lateral foot wounds with wound cleanser, apply skin prep, leave open to air daily. The order had a start date of 8/16/2023. Cleanse left ankle wound with wound cleanser, apply skin prep, leave open to air daily. The order had a start date of 8/16/2023. The resident's Treatment Administration Record (TAR) for August indicated the resident received treatments to his pressure injuries as ordered. On 8/22/2023 the Wound NP evaluated Resident #178's pressure injuries. The after-visit summary documented the following; Left lateral distal foot deep tissue injury, 2.7cm x 1.9cm x 0 Left lateral foot deep tissue injury, 1.2cm x 1.3cm x 0 Left ankle, deep tissue injury, 1.2cm x 1.3cm x 0 Sacrum deep tissue injury, 10cm x 8cm x .2cm with moderate serosanguinous exudate Recommendations for treatment of existing pressure injuries did not change from previous week. Wound care orders for the new deep tissue injury to the foot included cleaning, application of skin preparation, and leaving the wound open to air. The Wound NP recommended the staff continue turning and repositioning. The resident's August TAR revealed the resident received treatments to his pressure injuries as ordered. On 8/22/2023 the resident's medical record indicated he was febrile at 102 degrees and received Tylenol. The Medical Director (MD) evaluated Resident #178 on 8/23/2023 for suspected pituitary adenoma due to a very low thyroid stimulating hormone (TSH) level, low T3 (thyroid hormone) with normal T4 (thyroid hormone) . She documented cognitive decline since her previous evaluation one week prior. The MD spoke with the resident's Responsible Party (RP) who was concerned about the resident's cognitive decline over the previous 4 days. The MD documented the resident was difficult to arouse. She ordered labs including COVID-19, clostridium difficile, and made referral to endocrinology. A progress note indicated the resident's RP visit the facility on 8/23/2023 at 2:14 PM and requested the resident be sent out to the Emergency Department. Hospital records dated 8/23/2023 indicated the resident arrived at the Emergency Department febrile at 101 degrees, hypotensive (low blood pressure) at 98/36, and minimally responsive to stimuli. The medical record also indicated the resident had a large foul smelling unstageable sacral wound. There was no documentation regarding the deep tissue injuries to the left foot and ankle. The Emergency Department physician noted the resident was too unstable too thoroughly evaluate the wound in the Emergency Department. The resident was admitted to the Intensive Care Unit with a diagnosis of septic shock and required pressors (intravenous medication to support blood pressure). Hospital records also contained a consult by Infectious Disease. The Infectious Disease Physician indicated while the resident tested positive for COVID-19, there was no sign of pulmonary infiltrates on chest x-ray. He did not feel like COVID was contributing to his illness. Polymicrobial soft tissue infection of the sacral region was most likely the cause of his sepsis. Cultures were positive for Enterococcus and Staphylococcus. An interview with Nurse Assistant (NA) #3 was conducted 9/26/2023 at 9:45 AM. She stated she occasionally worked on the hall Resident #178 resided. She vaguely recalled the resident but did not recall his pressure injuries. NA#4 was assigned to the hall Resident #178 resided on during his stay. She stated she did not recall Resident #178. She stated the residents on that hall were short term and it was difficult to remember them all. On 9/27/2023 at 1:26 PM an interview was conducted with the MD. She stated she completed labs and ordered a dietary consult on admission. She further stated the resident's albumin was a little low at 3.4 on admission and he was diabetic. Those could have contributed to the development of pressure injuries. The MD stated she did not know why the resident's sacral pressure injury would have declined so quickly. She stated the Wound NP had not communicated the deterioration of the sacral wound to her. The Wound NP may have communicated with the facility's Physician Assistant regarding the wound. An interview was conducted with the Physician Assistant (PA) on 9/27/23 at 2:01 PM. He stated he was aware the resident had developed wounds around 8/13/2023. The PA stated the resident was not able to move himself in the bed or reposition himself in a wheelchair. He had spoken with the resident's family regarding the resident's decreased cognition and need for imaging. The resident had imaging completed on 8/15/2023 that was negative for cerebral vascular accident (stroke). The PA stated the Wound NP had not made him aware of the deterioration of the sacral wound and he was not aware it was significant enough to cause sepsis. On 9/27/2023 at 3:00 PM an interview was conducted with Unit Manager#1. Unit Manager #1 stated she performed the resident's wound care while he was in the facility. She recalled the wound was necrotic, had exudate, and declined rapidly. She stated she did rounds with the Wound NP on 8/15/2023 and they discussed placing the resident on a specialty mattress. She was in the process of determining if he met the criteria for a gel overlay or air mattress when the resident was sent to the hospital. The Unit Manager #1 provided an paper form titled, IDT Post Wound Investigation Summary that was dated 8/12/2023 10:37PM. The form indicated the care plan decision was to get gel overlay to bed. The form was signed by Unit Manager #1. Unit Manager #1 stated she was not sure why the gel overlay was not provided. Unit Manager #1also provided a paper form titled, IDT Post Wound Investigation Summary dated 8/19/2023 10:09PM. The care plan decision indicated possible air mattress if appropriate. Unit Manager #1 stated the resident did not meet the criteria for an air mattress. She further stated the resident was able to move himself independently in the bed. This made an air mattress a falls risk. A telephone interview was conducted with the Wound NP on 9/27/2023 at 3:15 PM. Stated the resident's sacral wound deteriorated rapidly. It was a DTI with necrosis. She did not recall if it had an odor but stated it did have some exudate. She was not concerned with the rapid deterioration of the wound. She was going to give the wound another week to declare itself. At the time of the interview, she was not aware the resident had been admitted to the hospital with septic shock related to the sacral wound. On 9/27/23 at 3:43 PM the Wound NP called back and stated when a sacral DTI deteriorates rapidly, she would typically recommend changing treatments, adding an air mattress, and recommending dietary add protein supplements. She did not recall if any of these interventions were started because she did not order interventions, she was only responsible for the actual wound care. She stated she did not recall speaking with the Physician Assistant or the Medical Director regarding the sacral wound deterioration as she was not always in the facility at the same time as the providers.

Based on record review, observations and interviews with staff, Dishwasher Repairman, and Regional Dietary Director, the facility failed to label opened food items stored in 1 of 1 walk in coolers, 1 of 1 reach in coolers, and 1 of 1 walk in freezers and failed to maintain water temperature during the wash and rinse cycles of the high-temp dishwasher according to manufacturer ' s instructions for 3 of 4 observations. This practice had the potential to affect food served to residents. Findings included: 1. During the initial tour of the kitchen on 09/25/23 at 09:18 AM in the presence of the Dietary Manager (DM) the following were observed: a. Located in the reach-in refrigerator available for use was one ham and cheese sandwich without a label. The DM verified the sandwich did not contain a label and she discarded the item. b. Located in the walk-in refrigerator available for use were two trays containing 64 single serving individual cups with a white substance with no label. The DM identified the white substance as sour cream and stated that it should have been labeled and dated when prepared. On 09/25/23 at 09:24 AM an interview was conducted with Dietary Aide #3. She stated she prepared the cups of sour cream this morning (09/25/23) for today ' s lunch but forgot to label the cups/trays. c. Located in the walk-in freezer available for use were the following items: - One opened box of four ounce Pork Choppette patties that was 1/4 full and undated. The DM stated that the box should have been labeled with the date it was delivered to the facility. -One 30 pound (lb) opened box of cut corn that was 1/4 full, undated and unlabeled. The DM stated that the box should have been labeled with the date it was delivered to the facility. -One 30 lb opened box of sliced zucchini that was 1/4 full, undated and unlabeled. The DM stated that the box should have been labeled with the date it was delivered to the facility. -One 30 lb opened box of cut cauliflower that was 1/2 full, undated and unlabeled. The DM stated that the box should have been labeled with the date it was delivered to the facility. -One 30 lb opened box of sweet peas that was 1/2 full, undated and unlabeled. The DM stated that the box should have been labeled with the date it was delivered to the facility. On 09/25/23 at 9:31 AM an interview was conducted with the Dietary Manager (DM). She stated that it was everyone ' s responsibility for labeling food when it was delivered to the facility, opening and/or preparing the items. She stated per policy, all foods stored in the refrigerator or freezer were to be covered and dated. Received dates (dates of delivery) will be marked on cases. All prepared food in refrigerators should be labeled with the date the item was prepared and with the Use by (expiration) date. 2. During the initial tour of the kitchen on 09/25/23 at 9:46 AM in the presence of the Dietary Manager (DM), racks of dirty dishes were being run through the high temperature dish-machine by Dietary Aide #2. The high temperature dish-machine rinse temperature gauge read 140 degrees Fahrenheit (F) and 145 degrees F during the wash cycle. Dietary Aide #1 was removing the racks of washed meal trays and putting them on a drying rack. The DM stated she thought the dishwasher was a low-temperature dish-machine and she checked the dish-machine temperature and chemical levels daily but had not checked them today. A container located on the wall with hoses connected to the dishwasher was empty. The DM stated the container was the washing detergent for the dishwasher and the shipment had not arrived yet. She reset the heat booster, ran empty racks through the dishwasher for 3 cycles and then used a temperature strip to check the temperature. The strip turned completely orange which indicated the water was at 180 degrees F. The DM implemented that washing/rinsing the dishes using the dishwasher was ceased until the wash detergent arrived at the facility. All lunch meals were served on disposable dinnerware with disposable silverware. The wash detergent arrived at approximately 2:00 PM. On 09/25/23 at 9:52 AM an interview was conducted with Dietary Aide #2. He stated he did not check the water temperature with the temperature strip today. He stated that they have had problems with the heater booster and would have to reset it prior to washing the dishes. He indicated he had reset the heater booster, but he did not realize the temperature gauge read 140 degrees F during the rinse cycle. He was unsure what the manufacturer ' s temperature requirement was. He also stated he did not realize the detergent solution was empty. On 09/25/23 at 9:52 AM an interview was conducted with Dietary Aide #1. He indicated he had not looked at the temperature gauge prior to washing the dishes today and was unsure what the manufacturer ' s temperature requirement was. He stated that they have had problems with the heater booster and would have to reset it prior to washing the dishes. On 09/26/23 at 10:19 AM the Regional Dietary Director was interviewed. He stated the dishwasher was a high temp dishwasher. The rinse temperature of 140 degrees F, and wash temp of 145 degrees yesterday may have been caused by the booster heater tripping. After resetting the booster heater, the temps read within recommended guidelines. He supplied a service call report dated 09/25/23 at 2:38 PM. The service report revealed the overload tripped on booster heater, reset and made sure all temperatures were correct at that time. A follow up kitchen observation was conducted on 09/26/23 at 1:24 PM. Dietary Aide #1 was observed running racks of dirty dishes through the high temperature dish-machine. A second observation at this time revealed the dish-machine temperature gauge read 135 degrees F during the rinse cycle. He stated he did not realize the temperature was at 135 degrees F. On 09/26/23 at 1:25 PM an observation and interview were conducted with the Regional Dietary Director. He verified the temperature gauge read 135 degrees F during the rinse cycle. He immediately educated the dietary aides that they needed to reset the booster heater and to run empty trays through the dishwasher until the gauge read the correct temperature which was 180 degrees F for the finale rinse cycle and 150-165 degrees F for the wash cycle. After the booster heater was reset, the dishwasher temperature gauge read 185 degrees F for the rinse cycle and 150 degrees F for the wash cycle. He also checked the water temperature which read 180 degrees F. The Regional Dietary Director had the Maintenance Director to call the Dishwasher Repairman to come back in to reevaluate the dishwasher. All dishes were rewashed when the appropriate temperatures were reached. On 09/27/23 at 12:47 PM through 1:05 PM an interview was conducted with the Dishwasher Repairman. He reset the booster heater and the temperature gauges went up to 185 degree F for the rinse cycle and 170 degree F for the resting wash temperature. He stated the temperature gauges were working correctly and that it seemed the heater booster was tripping causing the temperatures to drop during the wash/rinse cycle. The Dishwasher Repairman stated the staff needed to monitor the temperature gauges and reset the heater booster if the temperatures start to drop. A follow up kitchen observation was conducted on 09/27/23 at 12:59 PM. Dietary Aide #1 was observed running racks of dirty dishes through the high temperature dish-machine. The third observation revealed the dish-machine temperature gauge read 135 degrees F during the rinse cycle. He stated he did not realize the temperature was at 135 degrees F. The heater booster was reset, and the dishes were rewashed when the appropriate temperature was reached. On 09/27/23 at 1:05 PM an interview was conducted with the Maintenance Director. He stated repairs to the heater booster were conducted on 08/24/23. All terminal connections were checked and tightened, and the power feed contactor was replaced. He indicated they have had problems with the heater booster for a while. On 09/27/23 at 1:22 PM, the Administrator was interviewed. She stated that she expected the Dietary Manager (DM) to inform her and the Maintenance Director immediately when the dish-machine was not working properly. The administrator stated her expectation was that dietary properly label all food items per policy in the coolers and the freezer.

Based on record reviews, observations, Pharmacy Consultant, Hospice Aide, Physician's Assistant, Wound Nurse Practitioner, Dishwasher Repairman, Regional Dietary Director, resident and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following an annual recertification and complaint survey on 9/20/21. This was for five deficiencies that were cited in the areas of Accuracy of Assessments, Treatment/Services to Prevent/Heal Pressure Ulcers, Free of Accident/Hazards/Supervision/Devices, Free from Unnecessary Psychotropic Medications, and Food Procurement/Store/Prepare/Serve-Sanitary. In addition, five additional deficiencies were cited during the annual recertification and complaint survey on 7/20/22 in the areas of Accuracy of Assessments, Treatment/Services to Prevent/Heal Pressure Ulcers, Increase/Prevent Decrease in Range of Motion/Mobility, Residents are Free of Significant Medication Errors and Food Procurement/Store/Prepare/Serve-Sanitary. The duplicate citations during three federal surveys of record show a pattern of the facility's inability to sustain an effective QAPI program. The findings included: The citations are cross referenced to: 1) F758- Based on record review and interviews with the Pharmacy Consultant, Physician's Assistant and staff, the facility failed to have an adequate clinical indication for the use of an antipsychotic medication (Resident #73). This was for 1 of 5 residents whose medications were reviewed. During the facility's annual recertification and complaint survey dated 9/20/21, the facility failed to assess residents on antipsychotic medication for abnormal involuntary movement disorders, failed to identify target behavioral symptoms and to monitor those symptoms, failed to evaluate residents on psychotropic medications for gradual dose reductions and failed to ensure PRN (as needed) psychotropic medications were time limited in duration for 7 of 9 residents whose medications were reviewed. An interview was completed with the Administrator and DON on 9/28/23 at 10:30 AM and felt it was an oversight not to have an appropriate clinical indication for the use of a psychotropic medication. 2) F689- Based on staff and Hospice Aide #1 interviews along with record review, the facility failed to provide care safely which resulted in a fall without injury when Hospice Aide #1 left Resident #68's on his side in bed to retrieve a washcloth and failed to ensure two staff were presence for bed mobility. This was for 1 (Resident #68) of 8 reviewed for accidents. During the facility's annual recertification and complaint survey dated 9/20/21, the facility failed to implement a fall intervention for a resident who sustained a fall with the staff present for 1 of 3 residents reviewed for accidents. On 9/28/23 at 10:30 AM, an interview occurred with the Administrator and DON. They both indicated that education was needed for both staff and Hospice providers. A meeting was going to be held with the Hospice providers. 3) F686- Based on record reviews and interviews with staff, Physician Assistant (PA), Wound Nurse Practitioner, and Medical Director (MD), the facility failed to implement preventative measures for a resident assessed to be moderate to high risk for development of pressure ulcers. The resident developed a deep tissue injury to the sacrum, 2 deep tissue injuries to the left lateral foot, as well as a deep tissue injury to the left ankle. Deterioration of the sacral wound was not communicated to the MD or the PA. The resident was admitted to the hospital with septic shock for 1 of 8 residents (Resident #178) reviewed for pressure injuries. During the facility's annual recertification and complaint survey dated 9/20/21, the facility failed to obtain a treatment order when pressure ulcers were first identified for 1 of 4 residents reviewed for pressure ulcers. During the facility's annual recertification and complaint survey dated 7/20/22, the facility failed to complete pressure ulcer treatments as ordered and failed to provide a specialized wheelchair cushion as ordered for 3 of 5 residents reviewed for pressure ulcer care. In an interview with the Administrator and Director of Nursing (DON) on 9/28/23 at 10:30 AM, they indicated there had been turn over with wound care staff as well as wound care providers in the last year. Unit Managers were now responsible for wound care on their units. 4) F812- Based on record review, observations and interviews with staff, Dishwasher Repairman, and Regional Dietary Director, the facility failed to label opened food items stored in 1 of 1 walk in coolers, 1 of 1 reach in coolers, and 1 of 1 walk in freezers and failed to maintain water temperature during the wash and rinse cycles of the high-temp dishwasher according to manufacturer's instructions for 3 of 4 observations. This practice had the potential to affect food served to residents. During the facility's annual recertification and complaint survey dated 9/20/21, the facility failed to label and date food items in a container after opening, failed to date thawed nutritional supplements, and failed to wear hair and beard restraints for 2 of 2 kitchen observations. During the facility's annual recertification and complaint survey dated 7/20/22, the facility failed to ensure food items in the walk-in cooler, that had been opened were labeled and dated for 1 of 1 walk in coolers. During an interview with the Administrator and DON on 9/28/23 at 10:30 AM, they indicated there had been a lot of transition in the kitchen with new staff to include the dietary manager. Duty assignments were going to be put into place for dietary aides. The booster seemed to be an issue on the dishwasher and was going to be replaced with a low temperature dishwasher in two weeks. 5) F641- Based on record reviews, resident and staff interviews, the facility failed to code the Minimum Data Set (MDS) accurately in the area of bathing for 1 of 20 residents reviewed. During the facility's annual recertification and complaint survey dated 9/20/21, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of medications, urinary catheter, weight loss, skin condition, and smoking for 8 of 20 residents reviewed. During the facility's annual recertification and complaint survey dated 7/20/22, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of alarms, Hospice, and falls. This was for 3 of 19 resident records reviewed. An interview occurred with the Administrator and DON on 9/28/23 at 10:30 AM and indicated they felt the repeat citations in MDS accuracy were related to human error as well as turnover in staff. 6) F688- Based on observations, resident and staff interviews, and record review, the facility failed to apply a left lower extremity (LLE) brace as ordered. This was for 1 (Resident #44) of 1 resident reviewed for range of motion (ROM). During the facility's annual recertification and complaint survey dated 7/20/22, the facility failed to follow and implement Physician orders for a left resting hand splint for 1 of 1 resident reviewed for range of motion. During an interview with the Administrator and DON on 9/28/23 at 10:30 AM, they indicated there needed to be a process for when a resident was discharged from therapy services and the need for splint application. 7) F760- Based on record review and interviews with staff, Physician Assistant (PA) and Medical Director (MD), the facility failed to provide scheduled antianxiety medication resulting in multiple missed days of a significant medication for 1 of 5 (Resident #26) reviewed for unnecessary medications. During the facility's annual recertification and complaint survey dated 7/20/22, the facility failed to administer the Keppra (an antiseizure medication) to a resident as ordered from the hospital. This was for 1 of 4 sampled residents who were admitted /readmitted and were reviewed for medication errors. In an interview with the Administrator and Director of Nursing on 9/28/23 at 10:30 AM, they indicated that agency nursing ceased at the facility beginning of July 2023. They felt the use of agency staff could have contributed to this repeat citation.

Based on record review and interviews with staff, Physician Assistant (PA) and Medical Director (MD), the facility failed to provide scheduled antianxiety medication resulting in multiple missed days of a significant medication for 1 of 5 (Resident #26) reviewed for unnecessary medications. The findings included: Resident #26 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder and psychosis and anxiety disorder. Resident # 26's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was moderately cognitively impaired and received antipsychotics and antidepressants 7 out of 7 days during the assessment period. Resident #26's medical record contained an after-visit summary by the Mental Health Nurse Practitioner dated 8/23/2023. The summary indicated the resident had been on 0.5mg of lorazepam as needed for anxiety for 14 days. Staff reported Resident #26 showed reduction in anxiety behaviors with the lorazepam. The Mental Health Nurse Practitioner recommended changing the lorazepam from as needed twice daily to scheduled twice daily with a start date of 8/24/20253. Resident #26's August Medication Administration Record (MAR) indicated the resident received 0.5mg lorazepam every 12 hours as needed with a start date of 8/10/2023 and an end date of 8/24/2023. The resident did not receive lorazepam from 8/24/2023 through 8/29/2023. There was no active order for lorazepam during that time. The resident's behavioral monitoring did not reveal any behaviors related to anxiety between 8/24/2023 and 8/29/2023. Further review of the August MAR revealed the Medical Director (MD) wrote an order for lorazepam 0.5mg every 12 hours as needed for breakthrough anxiety was started on 8/30/2023 with an end date of 9/12/2023 due to staff reports of ongoing anxiety. The September MAR indicated the resident received 0.5mg of lorazepam every 12 hours as needed for anxiety until 9/12/2023. The resident did not receive any lorazepam from 9/12/2023 through 9/24/2023 as there was no active order for lorazepam at that time. The MAR indicated 0.5mg of lorazepam scheduled every 12 hours started on 9/25/2023. The order was written by the Medical Director (MD). The resident's behavioral monitoring revealed on 9/16/2023 the resident was observed yelling and crying out that something was wrong with her hand. Staff calmed the resident and assured her hand was fine. Nonpharmacological interventions were effective. An interview was conducted with the Physician Assistant (PA) on 9/27/2023 at 10:08 AM. He stated he had not seen the recommendation to make Resident #26's lorazepam scheduled instead of as needed. He further stated the mental health nurse practitioner faxed her visit summaries to the facility and they are placed in the communication notebook for him and the Medical Director (MD) to review. He would have initialed and dated the after-visit summary if he had reviewed it. He stated the summary was uploaded into the medical record without being reviewed. On 9/27/2023 at 10:56 AM an interview was conducted with the Director of Nursing (DON). She stated the visit summaries are faxed to the facility and should be placed in the provider's communication notebook for them to acknowledge. However, the after-visit summary for Resident #26 did not have a date or initials so it had not been acknowledged by the providers. She did not know why the error had occurred. She stated they needed to work on the process to ensure the providers review the after-visit summaries before they are uploaded into the medical record. On 9/27/2023 at 1:26 PM an interview was conducted with the MD. She stated she saw the recommendation when she reviewed the mental health providers after visit summaries as part of her regulatory visit on 9/25/2023. She had not seen the recommendation prior to that date. She further stated the after-visit summary should have been placed in the communication notebook for her or the PA to verify.

Based on observations, resident and staff interviews, and record review, the facility failed to apply a left lower extremity (LLE) brace as ordered. This was for 1 (Resident #44) of 1 resident reviewed for range of motion (ROM). The findings included: Resident #44 was admitted on [DATE] with a diagnosis of a Cerebral Vascular Accident (CVA) and multiple contractures. Resident #44's annual Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment, no behaviors, extensive assistance with all of her activities of daily living and she was coded for impairment to both upper and lower extremities. Review of Resident #44 September 2023 Physician orders included an order dated 8/22/23 and reordered on 9/25/23 that read she was to wear a knee brace on her LLE for 4 hours a day, or as tolerated while lying supine in the bed for contracture management. Resident #44 was care-planned for a self-care performance deficit which included the new intervention dated 8/23/23 to wear the knee brace on her LLE for 4 hours a day, or as tolerated while lying supine in bed. A review of the comprehensive care plan did not include any refusals or resistance to wearing her LLE brace. Review of Resident #44's undated electronic Care Guide read the following: Resident was to wear knee brace on LLE for 4 hours or as tolerated daily while lying supine. An observation was completed on 9/25/23 at 12:14 PM of Resident #44. She was lying supine (lying in bed with face upward) in bed with no LLE brace in use. Another observation was completed on 9/26/23 at 11:12 AM of Resident #44. She was lying supine in bed with no LLE brace in use. Resident #44 stated she was supposed to wear the LLE brace everyday but the staff were inconsistent with putting it on her. Observation of Resident #44's closet revealed the LLE brace lying on the bottom of the closet with a pillow on top of it. An interview was completed on 9/27/23 at 9:15 AM with Nursing Assistant (NA) #6, who had worked with Resident #44. She stated she was aware that Resident #44 was ordered an LLE brace and she was not known to refuse the LLE brace. Another observation was completed on 9/27/23 at 9:25 AM of Resident #44. She was lying supine in the bed with no LLE brace in use and observed on top of a nightstand beside her closet was her LLE brace. An interview was completed on 9/27/23 at 9:30 AM with the Therapy Director. He stated Resident #44's LLE brace was a new intervention and was recently put into place on 8/22/23. and she was discharged from Physical Therapy (PT) on 9/14/23. The Therapy Director provided a therapy note dated 9/14/23 which read the following: demonstrated and practiced with the aide donning Resident #44's LLE to reduce her hip and knee flexion contracture. Resident #44 was reminded she was to wear the LLE brace for 4 hours a day while lying supine in bed. The Therapy Director stated when therapy discharged a resident from therapy, they complete written instructions that were provided to nursing department on new interventions implemented. He provided a copy of a form titled Post Discharge Nursing Staff Care Services Communication Form dated 9/15/23 read as follows: Resident #44 had to wear her knee brace on her LLE fir 4 hours or as tolerated daily while supine in bed. The form was not signed by any staff in the nursing department. Review of Resident #44's nursing notes from 8/22/23 to 9/27/23 did not include any documented evidence of her refusing to wear her LLE brace as ordered. Review of the Nurse Aides task documentation for September 2023 did not include any evidence that Resident #44's LLE brace was being applied as ordered. Review of Resident #44's Medication Administration Records (MARs) for August and September 2023 read the following information: Resident #44 was to wear the LLE brace for 4 hours or as tolerated daily while lying supine in bed for contracture management. There was no place for the nurse to document the ordered application and removal of her LLE brace was completed. The Director of Nursing (DON) provided a copy of a nursing note dated 9/26/23 at 3:45 PM as only documented evidence from 8/23/23 to present that the nursing staff were applying Resident #44's LLE brace as ordered. An interview was completed on 9/27/23 at 1:55 PM with Nurse #4. She stated Resident #44 was to wear the LLE brace when supine in bed. Nurse #4 stated the aides put on and remove her LLE brace. Nurse #4 stated she was not aware that the application of Resident #44's LLE brace appeared on the September 2023 MAR. She stated since it was on the MAR, the nurse was responsible for ensuring the aide applied the brace as ordered however that there was no place to document it. She stated it appeared on the MAR as an FYI . Nurse #4 stated none of the aides had reported to her any occasion that Resident #44 refused to wear her LLE brace. An interview was completed on 9/27/23 at 2:00 PM with NA #7 who was assigned to Resident #44. She stated she was unaware that Resident #44's was ordered to wear LLE brace to be worn daily and she had not been applying it. An interview was completed on 9/27/23 at 2:20 PM with the DON. She stated she added the application of Resident #44's LLE brace to the aides daily task list and it would now populate for the aides to document her LLE brace placement, removal and refusals. The DON stated Resident #44's LLE brace should have been applied as ordered for contracture management. An observation was completed on 9/28 at 930 AM of Resident #44. She was lying supine in bed wearing her LLE brace.

Based on staff and Hospice Aide #1 interviews along with record review, the facility failed to provide care safely which resulted in a fall without injury when Hospice Aide #1 left Resident #68's on his side in bed to retrieve a washcloth and failed to ensure two staff were presence for bed mobility. This was for 1 (Resident #68) of 8 reviewed for accidents. The findings included: Resident #68 was admitted on [DATE] with a diagnosis of cerebral ischemia. Review of Resident #68's Fall Risk assessment dated [DATE] indicated he was a moderate risk for falls, no history of falls and required the presence of 1-2 staff. Review of the incident report read Resident #68 sustained a fall on 7/27/23 when Hospice Aide #1 independently positioned him on his side and stepped away from the bedside to retrieve a washcloth resulting in a fall with no injury. The new intervention implemented was to ensure Resident #68 was repositioned on his back when not providing ADL care. Review of Resident #68's Fall Risk Assessment completed after his fall dated 7/27/23 indicated he was a high risk for falls, no history of falls and required the presence of 1-2 staff. Review of Resident #68's last two quarterly Minimum Data Set (MDS) assessments dated 5/20/23 and 8/20/23 indicated he was coded for extensive assistance with two staff for bed mobility. Resident #68 comprehensive care plan last revised on 9/14/23 read his bed mobility required supervision assistance by one staff to turn and reposition in bed as necessary for his activities of daily living (ADLs). An interview was completed on 9/26/23 at 2:40 PM with the Director of Nursing (DON). She stated she completed one-on-one education with Hospice Aide #1 and the aide notified the hospice agency of the fall. The DON stated Hospice Aide #1 rolled Resident #68 onto his side and then stepped away from the bedside to grab something to provide incontinence care. The DON stated she educated Hospice Aide #1 to return Resident #68 onto his back if she needed to step away from the bedside. An interview was completed on 9/27/23 at 9:20 AM with Nursing Assistance (NA) #7. She stated Hospice Aide #1 came to provide Resident #68's ADL assistance Monday through Friday. She stated Resident #68 did require two staff assistance with turning and repositioning in bed especially with pulling him up in bed. NA #7 stated residents should never be left alone on their side while staff stepped away from the bedside and should always have another staff member present if the residents required two staff assistance with their bed mobility due to increased risk of the resident sustaining a fall. A telephone interview was completed on 9/27/23 at 9:48 AM with Hospice Aide #1. She stated Resident #68 was in his bed. Hospice Aide #1 stated she was washing him up when she rolled Resident #68 onto his side and stepped away from his bedside to grab a washcloth. She stated she tried to grab him to stop the fall but there was nothing to really grab onto. She stated after the fall, she notified her supervisor at the hospice agency and also the DON for the facility. She stated she received re-education from both her hospice supervisor and the facility DON regarding not leaving a resident unattended on their side. She stated at one time, hospice was sending two aides to the facility but then it changed to one due to staffing. Hospice Aide #1 stated about month ago, the agency resumed sending two aides. An interview was completed on 9/27/23 at 11:25 AM with NA #1. She stated Resident #68 always required two staff assistance bed mobility because of how his right side and right leg were contracted and difficult to safely move alone. Another interview was completed with the DON on 9/28/23 at 9:40 AM. She stated she was not aware that Resident #68 was coded for extensive assistance of two staff with his bed mobility until 9/27/23 when she revised his care plan to reflect his bed mobility status to reflect he required to staff present with turning and positioning in the bed. An interview was completed on 9/28/23 at 8:30 AM with the Administrator. She stated it was the responsibility of the facility to ensure Resident #68 not sustain any falls and to ensure there were two hospice aides or the hospice aide to obtain a facility staff member to assist her with Resident #68's bed mobility if the second hospice aide was not available. The Administrator stated there were two hospice aides coming now to provide Resident #68's ADL assistance.

Based on record review, Physician Assistant and staff interviews, the facility failed to transcribe pulse parameters for a heart medication for 1 of 5 residents whose medications were reviewed (Resident #73). The findings included: Resident #73 was initially admitted to the facility on [DATE] with diagnoses of hypertension, presence of a cardiac implant and atrial fibrillation. A physician's progress note dated 7/26/23 indicated that Digoxin 125 micrograms (mcg) was being provided daily for atrial fibrillation and should be held for a pulse rate less than 60. A review of the August 2023 physician orders revealed an order dated 7/26/23 for Digoxin 125 mcg 1 tablet by mouth daily for atrial fibrillation. Hold for pulse less than 60. Review of the August 2023 Medication Administration Record (MAR) from 8/1/23 to 8/21/23 indicated the pulse rate was being monitored when the Digoxin was administered. There were no days that Resident #73's pulse was below 60 and the Digoxin was held. A review of the medical record indicated Resident #73 was admitted to the hospital on 8/21/23 and was readmitted to the facility on [DATE]. Per the hospital discharge summary dated 8/28/23 an order was present for Digoxin 125 mcg 1 tablet by mouth daily in the morning. An interview occurred with Nurse #2 on 9/26/23 at 1:47 PM as she was the nurse who transcribed the Digoxin order when Resident #73 was readmitted to the facility on [DATE]. She reviewed the August 2023 Digoxin orders and confirmed she failed to include when to hold the medication. Nurse #2 stated she should have clarified the order with the Physician's Assistant or Physician when the resident returned back to the facility from the hospital. Review of the August 2023 MAR from 8/29/23 to 8/31/23 indicated the Digoxin 125 mcg was initialed as administered and there were no parameters of when to hold the medication included on the MAR. Review of the September 2023 physician orders revealed an order dated 8/28/23 for Digoxin 125 mcg 1 tablet by mouth daily for atrial fibrillation. The parameters of when to hold the medication were not listed with the order. The September 2023 MAR was reviewed from 9/1/23 through 9/26/23 and revealed the Digoxin 125 mcg was initialed as administered and there were no parameters of when to hold the medication included on the MAR. The Director of Nursing was interviewed on 9/26/23 at 1:29 PM and reviewed the August 2023 and September 2023 MARs and orders. She stated Resident #73 was in the hospital from 8/21/23 to 8/28/23 and when she returned to the facility the transcribing nurse failed to put the parameters in the order. She felt this was an oversight. The Physician's Assistant (PA) was interviewed on 9/27/23 at 9:58 AM and reviewed Resident #73's Digoxin orders from August 2023 and September 2023. He confirmed the pulse parameter of when to hold the medication was not transcribed when Resident #73 returned to the facility on [DATE] and would have expected a pulse be taken prior to giving the medication. He further stated that he felt there was no serious harm caused as he monitored her Digoxin level lab work very closely.

Based on record review and interviews with the Pharmacy Consultant and the staff, the facility's Pharmacy Consultant failed to identify and to report drug irregularity to the Director of Nursing and or the Attending Physician regarding the facility's failure to transcribe and to administer the [MEDICATION(S)] (antiseizure medication) to a resident as ordered upon readmission from the hospital (Resident #175). Resident #175 was discharged to the hospital on 11/9/21 due to possible stroke like symptoms and tremors and was readmitted back to the facility on [DATE] with a diagnosis of [CONDITION(S)] and was prescribed [MEDICATION(S)]. [MEDICATION(S)] was not transcribed by the admitting Nurse and therefore was not administered to the resident from 11/14/21 through 3/3/22. On 3/4/22, Resident #175 had [CONDITION(S)] like activity and was sent to emergency room . The Pharmacy Consultant had reviewed Resident #175's drug regimens on 11/29/21, 12/27/21, 1/24/22 and 2/25/22 and did not identify the drug irregularity. This was for 1 of 6 sampled residents whose drug regimens were reviewed (Resident #175). Immediate jeopardy began on 11/29/21 when the Pharmacy Consultant failed to identify and to report the drug irregularity regarding the [MEDICATION(S)] for Resident #175. The immediate jeopardy was removed on 7/20/22 when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of an E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure interventions put into place are effective related to drug regime review. Findings included: Resident #175 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with multiple diagnoses including non-traumatic intracerebral hemorrhage and [CONDITION(S)]. The hospital discharge summary dated 11/13/21 revealed that Resident #175 presented to the ER due to altered mental status. On arrival to the ER, the resident became unresponsive, and he had a witnessed [CONDITION(S)] and was given a dose of [MEDICATION(S)] (a sedative used to treat [CONDITION(S)]). The discharge summary indicated that Resident #175 was discharged back to the facility on [DATE] with a diagnosis of [CONDITION(S)] and [MEDICATION(S)] 500 milligrams (mgs) 1 tablet by mouth twice a day was included on the discharge medications. The nurse's note dated 11/13/21 at 4:01 PM revealed that Resident #175 was readmitted back with a new diagnosis of [CONDITION(S)]. Resident #175's admission orders (11/13/21) were reviewed. [MEDICATION(S)] was not listed on the admission orders. Resident #175's Medication Administration Records (MARs) from 11/14/21 through 3/3/22 were reviewed and [MEDICATION(S)] was not administered to the resident. The nurse's note dated 3/4/22 at 9:19 AM indicated that Resident #175 was observed having [CONDITION(S)] like activity [MEDICATION(S)] approximately 3 minutes. Few minutes later, the resident had another [CONDITION(S)] activity. The NP, who was in the building, was notified and ordered to send the resident to the ER. This note was written by Nurse #4. The hospital discharge summary dated 3/7/22 revealed that Resident #175 presented to theER on [DATE] after having 2 focal seizures. The resident had received a dose of [MEDICATION(S)] and [MEDICATION(S)] [MEDICATION(S)]. The resident had a history of significant intracranial hemorrhage and on 11/2021 hospitalization he had seizures and was discharged on [MEDICATION(S)] 500 mgs twice a day. It was unclear if the resident was receiving the [MEDICATION(S)] at the facility. Review of Resident #175's monthly drug regimens were conducted. The Pharmacy Consultant had reviewed the resident's drug regimens on 11/29/21, 12/27/21, 1/24/22 and 2/25/22. The drug regimen reviews indicated that there were no drug irregularities noted and with no recommendations. The DON was interviewed on 7/18/22 at 2:35 PM. The DON indicated that after the resident was sent to the ER, she reviewed the resident's medical records and found out that the admitting nurse (previous DON) failed to transcribe the [MEDICATION(S)] when the resident was readmitted on [DATE]. She reported that she developed an action plan for the medication error but not for the drug regimen review. A follow up interview was conducted with the DON on 7/19/22 at 9:30 AM. The DON reported that she expected the Pharmacy Consultant to review the hospital discharge summary including the medications listed to ensure medications were transcribed accurately into the resident's electronic medical records. The Pharmacy Consultant was interviewed by telephone on 7/19/22 at 11:01 AM. She stated that she was the Pharmacy Consultant assigned to conduct the monthly drug regimen review at the facility. She acknowledged that she had reviewed Resident #175's drug regimen on 11/29/21, 12/27/21, 1/24/22 and 2/25/22 with no irregularities noted. When asked if she had been reviewing the hospital discharge summary for new admit/readmit residents, she replied that normally she did not review the hospital discharge summary unless she had questions about the resident's medications. The Pharmacy Consultant reported that she was not aware that Resident #175 was readmitted on [DATE] on [MEDICATION(S)]. She was also not aware that the [MEDICATION(S)] was not transcribed and was not administered to the resident. The administrator was notified on the immediate jeopardy on 7/19/22 at 3:22 PM. On 3/20/22 at 11:20 AM, the facility provided the following credible allegation of immediate jeopardy removal. Alleged date of immediate jeopardy removal 7/20/22. The Director of Nursing and the Pharmacy Consultant conducted an audit on 7/19/22 of all residents to ensure that no other medication reconciliation were inaccurate and no other medication errors were identified. Education was completed by the Vice President of Clinical Services of the facility's pharmacy on 7/19/22 for the facility's Pharmacy Consultants who provide services to the facility on medication regimen reviews which included ensuring a thorough and complete review of resident's medications was completed within 31 days of admission/readmission. No other Pharmacy Consultant will provide services to the facility prior to receiving the education. All new admit/readmit residents will be communicated by admissions email distribution to include the Pharmacy Consultants. Consultant Pharmacists will meet with the Director of Nursing at each visit to identify residents with significant changes for medication regime review to occur to ensure that orders were accurately transcribed and administered as directed by the provider/hospital in accordance with professional standards and appropriate medication use/dosage. The medication regimen review will also include review of the medications listed on hospital discharge summary for new admit/readmit residents. Any irregularities noted by the Pharmacy Consultants will be relayed to the facility's Director of Nursing and when applicable to the facility's medical director and the irregularity will be acted upon in a timely manner. The Director of Nursing and the facility Administrator were provided in-service education and worked in conjunction with the Regional Director of Operation to this plan. On 7/20/22, the credible allegation of immediate jeopardy removal was validated by onsite verification. Review of the Pharmacy Consultants sign in sheets for the in-service conducted on 7/19/22 on complete and accurate drug regimen review and the review of the audit conducted by the Director of Nursing and the Pharmacy Consultants on 7/19/22 of all resident's medications to ensure no other residents had inaccurate medication reconciliation and no significant medication errors. Interview with the admission Director, DON, and the Unit Managers revealed that they received the in-service on the new system regarding the drug regimen review. The facility's date of Immediate Jeopardy removal of 7/20/22 was validated.

Based on record review and interview with the Nurse Practitioner and the staff, the facility failed to administer the [MEDICATION(S)] (an antiseizure medication) to a resident as ordered from the hospital (Resident #175). Resident #175 was discharged to the hospital due to tremors and altered mental status on 11/9/21 and was discharged back to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #175 did not receive the [MEDICATION(S)] from 11/14/21 through 3/3/22 and on 3/4/22, Resident #175 had [CONDITION(S)] activity and was sent to the emergency room . The resident had received a dose of [MEDICATION(S)] and [MEDICATION(S)] (intravenous) [MEDICATION(S)]. Resident #175 was readmitted back to the facility on [DATE]. This was for 1 of 4 sampled residents who were admitted /readmitted and were reviewed for medication errors. Findings included: Resident #175 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurse's note dated 11/9/21 at 8:00 AM revealed that Resident #175 had tremors, the Nurse Practitioner (NP) was notified, and the resident was sent to the emergency room (ER). This note was written by Nurse #6, who was no longer employed by the facility. The hospital discharge summary dated 11/13/21 revealed that Resident #175 presented to the ER due to altered mental status. On arrival to the ER, the resident became unresponsive, and he had a witnessed [CONDITION(S)] and was given a dose of [MEDICATION(S)] (a sedative used to treat [CONDITION(S)]). The discharge summary revealed that Resident #175 was discharged back to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note dated 11/13/21 at 4:01 PM revealed that Resident #175 was readmitted back with a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The note was written by the previous Director of Nursing (DON). Resident #175's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #175's Medication Administration Records (MARs) from 11/14/21 through 3/3/22 were reviewed and [MEDICATION(S)] was not administered to the resident. The quarterly Minimum Data Set (MDS) dated [DATE] indicated that Resident #175 had severe cognitive impairment and he had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note dated 3/4/22 at 9:19 AM indicated that Resident #175 was observed having [CONDITION(S)] like activity [MEDICATION(S)] approximately 3 minutes. Few minutes later, the resident had another [CONDITION(S)]. The NP, who was in the building, was notified and ordered to send the resident to the ER. This note was written by Nurse #4. The hospital discharge summary dated 3/7/22 revealed that Resident #175 presented to theER on [DATE] after having 2 focal (partial) seizures (a [CONDITION(S)] that begins in one part of the brain). The resident had received a dose of [MEDICATION(S)] and [MEDICATION(S)] [MEDICATION(S)]. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . It was unclear if the resident was receiving the [MEDICATION(S)] at the facility. The DON was interviewed on 7/18/22 at 2:35 PM. The DON stated that she was called to Resident #175's room by Nurse #4 on 3/4/22. The resident was having seizures. The DON reported that the resident had 2 episodes of [CONDITION(S)] activity that day. The first [CONDITION(S)] activity, the NP was notified, and he ordered [MEDICATION(S)] 500 mgs by mouth every 12 hours. Few minutes later, the resident had another [CONDITION(S)] and more severe than the first one, the NP was notified, and the resident was sent to the ER. The DON indicated that after the resident was sent to the ER, she reviewed the resident's medical records and found out that the admitting nurse (previous DON) failed to transcribe the [MEDICATION(S)] when the resident was readmitted on [DATE]. She reported that she developed an action plan for the medication error. The NP was interviewed on 7/19/22 at 8:36 AM. The NP reported that he was at the facility on 11/9/21 when he was informed that Resident #175 was having stroke like symptoms. He ordered to send the resident to the ER. He added that Resident #175 was readmitted back to the facility on [DATE] and he saw the resident on 11/14/21. He stated that he did not read the hospital discharge summary when the resident was readmitted , and he should have but he missed it. The NP indicated that the admitting nurse should have verified the medications listed on the hospital discharge summary with the on-call physician since the resident was admitted after 4 PM. The NP reported that on 3/4/22 at 8:00 AM, he was called to the resident's room and the resident was having [CONDITION(S)] like activity. He ordered [MEDICATION(S)]. At 8:44 AM (same day), the resident had tremors again and he ordered to send the resident to the ER. A follow up interview was conducted with the DON on 7/19/22 at 9:30 AM. The DON reported that she expected the admitting nurse to verify the medications listed on the hospital discharge summary with the physician/on-call physician or the NP on admission/readmission. She also expected the NP to read the hospital records on admission/readmission to ensure orders were not missed. Attempted to call the previous DON, who transcribed the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #4 was interviewed on 7/20/22 at 10:35 AM. Nurse #4 stated that she was assigned to Resident #175 on 3/4/22. She was called to the resident's room, and she observed the resident having seizures. She informed the NP and he ordered [MEDICATION(S)]. Few minutes later, the resident had another [CONDITION(S)], the NP ordered to send the resident to ER. The Administrator and the DON were notified of the Immediate Jeopardy on 7/19/22 at 3:22 PM. The facility provided the following corrective action plan: Corrective action that will be accomplished: Resident #175 was transferred to the hospital on 3/4/22 due to [CONDITION(S)] activity. Resident #175 returned to the facility on [DATE] with order for [MEDICATION(S)] 1000 mgs twice a day. Identification of other residents: The Director of Nursing and the Unit Managers completed an audit on 3/8/22 for all residents that were admitted or readmitted from 8/1/21 through 3/7/22 to validate that orders were transcribed as ordered upon admission. Measures for systemic change: The Regional Clinical Director completed education on 3/7/22 for the Director of Nursing regarding facility protocol for reconciliation of medications upon admission/readmission. The Director of Nursing and or Unit Managers completed education on 3/8/22 for current licensed nurses regarding facility protocol for reconciliation of medications upon admission. Licensed nurses that were not working will be educated upon return to work prior to accepting an assignment. Newly hired licensed nurses will be educated during new hire orientation. The process includes upon admission, the licensed nurse will review the discharge summary and will notify the physician or NP to verify the orders. The licensed nurse will transcribe the orders into the electronic medical records. A second nurse will review the orders to validate that the orders are input accurately into the electronic medical record. The Unit Manager and or the nursing supervisor will review the orders within 24 hours of admission to validate that physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . How corrective action will be monitored: The Director of Nursing and or Unit Managers will audit admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing will review the audits monthly to identify patterns/trends and will adjust the plan as necessary to maintain compliance. The Director of Nursing will review the plan during the monthly QAPI meeting, and the audits will continue at the discretion of the QAPI committee. The facility's alleged corrective action plan was verified by the following: On 7/19/22, the facility's corrective action plan was validated onsite by record review, and staff interview. Review of the audit conducted on 3/8/22 of all residents who were admitted /readmitted from 8/1/21 through 3/7/22. Interview with nursing staff revealed that they had received an in-service on how to reconcile orders on admission. They must verify medications listed on the hospital discharge summary with the physician or the NP. The admitting nurse will transcribe the orders into the electronic medical records. A second nurse will review the medical records and the hospital discharge summary to validate that orders were transcribed accurately. Interview with the Unit Managers revealed that they must review the orders and the hospital discharge summary within 24 hours of admission to validate that orders were transcribed accurately into the electronic medical records. Review of the sign in sheets of the in-service conducted on 3/7/22. Review of the monitoring conducted by the Unit Managers on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] F760 was corrected on 3/9/22.

Based on resident, staff, Consultant Pharmacist, Pharmacist #1, Nurse Practitioner (NP) and Medical Director (MD) interviews, observations and record review, the facility failed to obtain and administer prescribed medications to treat pain for a newly admitted resident (Resident #171) with a left acetabulum (the socket part of the hip ball and socket joint) fracture and a pelvic fracture. This lack of pain medication resulted in observed evidence of pain and a reported pain numerical level of 10 out of 10. This was for 1 of 2 residents reviewed for pain. The finding included Resident #171 was admitted on [DATE]. There was no Minimum Data Set (MDS) assessment information except for the entry MDS and there was no documented evidence of a baseline care plan. Review of Resident #171's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . His orders also included orders for Tylenol (analgesic) 1000 mgs every 6 hours as need for pain and [MEDICATION(S)] (anticonvulsant used to treat nerve pain) 500 mgs at bedtime for pain. An interview with Resident #171 was attempted on 7/17/22 at 2:20 PM. He appeared angry, restless and complained of pelvic pain described as 10 out of 10 in intensity. He stated he fell at home and fractured his pelvis in several places. Resident #171 stated he was supposed to be admitted to the facility on [DATE] but for some reason, his admission was postponed till 7/16/22 at around 1:00 PM. Resident #171 stated he was medicated for pain at the time of his hospital discharge so his pain was controlled when he arrived at the facility. He stated the nurses told him that his pain medication would arrive until later on 7/16/22 but apparently that didn't happen. He stated the only thing he had received for pain since his admission was Tylenol and one dose of his [MEDICATION(S)] at around 10:00 AM this morning. Review of Resident #171 electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A dose of Tylenol was also administered on 7/17/22 until 10:49 PM. Review of Resident #171's electronic medical record (EMR) read his that vital signs on 7/16/22 and 7/17/22, his blood pressure remained at 116/84 and his highest recorded pulse rate was 107. An interview was completed on 7/20/22 at 9:13 AM with the Unit Manager (UM). She stated Resident #171 was expected to be admitted the evening of 7/15/22. She stated she stayed at the facility until 11:00 PM waiting for his arrival when the hospital called and stated there was a delay and he would arrive at the facility for admission the next morning on 7/16/22. The UM stated she already had Resident #171's hard prescription for his [MEDICATION(S)] and orders for his home medications. She stated she faxed the [MEDICATION(S)] prescription to the pharmacy and entered all his additional medication orders. The UM explained that the way their EMR system was set up it would not let her activate Resident #171's orders because he had not been assigned a room and another nurse still had to review the orders when he arrived for the second review for accuracy then activated. The UM stated the admitting nurse would have to go into the EMR and activate the orders in order for the pharmacy to begin processing the prescriptions. She stated she was the manager on call for 7/16/22 and 7/17/22 and she did not receive any calls regarding Resident #171. The UM stated apparently the facility did not provide any education to the agency nurses on the process of activating the orders and no education on the how to correctly access the Pixis (an automated medication dispensing system present at the facility with a supply of commonly prescribed medications) while waiting for his pain medications to arrive from the pharmacy. She stated when a medication was retrieved from the Pixis, it required calling the pharmacy and obtaining a code to access the medications along with a second nurse entering a code as well to verify the correct medication, dose and number of pills were retrieved for the correct resident. Review of the undated Pixis medication inventory read there were 15 capsules of [MEDICATION(S)] and 11 [MEDICATION(S)] available in the Pixis. An interview was completed on 7/17/22 at 2:40 PM with Nurse #1. She stated she was an agency nurse who had worked at the facility a few months. She stated when Resident #171 arrived at the facility on 7/16/22, she faxed the hard prescription for his [MEDICATION(S)] and reviewed the orders put in on 7/15/22. She stated on admission, he had been premedicated at the hospital and did not complain of uncontrolled pain and voiced felt discomfort with any movement. Nurse #1 stated around 3:00 or 4:00 PM, Resident #171 requested something for pain but his [MEDICATION(S)] would not arrive from the pharmacy until later that evening so she gave him two Tylenol, called the pharmacy and verified receipt of the [MEDICATION(S)] prescription and she sent a text to the on-call provider about his pain. Nurse #1 stated she forgot to document that she administered Tylenol on 7/16/22 around 4:00 PM. She stated at the end of her shift, Resident #171 did not report any unrelieved pain but she reported off to Nurse #2 that she had reached out to the pharmacy and a texted the on-call provider because his pain medications had not yet arrived. She stated when she came in again on 7/17/22 at 7:00 AM, Resident #171's medications had still not arrived so she and another nurse accessed the Pixis to retrieve a dose of [MEDICATION(S)] and she administered it at 9:43 AM. Nurse #1 stated she was never educated on the process of accessing medications in the facility Pixis until 7/17/22 and she did not ask anyone to assist her with obtaining a [MEDICATION(S)] from the Pixis on 7/16/22. An telephone interview was completed on 7/19/22 at 3:58 PM with Nurse #2. She stated she was an agency nurse and worked 7:00 PM to 7:00 AM on 7/16/22 with Resident #171. She stated Nurse #1 reported to her that none of Resident #171's pain medications had not arrived. Nurse #2 stated late on 7/16/22 Resident #171 verbalized pain at a 10 out of 10 so she resubmitted his prescription orders and again faxed the hard prescription for his [MEDICATION(S)] to the pharmacy. She stated if the nurse did not know to hit the activate button in the EMR, the medication orders would not be activated for the pharmacy to process. She stated she hit the activate button in the EMR and called the pharmacy to confirm the orders would be processed and would arrive at the facility likely the next morning due to the late activation of his medication orders in the EMR. She stated it was round this time at approximately 10:30 PM on 7/16/22 that she administer his Tylenol and again sometime after 6:00 AM but she forgot to document it in his EMR. Nurse #2 stated she never received a call or text from the on-call provider and she did not know how to access the Pixis. She stated she was under the impression none of the agency nurses could access the Pixis so she administered Resident #171 Tylenol every 6 hours for pain control. Nurse #2 stated Resident #171 was not happy with it but he agreed. Nurse #2 stated at 7:00 AM on 7/17/22 when Nurse #1 came in, she reported that he still had not received any [MEDICATION(S)]. Nurse #2 stated before she left work she again called the pharmacy to see when Resident #171's medications would arrive and was told the orders were processed and enroute in the truck or with a transporter. Review of the pharmacy manifest dated 7/17/22 read Nurse #1 signed the manifest acknowledging received Resident #171's [MEDICATION(S)] and [MEDICATION(S)] at 1:27 PM. An interview and observation was completed on 7/18/22 at 10:50 AM with Resident #171. He stated his pain was much better until he repositioned himself in bed but eased off and controlled. An interview was completed on 7/18/22 at 9:47 AM with the NP. He stated he was at the facility Monday through Friday 7:00 AM to 1:00 PM. He stated he was not aware that Resident #171 did not received his prescribed pain medications until today. The NP stated on weekends, the nurses must call or video call the provider rather than sending a text. The NP stated apparently the facility had not communicated or provided instructions to the agency staff on the process for the weekends. He stated that would explain why the facility never received a call or text from the on-call provider on 7/16/22. An interview was completed on 7/19/22 at 8:45 AM with the MD. She stated it was her expectation that Resident #171 received his prescribed pain medications timely after his admission but it appeared the be related to a knowledge deficit on behalf of the agency nurses not aware of the need to activate the medication orders prompting the pharmacy to fill the prescription and agency staff not educated in access to the Pixis. An interview was completed on 7/19/22 at 9:05 AM with Nurse #3. He stated he started out as an agency nurse but had recently accepted a permanent position at the facility. He stated Resident #171 complained of pain on 7/18/22 during his 12 hour shift and he medicated him twice with his prescribed [MEDICATION(S)] which Resident #171 stated was effective. Nurse #3 stated when entering orders into the EMR, two nurses have to review the orders and then hit an activate button in the EMR in order for the pharmacy to start processing any the prescriptions. He stated he did not think he was told that when he started but someone at some time must have told him the orders would not be proceed at the pharmacy until they were activated. He also stated someone told him on weekends to just call the on-call provider and not sent a text because when contacting a provider on the weekends there would be some degree of immediacy needed and when just sending a text was viewed as less immediate. A telephone interview was completed on 7/19/22 at 11:10 AM with the Consultant Pharmacist. She stated the pharmacy did not utilize a local back up pharmacy for narcotic medications because of the need for a hard copy of the prescription. She stated all nurses were able to access the Pixis. The nurse would only need to call the pharmacy while at the Pixis with another nurse to obtain an access codes to retrieve the medication because two were required to verify and enter both access codes. This was a real-time method of record keeping and prevented possible medication diversion. A telephone interview was completed on 7/19/22 at 3:27 PM with Pharmacist #1. She stated the pharmacy could not process and medication orders until the facility confirmed or activated the orders in the EMR. She stated Resident #171's prescription orders to include his [MEDICATION(S)] and [MEDICATION(S)] were not activated to be processed until 7/16/22 at 10:32 PM. Pharmacist #1 confirmed only one dose of [MEDICATION(S)] was obtained from the Pixis on 7/17/22 at 9:43 AM and no [MEDICATION(S)] was retrieved. She stated the pharmacy had the ability to go ahead and deliver a 3 day emergency supply prior of opioids until the hard prescription was received as long as the pharmacy was faxed a copy of the hard prescription. She stated this was rarely done due to the availability in the Pixis. An interview was completed on 7/17/22 at 2:50 PM with Nursing Assistant (NA) #1. She confirmed she was assigned Resident #171 on 7/16/22. She stated he refused any assistance with his activities of daily living (ADLs) stating it was too painful to move. She stated he only used his call bell so far today to request something for pain. Nurse #1 was aware of Resident #171's pain. A telephone interview was completed on 7/17/22 at 3:37 PM with NA #6. She confirmed she was assigned Resident #171 on 7/16/22 for second shift. She stated Resident #171 never complained of pain. A telephone interview was completed on 7/19/22 at 3:44 PM with NA #2. She verified she worked with Resident #171 on 7/17/22 on first shift. She stated he refused staff assistance with his ADLs stating his wife would assist him later in the day. She stated he displayed outward signs of pain in his facial expressions and vocalizations like groans but he never asked her to get the nurse about his pain. An interview was completed on 7/20/22 at 8:40 AM with the Director of Nursing (DON). She stated the floor nurses seldom do admissions because the Assistant Director of Nursing (ADON) and the UM did the admission paperwork during the week. The DON stated it was unusual to have an admission on a Saturday but in the event it happened, the Registered Nurse (RN) Supervisor would then complete the admission paperwork and process the Physician orders. The DON stated this past weekend, the RN Supervisor called out for Saturday and Sunday and Nurse #1 did not call the on-call UM for directions. The DON stated once the resident was assigned a room number and the nurse confirmed that the orders had been reviewed by two nurses, the nurse had to activate the orders to remove the orders from the que to be processed at the pharmacy. The DON stated apparently Resident #171's medication orders were not activated by Nurse #2 until late Saturday night. Another interview was completed on 7/20/22 at 1:00 PM with Nurse #1. She stated she was not aware until 7/17/22 that anytime an order was entered into the EMR it had to be activated in order for the pharmacy to process and fill the prescription. She also stated she was not aware until 7/17/22 that she could have accessed the Pixis on 7/16/22 because she had never been shown or educated by the facility on the procedure for using the Pixis. An interview was completed on 7/20/22 at 2:35 PM with the DON. She stated Resident #171's acute pain should have been treated with his prescribed pain medications as ordered on 7/16/22. She also stated she expected any nurse with an issue obtaining a medication on the weekend to reach out to her, the ADON or the UM for instruction. The DON further stated the orientation of the agency nurses was not being done regarding the facility's processes and procedures to ensure they were knowledgeable in the procedures needed to effectively take care of the residents due to a recent significant turnover in the nursing management department.

Based on staff interviews and record review, the facility failed to ensure 2 (Nurse #1 and Nurse #2) of 3 agency nurses interviewed were oriented to the facility processes and procedures regarding the following: contacting the on-call medical provider on the weekends, how to activate the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This was for 1 (Resident #171) of 2 residents reviewed for pain. This resulted in uncontrolled pain for Resident #171 admitted with multiple fractured areas of his pelvis. The finding included: This citation is cross referred to F697-G: Based on resident, staff, Consultant Pharmacist, Pharmacist #1, Nurse Practitioner (NP) and Medical Director (MD) interviews, observations and record review, the facility failed to obtain and administer prescribed medications to treat pain for a newly admitted resident (Resident #171) with a left acetabulum (the socket part of the hip ball and socket joint) fracture and a pelvic fracture. This lack of pain medication resulted in observed evidence of pain and a reported pain numerical level of 10 out of 10. This was for 1 of 2 residents reviewed for pain.

Based on record review, and staff, Physician, and Physician Assistant interviews, the facility failed to notify the physician of newly identified pressure ulcers resulting in a delay in obtaining treatment orders for two separate instances. This was for 1 of 4 residents reviewed for pressure ulcers (Resident #85). The findings included: Resident #85 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was diagnosed with COVID-19 on 12/1/20. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #85 had severe cognitive impairment. He required extensive assistance from staff for bed mobility and toileting, was incontinent of bowel and bladder, and was at risk for pressure ulcers. The assessment further revealed he had no pressure ulcers or other skin conditions, but a pressure reducing device was present to the bed. A nursing progress note dated 1/28/21 indicated Resident #85 was found to have open areas to the right and left heel with mild drainage and the size of a quarter. The wound nurse was notified, the areas were cleansed, and a dry dressing was placed over both areas. Resident #85's spouse was notified of the wounds. There was no indication the physician or physician's assistant (PA) were made aware. Resident #85's physician orders, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's assistant (PA) progress note for 2/3/21 was reviewed and indicated Resident #85 was seen for new wounds to his bilateral heel. There was no pain at rest and minimal discomfort was present with the assessment of the wounds. There had been no unexpected weight change, there was no [CONDITION(S)] to the right or left leg and his skin was warm and dry. The left heel was described as 2.4 cm in length and 2 cm in width with 100% slough and unstageable pressure ulcer. The right heel was described as 4 cm in length and 3 cm in width with non-blanchable [CONDITION(S)] (skin redness that does not turn white when pressed) and was classified as deep tissue pressure injury. A nursing progress note dated 2/5/21 indicated Resident #85 was found to have two small open areas to his buttocks. The first was centrally located on the sacrum and the second smaller one was on the buttock. No drainage was present, or pain expressed by Resident #85. Both areas were cleansed, dry dressings applied, and the wound care nurse was notified. There was no indication that the physician or PA were notified of the new skin breakdown. Resident #85 was transferred to the emergency roiagnom on [DATE] due to respiratory distress. He did not return to the facility. A phone interview was conducted with Nurse #3 on 3/11/21 at 11:00 AM, who was assigned to Resident #85 on 1/28/21. She explained on 1/28/21 the newly found pressure areas to both heels and reported this to the former wound care nurse as well as notified Resident #85's family member. On 3/10/21 at 3:26 PM, an interview occurred with Nurse #4 who was assigned to Resident #85 on 2/5/21. Nurse #4 stated when he observed the open areas on Resident #85's buttocks there were 2 small, superficial openings. He recalled alerting the former wound care nurse to the new pressure areas, as well as Resident #85's spouse. Another interview was completed with Nurse #4 on 9/14/21 at 4:10 PM and recalled when he identified skin breakdown to Resident #85's buttocks area he notified the former wound care nurse as well as Resident #85's spouse. He further stated at that time the former wound care nurse would have been responsible for notifying the physician or PA. The Director of Nursing (DON) was interviewed by phone on 3/11/21 at 12:07 PM and stated she was aware Resident #85 had pressure areas to his heels and buttocks. She further stated at the time, the staff nurses informed the wound care nurse of the wounds when they were identified, and she would have been responsible for notifying the physician or PA. The DON further stated she expected the nurse who identified the open area to obtain a treatment order by following the facility's wound protocol or calling the physician. The Medical Director was interviewed via phone on 9/14/21 at 1:21 PM and was familiar with Resident #85 and stated the facility staff had notified himself or the facility PA when Resident #85 developed skin breakdown. Although, he was unaware the notification was not when the wounds were first observed on 1/28/21 and 2/5/21. The Medical Director stated he expected to be notified when areas of skin concerns were first identified either by the staff nurse or wound care nurse. A phone interview was conducted with the former wound care nurse on 9/15/21 at 2:00 PM who left her employment at the facility in March 2021. She was able to recall Resident #85 and stated she remembered the floor nurse telling her about his heel wounds and instructed the nurse how to dress the wounds until she could get there to look at them on 1/28/21. She went onto say notified the facility PA on the date of the initial wound evaluation (2/2/21) and requested the facility PA to assess the wounds the following day. The former wound care nurse recalled being informed by the floor nurse when Resident #85 developed breakdown to his buttocks area on 2/5/21, recalled assessing those wounds a few days later (2/8/21) and notified the facility PA/physician of the new areas on the same day as the assessment. The former wound care nurse acknowledged the facility PA or physician should have been notified on the day the wounds were first identified. On 9/15/21 at 2:38 PM, a phone interview was held with the facility PA who was able to recall Resident #85. She reviewed her notes and stated she was notified by the former wound care nurse on 2/2/21 regarding Resident #85's wounds to both heels and assessed them the following day. She stated the facility staff had notified herself or the Medical Director when Resident #85 developed skin breakdown, however, she was unaware the notification was not when the wounds were first observed on 1/28/21 and 2/5/21. The facility PA stated it was her expectation for either herself or the Medical Director to be notified when areas of skin concerns were first identified by the staff nurse or wound care nurse. Another phone interview was completed with Nurse #3 on 9/15/21 at 3:03 PM, who was assigned to Resident #85 on 1/28/21. She explained when she observed the skin changes to Resident #85's heels on 1/28/21, she reported this to the former wound care nurse who provided how to cleanse and dress the wounds as well as the Director of Nursing. Nurse #3 added she notified Resident #85's family of the skin changes, but at that time the former wound care nurse notified the physician or PA. The Administrator and current DON were interviewed on 9/16/21 at 1:40 PM and stated it was their expectation for the physician/PA as well as the resident and/or responsible party to be notified the same day a skin issue was observed.

Based on record review and staff interviews, the facility failed to develop a comprehensive care plan for the risk of pressure ulcers for 1 of 4 residents reviewed for pressure ulcers (Resident #85). The findings included: Resident #85 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #85 had severe cognitive impairment, required extensive assistance from staff for bed mobility and toileting, was incontinent of bowel and bladder, and was at risk for pressure ulcers. The assessment further revealed he had no pressure ulcers or other skin conditions. The pressure ulcer care area assessment (CAA) summary dated 12/14/20 revealed Resident #85 was at risk for pressure ulcer development related to impaired bed mobility, weakness, and incontinence and would be care planned as such. The care plan for Resident #85 was reviewed and a focus area for pressure ulcers was initiated on 1/28/21 and revised on 2/8/21, that read in part, actual pressure ulcer development to sacrum and left buttock and bilateral heels. Is at risk for further pressure ulcer development related to impaired bed mobility, weakness and incontinence. There was no original care plan developed for the risk of pressure ulcers as stated in the pressure ulcer CAA summary dated 12/14/20. An interview was completed with MDS Nurse #2 on 9/15/21 at 3:54 PM and indicated it was an oversight not to develop an initial care plan for the risk of pressure ulcers as Resident #85 was incontinent and had decreased mobility. On 9/16/21 at 1:40 PM, an interview occurred with the Administrator and current Director of Nursing. They both stated it was their expectation for the care plan to be comprehensive and patient centered. They both agreed per the CAA summary a risk for pressure ulcer care plan should have been developed as Resident #85 had weakness, incontinence, and decreased mobility.

Based on record review, staff interviews and physician interview the facility failed to implement their coronavirus (COVID-19) testing policy when staff failed to conduct required COVID-19 testing on 103 of 103 residents and 28 of 28 staff after receiving a positive test result for Nursing Assistant (NA) #1 on [DATE] and failed to ensure NA #2 did not work at the facility after a known community exposure. These failures occurred during the COVID-19 Pandemic. As of [DATE], the facility reported 82 residents and 22 staff had tested positive for the COVID-19 virus. Immediate Jeopardy began on [DATE] when NA #1 tested positive for the COVID-19 virus and the facility failed to initiate testing of all residents for [MEDICAL CONDITION]. Immediate Jeopardy was removed on [DATE] when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level F (no actual harm with the potential for more than minimal harm). Findings included: Review of the facility's policy titled: COVID-19 CMS Mandated Long Term Care (LTC) Facility Testing Requirements dated [DATE] read as follows at item #4b: Outbreak any new case (employee or resident) arises in facility: test all staff and residents that previously tested negative every ,[DATE] days until no new cases are identified for a period of at least 14 days since the most recent positive result. Review of COVID-19 test results revealed NA #1 tested positive on [DATE] and NA #2 tested positive on [DATE]. A telephone interview was conducted with NA #1 on [DATE] at 11:00 AM. NA #1 stated she had been caring for a sick family member who tested COVID-19 positive at the hospital on [DATE]. She stated she last worked at the facility on [DATE] because she was a prn (as needed) employee. NA #1 stated she notified the facility on [DATE] that she had been exposed to a COVID-19 positive family member and asked about whether she needed to be tested at that time. She stated the IP told her to wait and be tested the following week and that she could not work the following week unless she tested negative for COVID-19. She stated the facility did not say anything to her about quarantining herself at that time. She stated she went to the facility on [DATE] and she tested COVID-19 positive on the POC test and the facility sent her to the health department to be PCR tested that same day. She stated the PCR test done at the health department on [DATE] was also COVID-19 positive. A telephone interview was conducted with NA #2 on [DATE] at 11:59 AM. NA #2 confirmed she was POC tested the night of [DATE] and was sent home because she tested positive for the COVID-19 virus. NA #2 denied any symptoms of COVID-19 on [DATE]. She stated the next day was a routine testing day at the facility, so she was PCR tested for COVID-19 on [DATE] and again tested positive. A telephone interview was conducted with Nurse #1 on [DATE] at 11:47 AM. She stated she went to work on [DATE] at 7:00 PM. She stated when the third shift aides came in at 11:00 PM, a few hours into the shift she overheard NA #2 saying she had 2 family members who were COVID-19 positive. Nurse #1 stated she told NA #2 she should not be at work. She stated NA #2 tested COVID-19 positive on [DATE] and was sent home. NA #2 was instructed to come back the next day to be PCR tested . Nurse #1 stated she was upset that NA #2 put the residents and staff at risk. Nurse #1 stated she was scheduled to work on [DATE] but called out sick because on [DATE] she had a scratchy throat and did not feel well. She was instructed to come to the facility on [DATE] for a POC and PCR tested . Both test results were COVID-19 positive. During an interview on [DATE] at 10:00 AM with the Administrator, Director of Nursing (DON) and Infection Preventionist (IP). The DON stated all routine COVID-19 testing for staff and residents was done every Wednesday. The DON specified the first case of COVID-19 was identified on [DATE] when NA #1 tested positive using the Point of Contact (POC) test. She further stated NA #1 was tested because a family member tested COVID-19 positive on [DATE]. The DON stated NA #2 was symptomatic and was sent home immediately the night of [DATE]. During the interview on [DATE] at 10:00 AM, the IP stated that he did not contact the health department when NA #1 tested COVID-19 positive because NA #1 was sent to the health department on [DATE] to be Polymerase Chain Reaction (PCR) tested for COVID-19 that day. The IP specified NA #2 tested COVID-19 positive on [DATE] using the POC test. The IP stated he first contacted the health department on [DATE] for instructions as to what the facility should do at that time. He stated he was told by the health department DON that the two aides COVID-19 positive cases were unrelated, community acquired and the facility only needed to test the residents that NA #2 was assigned on [DATE]. The IP stated NA #2 was told to come to the facility on [DATE] to be PCR tested . He stated NA #2's PCR test was also COVID-19 positive. He stated the residents that NA #2 was assigned on [DATE] were tested using the POC test and they all tested negative. He further stated on the advice of the health department, the facility completed a PCR test on those residents on [DATE] because waiting 5 to 7 days was more accurate for early detection. Those resident's PCR test results were negative again on [DATE]. The IP stated the third case of COVID-19 was when Nurse #1 tested COVID-19 positive on [DATE]. He stated he contacted the health department when Nurse #1 tested positive but since routine testing was completed on [DATE] anyway, there was no additional guidance offered by the health department. In an email correspondence with the DON dated [DATE] at 9:31 AM, she indicated the health department told the facility that they did not think it was a COVID-19 outbreak because the two aides that tested COVID-19 positive on [DATE] and [DATE] were community acquired and the aides had not worked after testing COVID-19 positive. The email indicated the instruction from the health department was to only test the residents that NA #2 was assigned on [DATE]. A telephone interview was conducted with the health department DON on [DATE] at 1:49 PM. She stated the facility contacted her when two aides tested COVID-19 positive on [DATE]. She stated she told the facility that she did not think the two staff COVID-19 positive cases were related and both were community acquired. She stated she directed the facility to only test those residents that NA #2 had cared for on [DATE]. A telephone interview was conducted with the Medical Director (MD) on [DATE] at 3:39 PM. He stated his understanding from the facility was that the 2 staff COVID-19 positive cases on [DATE] and [DATE] had not worked and the health department instructed the facility to only test the residents the NA #2 cared for on [DATE]. The MD stated the facility followed the recommendations of the health department. An interview was conducted with the DON and IP on [DATE] at 12:45 PM. The DON stated routine testing of all residents and staff was done on [DATE]. She stated a Fed-Ex pick up was scheduled for [DATE] between 3:00 PM and 5:00 PM. The DON stated the facility contacted her stating the package had not been picked up by Fed-Ex so she picked up the package and placed it in a Fed-Ex drop box on [DATE]. The DON stated she did not know until after the fact that the package would not have been picked up until [DATE]. She stated she checked online on [DATE]. The DON stated she called the lab on [DATE] because there was only 1 resident test result in the computer. She stated the lab told her the results were only waiting to be entered. The DON stated the lab was closed Sunday [DATE] so she called them again on [DATE] and the lab told her that the test results should be entered into the computer by the end of the day. The DON stated when still no results available on [DATE], the facility reached out to the health department for direction. The DON stated the facility began POC testing for all residents and staff on [DATE] in order to quickly identified any additional positive COVID-19 residents or staff. Record review of facility COVID19 test results revealed the following: between [DATE] and [DATE], there were 5 symptomatic residents and 1 asymptomatic resident that POC tested positive for COVID-19. All 6 residents were moved to an isolation hall: a. Resident #6's oxygen saturation on [DATE] dropped. He tested COVID-19 positive on the POC test, and he was moved to the isolation hall. Resident #6 expired at the facility on [DATE]. b. Resident #7 developed a cough on [DATE]. She tested COVID-19 positive on the POC test, and she was moved to the isolation hall. c. Resident #8 reported a headache and sinus pain on [DATE]. She tested COVID-19 positive on the POC test, and she was moved to the isolation hall. d. Resident #9 became lethargic with a decreased appetite on [DATE]. He tested COVID-19 positive on the POC test, and he was moved to the isolation hall. e. Resident #10 had a temperature of 101.5 degrees on [DATE]. He tested COVID-19 positive on the POC test, and he was moved to the isolation hall. f. Resident #11 was identified as having COVID-19 exposure on [DATE]. She tested COVID-19 positive on the POC test, and she was moved to the isolation hall. In an email correspondence with the DON dated [DATE] at 4:41 PM, the DON was questioned as to why there was no facility wide POC testing completed prior to [DATE] after 6 residents had tested COVID-19 positive over the weekend, she indicated it was because she was assured the lab results would be available on [DATE] and that COVID-19 testing could be very intrusive especially to the dementia population. In an email correspondence with the DON dated [DATE] at 4:46 PM, she indicated the facility did not have a set policy for COVID-19 testing due to the influx of testing materials but rather followed the direction of the health department. The DON indicated the health department was informed on [DATE] that the routine COVID-19 testing completed on [DATE] was still not available. She stated the health department instructed the facility to perform POC testing and PCR test all the residents and only POC test all staff on [DATE]. In an email correspondence with the DON dated [DATE] at 2:40 PM, she provided the policy regarding COVID-19 facility testing dated [DATE]. The DON indicated the facility had overlooked the policy. A telephone interview was conducted on [DATE] at 3:39 PM with the MD. He stated he was unaware of the delay in receiving the routine PCR test results completed on [DATE]. He stated early testing may or may not have slowed the spread of COVID-19. The MD stated the delay in getting the PCR results from [DATE] would have not changed the outcome. He stated the six COVID-19 positive residents identified over the weekend using POC test were likely COVID-19 positive on the PCR test completed on [DATE]. Review of the 6 residents identified as COVID-19 positive using the POC test between [DATE] and [DATE], 2 were COVID-19 positive on the [DATE]. Review of cumulative COVID-19 test results from [DATE] to [DATE] revealed 82 of 103 residents and 22 staff had tested positive for the COVID-19 virus A telephone interview was conducted on [DATE] at 11:00 AM with the health department DON. She stated when the COVID-19 PCR testing results were not available within 48 hours, that should have prompted the facility to complete another facility wide test. The Administrator and DON were notified of the Immediate Jeopardy on [DATE] at 8:00 PM. On [DATE] at 1:45 PM, the facility provided the following credible allegation for Immediate Jeopardy Removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: An outbreak started on [DATE] with the identification of one employee who tested positive for COVID -19. A second employee tested positive on [DATE]. The facility policy was to initiate testing of all staff and residents once an outbreak was determined. Facility wide testing of employees and residents due to a new outbreak was not completed [DATE]. The facility does have a policy CMS Mandated LTC Facility Testing Requirements dated [DATE] however the DON and IP were unaware of it and the Infection Preventionist took directions from the Health Department. The facility conducted routine facility wide Covid-19 testing of employees and residents on [DATE]. The facility did not receive results within 48 hours. The facility completed rapid [MEDICATION NAME] testing on [DATE] for all residents and staff. The facility failed to call state and local health departments when the COVID test results were not returned within 48 hours. When the infection control survey started on [DATE] there were 48 positive residents and 10 positive staff members. The facility does in fact have a policy CMS Mandated LTC Facility Testing Requirements dated [DATE] that states if one resident or employee tests positive the facility must test all residents and employees. The facility followed the guidance from the local health department. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: Education was provided by the Regional Clinical Director, to the Administrator, Director of Nursing and the infection preventionist on [DATE] regarding following the facility's policy CMS Mandated LTC Facility Testing Requirements dated [DATE] which addresses outbreak status and the requirement to test all employee and resident once one confirmed case of COVID-19 is identified. The facility will follow the guidance set forth by CMS and our policy and will complete testing of all employees and resident if a future outbreak as defined by one positive employee or resident occurs. The Director of Nursing and/or the Infection Preventionist, will monitor the outbreak status and complete daily audits of any new cases that occur once the facility is clear from current outbreak status for the duration of three months. The Administrator will review the audits weekly to ensure compliance. The policy CMS Mandated LTC Facility Testing Requirements dated [DATE] includes that after the initial testing of all staff and residents, all staff that tested negative should be retested every 3 to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive results. Education provided to the DON/Infection preventionist, by the Regional Clinical Director of Clinical Operations on [DATE], regarding ensuring that labs are picked up and contacting the health department if COVID tests results are not received within 48 hours. The Don/Infection preventionist will be responsible for making sure specimens are picked up by the lab and specimens are reported. The Regional Clinical Director will monitor weekly and provide oversight since the facility did not follow policies and procedures for outbreak testing. The facility alleges the removal of the IJ on [DATE]. On [DATE] the credible allegation of Immediate Jeopardy removal was validated by an onsite visit. The facility provided evidence of education completed by the Regional Clinical Director with the Administrator, DON and IP dated [DATE]. The Administrator stated they were instructed to follow the stricter guidance set forth by CMS. She stated the facility policy on COVID-19 testing was over looked until found on [DATE]. She stated management would now sign off on any new policies henceforth. The education included the facility policy on CMS Mandated LTC Facility Testing Requirements and educated regarding the facility completing facility wide testing of residents and staff in the event that a future outbreak as defined as one positive case of a staff member or a resident. There was evidence of daily audits for new cases and surveillance for COVID-19 current as of [DATE]. The Administrator confirmed the daily audits would continue until the facility resolved the current COVID-19 outbreak and continue for the next 3 months. The Administrator stated she would audit the results of the daily results every week and that the Regional Clinical Director would also visit weekly to review the facility's surveillance and auditing. The DON stated the facility was receiving the COVID-19 PCR test results with 48 hours. The IP stated PCR testing was last completed on [DATE] and as of [DATE], the he stated there were 82 residents who tested positive for COVID-19 and 22 staff who tested COVID-19 positive with a facility census of 94. The facility's Immediate Jeopardy removal date of [DATE] was validated.

Based on record review, observation and staff interview, the facility failed to prevent a resident who had cognitive impairment with poor decision-making skills and displayed exit seeking behaviors from exiting the facility unsupervised for 1 of 5 sampled residents reviewed for accidents (Resident #16). Resident #16 exited the facility through a window in his room at night. Resident #16 was heard knocking on the door outside the facility which was 40 feet away from the road at 1:30 AM. Resident #16 was assessed at the facility and found to have no injuries. Findings included: Resident #16 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A wandering risk assessment was completed for Resident #16 on 7/16/20. The assessment indicated that the resident had cognitive impairment with poor decision-making skills, able to ambulate independently and had talked about the desire to go home. The assessment further indicated that wandering was a new behavior for the resident. Resident #16 had an interim care plan dated 7/16/20. The problems were the resident is a wanderer and the resident is an elopement risk. The approaches included distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books and wander guard in place. A nurse's note dated 7/16/20 at 6:13 PM, revealed Resident #16 was admitted to the facility with admitting [DIAGNOSES REDACTED]. He ambulated in room and in the hallways with no assistance. He was wandering up and down the hall looking for his wife. A wander guard was placed on resident due to exit seeking behavior. He was oriented to his room and his call bell but due to confusion unable to determine if he could comprehend. The resident was sitting in his room at present looking out of the window for his wife's car. A nurse's note dated 7/17/20 at 3:30 AM, indicated that the resident was alert with confusion. He was up ambulating throughout hallway beginning of the shift. A nurse's note dated 7/20/20 at 1:40 AM, written by Nurse #6, revealed that at approximately 1:35 AM, there was a knock at the T-hall (quarantine hall) door. Resident #16 was noted to be outside the door knocking and requesting to come back into the facility. The resident had a wander guard in place after admission, but the staff did not hear an alarm. The resident was brought back in through that door and a complete assessment was completed to check for injuries. There were no injuries noted at that time. Upon investigation of the resident's room, it was noted that the window was wide open, and the screen was detached from the window. There was an over-turned trash can and a chair beside the window. When asked, the resident stated that he stepped on the trash can and then the chair after he opened the window and climbed out. When asked how he was able to open the window he stated, I tinkered with it until I got the screw loose. He also stated that he just wanted to walk in the garden outside, but he had to hold onto the building to keep from falling. The resident was placed in a chair at the nurse's station and a staff member sat with him through remainder of the shift. The attending physician, Director of Nursing (DON) and the family were notified of the incident. The maintenance director was made aware of the incident and he responded to the facility to secure the window. The facility's investigation of the incident was reviewed. The investigation indicated that Resident #16 was noted to have exited the facility on 7/20/20 through a window in his room and was noted knocking on the T hall door. The resident has dementia and was a wander risk and was wearing a wander guard. The plan of care was to provide one on one sitter and to look for alternate placement in facility with a secured unit. A written statement from NA #6 (assigned on the hall Resident #16 resided) dated 7/20/20 was reviewed. The written statement indicated that at 10:00 PM on 7/19/20, she tried to enter the resident's room and the resident had a chair blocking the door. She told the resident that he could not do that and moved the chair away from the door. He changed the resident and put him to bed. At around 1:35 AM, she noticed a man knocking on the T hall door, it was Resident #16. While the nurses letting the resident in, she went to the resident's room. She noticed the trash can flipped over upside down and the chair that she moved was placed under the windowsill. The window was open, and the screen was out and was placed on the ground. She helped placed the resident in a Geri chair and watched him until the maintenance came to put the window back together. She also removed the chair and put them in the hallway. On 7/28/20 at 1:34 PM, Nurse Aide (NA) #6 was interviewed. She stated that she was assigned to Resident #16 on 7/19/20 until 11:00 PM. NA #6 reported that she last saw the resident on 7/19/20 between 10:00 PM to 10:30 PM. The resident was very confused, and he was able to ambulate but was unsteady. The NA stated that night of 7/19/20, she found the resident in his room with the door closed and a chair was blocking behind the door. She told the resident not to close the door and to leave it open. The NA also indicated that the resident had called his wife that night to come pick him up. The NA further stated that around 1:35 AM, she heard a knock on the T hall door and Nurse #6 opened the door and noticed the resident outside. She then went to the resident's room and noticed a trash can flipped over upside down and a chair under the windowsill, and the screen was on the ground. On 8/4/20 at 3:10 PM, a follow up interview was conducted with NA #6. She indicated that she informed Nurse #6 and NA# 7 that Resident #16 had blocked his door with a chair, and she told him that he should leave the door open. She also told the nurse that she moved the chair away from the door and left the door open. NA #6 stated that when she saw the resident, he was wearing a white T shirt and an incontinent brief and was in bed. A written statement from NA #7 (assigned on the hall Resident #16 resided) dated 7/20/20 was reviewed. The statement indicated that the last time the NA saw the resident was at 1:00 AM. The resident was in his bed, looked asleep. At around 1:35 AM, there was knocking on the T hall door. She headed down the hall and noted that the nurses were letting Resident #16 in. She went to the resident's room and noted a chair by the window and the waste basket was flipped over. The window screen was out of the window and was on the ground. She then went and informed the nurses. She helped the resident into a Geri chair to be watched at the nurse's station. On 7/28/20 at 5:05 PM, NA #7 was interviewed. The NA stated that she was assigned to Resident #16 on 7/20/20 from 11:00 PM to 7:00 AM. She reported that she last saw the resident at 1:00 AM and the resident was in bed. She stated that the window was hard to open, and he must have been working on it for a while. The resident was determined to leave the building, he kept saying he wanted to go home. He was very confused and was up and down the hall throughout the night. NA #7 indicated that around 1:35 AM, there was a knock on the T hall door. Nurse #6 opened the door and the resident was outside. She then went to the resident's room and found a chair by the window and a waste basket that was flipped over. The window screen was out of window and was on the ground. A written statement from Nurse #6 (assigned to Resident #16) dated 7/20/20 was reviewed. The Nurse stated that the last time she made rounds was after midnight medication pass. She was down the T hall at 12:30 AM. Resident #16 was lying in his bed at that time. She went back to the nurse's station and started working on her charting. She was also with another resident who needed to be monitored. She heard someone banging on the T hall door at around 1:35 AM, it was Resident #16. She brought the resident back inside, assessed him from head to toe and no injuries were noted. On 7/28/20 at 11:51 AM, Nurse # 6 was interviewed. The nurse stated that she was assigned to Resident #16 on 7/20/20 from 7:00 PM to 7:00 AM. She stated that the last time she saw him was at 12:30 AM when she was passing the medications on T hall. The resident was in bed. After her medication pass, she was at the nurse's station watching another resident who was also a wanderer. She could see the hallway on the T hall but not the inside of the resident's rooms. She had 26 residents (T hall and Heritage hall) that shift with 2 nurse's aides (NAs). The NAs were doing their rounds. Resident #16 was on quarantine due to being a new admit from the hospital. He was confused and able to ambulate but was unsteady. The nurse reported that around 1:35 AM on 7/20/20, she heard a knock on the T hall door and when she opened the door, it was Resident #16. The nurse stated that it was dark outside. She assessed the resident for injury and there was none. The Nurse indicated that the resident kept saying that night I'm going home. Nurse #6 stated that the resident had removed the screw from the window and pushed the screen out. He also placed a trash can near the window and used it to get out the building. On 8/4/20 at 2:34 PM, a follow interview was conducted with Nurse #6. She stated that Resident #16 was wearing street clothes, with pair of shoes and socks on when staff assisted him back into the facility, during the night of 7/20/20. He was carrying a plastic bag with personal clothes. He stated that he was going home. Nurse #6 also reported that she was informed by NA # 6 that the resident had his door closed and he blocked it with a chair. She was also informed by the NA that she had moved the chair away from the door and kept the door open. The Nurse indicated that she could not remember if she was informed of this before or after the incident. She stated that if she was informed before the incident, she would have done the same thing, remove the chair behind the door and keep the door open. On 7/29/20 at 8:40 AM, the Maintenance Director was interviewed. He stated that all windows had a rubber [MEDICATION NAME] that was secured into the windowsill with a screw (2 inches long) to allow the window to open 6 inches as required. He stated that the screw was hard to remove without a tool and the resident must have been messing with it for several days to be able to unscrew it. He added that the rubber [MEDICATION NAME] had been installed since the facility was built and he had changed all the rubber window [MEDICATION NAME] to a metal [MEDICATION NAME] on 7/20/20. The Maintenance Director stated that the distance from the resident's window to the T hall door was about 40 feet. On 7/29/20 at 8:55 AM, Resident #16 was observed lying in bed in his room. When asked about the incident where he exited the window, he replied that he did go out the window, but he could not remember the date and time. He had a sitter siting outside his door during the observation. On 7/29/20 at 9:05 AM, the window Resident #16 exited from was observed with the Maintenance Director. It was a slide window with a metal [MEDICATION NAME] secured to the windowsill to allow the window to open for 6 inches. The distance from the window to the ground was about 3 feet high. The distance from the window to the T hall door was about 40 feet and the T hall door was about 40 feet to the road. The road was observed to have 2 lanes with a posted speed limit of 35 miles per hour. On 7/29/20 at 3:01 PM, the Director of Nursing (DON) was interviewed. She stated that all facility's windows have rubber [MEDICATION NAME] secured with a screw to the windowsill. The DON reported that the resident must have been working on the screw for awhile and for some reason he was able to unscrew the [MEDICATION NAME], opened the window and came out. She verified that the resident was a wanderer and he was wearing a wander guard. He expected the staff to monitor the resident every rounds, which was every 2 hours. On 8/4/20 at 3:34 PM, a follow up interview was conducted with the DON. She stated that she thought Resident #16 has dementia and has decreased safety awareness. The DON reported that the resident's physician had not seen him before the incident on 7/20/20 but he was notified of the incident and had seen him on 7/20/20. The DON further indicated that the care plan was reviewed and revised after the incident on 7/20/20 to include redirection, checking of windows, monitoring of behaviors that indicate a plan to exit the facility and to notify the nurse or nurse supervisor if any. The corrective action for the past non-compliance dated 7/20/20 was as follows: All items listed on this self-imposed action plan have been completed and implemented on 7/20/20 with ongoing monitoring to ensure compliance. This concludes the action plan and any potential citation associated with this action plan should be considered past non-compliance as of 7/20/20. On 7/20/20, Resident #16 exited the facility unattended by opening the window in his room and using a chair to climb out of the window. He was last seen by the staff member at 1:00 AM and was noted to be sleeping. He was noted to be knocking on the T-hall door at approximately 1:35 AM. Through investigation it is determined that the resident exited the facility between 1:00 AM and 1:35 AM. The DON and the Maintenance Director retraced his steps and using the fact that he is unsteady and held onto the wall it would have taken approximately 2 minutes from the time he exited the window until he reached the door he knocked on. After investigation, we were able to determine that the resident was able to move the window back and forth until he loosened the screw and was able to remove the screw and open the window completely. The resident walked around the corner of the building and knocked on the exit door for the staff to let him back into the facility. CORRECTIVE ACTION THAT WILL BE ACCOMPLISHED: Resident #16 was assessed for injury on 7/20/20 at 1:40 AM and there was no apparent injury. The resident was placed in a wheelchair and placed at nurse ' s station for the remainder of the night so that he could be monitored. The resident was placed on one on one on 7/20/20 until such time the attending physician determines his behaviors have subsided. The resident was reassessed for elopement and care plan was updated to indicate elopement on 7/20/20. Maintenance Director responded to facility and secured the window. The Physician, DON and Administrator were made aware of situation on 7/20/20. IDENTIFICATION OF OTHER RESIDENTS: A 100% audit of all residents was conducted on 7/20/20 to ensure that all residents were present in the facility. All residents were present. A 100% audit was conducted on all residents on 7/20/20 with current wander guard use and it was determined that there were 15 residents at risk for elopement. All 15 residents had a new wander risk assessment performed to determine if they had any changes since the last assessment. No other changes were noted. MEASURES FOR SYSTEMIC CHANGE: The Maintenance Director secured all windows on 7/20/20 so that they will only open to 6 inches to meet life safety guidelines while preventing resident from exiting through the windows. All staff were educated on elopement on 7/20/20 by the DON and Assistant DON and elopement will continue to be discussed during orientation for newly hired employees. HOW CORRECTIVE ACTION WILL BE MONITORED: The Maintenance Director will audit all room of residents with wander guards five times weekly for 2 weeks and then 3 times weekly for four weeks and then monthly for two months beginning 7/21/20 to ensure that the windows remain secured. These audits will be reviewed by the Administrator and or DON upon completion. DON/Assistant DON will monitor for residents that have increased exit seeking behaviors that may indicate risk for elopement through nurse ' s notes and interview daily. These audits will be completed on 5 residents at risk weekly for 4 weeks and then 10 residents monthly for 2 months. All audits will be reviewed during the monthly Quality Assurance (QA) meeting to determine continued compliance and or changes needed to plan of correction (POC). This POC will continue until such times as the QA committee determines compliance has been maintained. Date of compliance: 7/21/20 On 7/29/20 as part of the validation process, the POC was reviewed and verified through review of the audit sheets, and the in-service records, observation of the windows and staff interview. Interview with the staff revealed that they had received in-service on elopement/wandering resident and a drill on missing resident on 7/20/20. A review of the audit sheets from 7/21/20 -7/27/20 of window securement by the Maintenance Director and the audit sheets of increased exit seeking behaviors by the DON/ADON and the in-service records including their sign in sheets was conducted. Observation of windows was conducted on 7/29/20. Windows were secured and could not be opened more than 6 inches. Resident #16 was observed with 1:1 Sitter on 7/29/20. The validation process verified the facility's date of compliance as 7/21/20.

Based on observation, resident and staff interviews and record review, the facility failed to prevent a dependent resident from falling out of the bed during incontinence care for 1 (Resident #1) of 4 residents reviewed for falls. Resident #1 fell from the right side of the bed while the bed was in the high position sustaining bilateral femoral fractures requiring surgical intervention. The finding included: Resident #1 was admitted [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #1's quarterly fall assessment dated [DATE] read she had no history of falls in the last six months, she was cognitively intact. She was coded as non-ambulatory. Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] indicated she was cognitively intact and exhibited no behaviors. She was coded as requiring extensive assistance of two staff for bed mobility, extensive assistance of one staff for toileting and personal hygiene. Resident #1 was coded for one side impairment to the upper extremity and bilateral impairment to lower extremities. She was coded as having had no falls since the previous MDS assessment. Review of Resident #1's plan of care initiated on 11/09/17 and in place on 10/08/18 identified the resident as being a fall risk. The interventions for Resident #1 included to reinforce her to call for assistance. A review of a nursing note dated 10/8/18 at 6:45 AM read Resident #1 was heard screaming. On entry to the room, Resident #1 was observed lying on the floor. She complained of pain to both knees. Nursing Assistant (NA) #1 stated she rolled Resident #1 to change her brief and Resident #1 was trying to get something off the nightstand when she rolled onto the floor. Resident #1 requested to be transferred to the hospital for an evaluation. The Physician was notified, and Resident #1 was transported to the hospital by Emergency Medical Services (EMS). Review of the facility incident report and investigation dated 10/8/18 read Resident #1 fell to the floor while NA #1 was providing care. The report indicated Resident #1 was alert and oriented, but no statement was obtained at the time of the fall at 6:45 AM. The Post Fall Investigation Summary dated 10/8/18 at 7:15 AM read Resident #1 rolled out of the bed to the floor while NA #1 was rendering care. Resident #1 was receiving perineal care at the time of the fall. The new intervention care plan decision read the facility would assess for safe bed mobility on Resident #1's return from the hospital. Review of the hospital records 10/8/18 revealed Resident #1 fell from the bed while being changed. Resident #1 was diagnosed with [REDACTED]. She was discharged back to the facility on [DATE]. Review of Resident #1's readmission fall assessment dated [DATE] read she had a history of [REDACTED]. She was coded as non-ambulatory. Review of Resident #1's revised care plan dated 10/12/18 included the following new interventions: Discourage Resident #1 from rearranging her nightstand and over the bed table during turning and repositioning, have commonly used articles within easy reach, total care of two staff for bed mobility and transfers. In an interview on 11/6/18 at 10:05 AM, the Director of Nursing (DON) stated Resident #1 could not move independently in the bed and required two staff assistance with bed mobility and incontinence care. An observation and interview with Resident #1 was conducted on 11/6/18 at 10:10 AM. Resident #1 was lying in the bed with her nightstand and her bedside table on the right side of the bed. She was deemed cognitively intact and recalled the fall that occurred on 10/8/18. Resident #1 stated NA #1 was changing her early that morning. She stated NA #1 raised her bed to the highest position and was rolling her back and forth to change her brief when NA #1 rolled her onto her right side and she was too close to the edge of the bed. She recalled suddenly rolling onto the floor and landing on her knees. Resident #1 stated she thought NA #1 took her hands off her to reach for something when she rolled onto the floor. Resident #1 stated as soon as she fell , the aide stated, I'm so sorry and yelled for help. She stated she was experiencing extreme pain to both knees and was sent to the hospital. Resident #1 said while at the hospital, she required surgery to both legs and was now having to wear bilateral knee immobilizers when she was up to the chair. She stated she spoke with the DON and requested NA #1 not work with her anymore. Resident #1 stated she could not independently reposition or roll herself in the bed prior to the fall due to her MS and limited range of motion in her left arm. She stated she had not experience any other falls. In an interview on 11/6/18 at 11:50 AM, NA #2 stated Resident #1 was only one-person assistance for bed mobility and incontinence care prior to the fall but now she needed the assistance of two staff. NA #2 stated Resident #1 had limited movement in her left arm prior to the fall on 10/8/18. NA #2 stated after the fall, the staff were in-serviced on proper bed positioning when providing incontinence care to dependent residents and that the resident was positioned in the middle of the bed. In an interview on 11/6/18 at 2:20 PM, NA #4 and NA #3 stated Resident #1 could not roll herself independently and could not reposition herself independently due to limited range of motion in the left upper extremity and bilateral lower extremities prior to the fall and after the fall. NA #4 stated she had not observed Resident #1 reaching for items off the nightstand during care. NA #3 stated she had observed Resident #1 reaching for things off her bedside table but not during incontinence care. In a telephone interview on 11/6/18 at 2:23 PM, Nurse #1 stated she was working that night and was standing at the nursing station when she heard a thump and a scream. She stated she and another nurse entered Resident #1's room and noted there was no lights on in the room. Resident #1 was on the right of her bed on the floor. Nurse #1 stated NA #1 was standing near Resident #1 and stated she rolled Resident #1 over to clean her and she just keep rolling. Nurse #1 stated NA #1 stated she did not leave Resident #1 unattended but could not stop her fall because it happened so fast. She recalled NA #1 stating Resident #1 was reaching for her nightstand when she fell . Nurse #1 stated she was not sure if Resident #1 was near the edge of the bed when the fall occurred but stated the bed was observed in the high position. Attempts to speak with Nurse #2 who was assigned Resident #1 on third shift at the time of her fall on 10/8/18 were unsuccessful. In a telephone interview on 11/6/18 at 2:34 PM, NA #1 stated she was changing Resident #1 toward the end of her shift on 10/08/18. She stated Resident #1 preferred to keep her bed control and light cord near her right side since her left arm was weak. NA #1 stated she turned on the overbed light and raised Resident #1's bed. NA #1 stated she removed her brief and rolled Resident #1 over to clean her. NA #1 stated she rolled Resident #1 onto her right side and she just keep rolling and she couldn't catch her. She stated when Resident #1 rolled off the bed, her overbed light cord was near Resident #1's right hand and it must have got caught when she fell and the overbed light was turned off. NA #1 stated Resident #1 was reaching for something on the nightstand causing her to roll off the bed. NA #1 confirmed Resident #1 was lying on her right side. NA #1 could not offer an explanation how Resident #1 was able to reach over to her nightstand using her left arm. NA #1 stated she could not recall removing her hand off Resident #1, but it happened so fast. NA #1 stated she thought Resident #1 was repositioned into the middle of the bed when she rolled her over. NA #1 stated the DON asked for her statement and she was reminded to keep Resident #1 in middle of bed prior to turning her. In an interview on 11/6/18 at 3:45 PM, NA #5 stated she had not observed Resident #1 reaching for her bedside table or nightstand during care. NA #5 stated Resident #1 was total staff assistance for bed mobility and had limited range of motion in her legs and left arm prior to her fall and after the fall. NA #5 stated the DON educated the aides after Resident #1's fall to ensure any resident dependent on staff assistance for bed mobility or incontinence care was re-positioned in the middle of the bed prior to being turned. In another interview on 11/6/18 at 4:43 PM, the DON produced an undated in-service which reminded the staff to ensure the resident was re-positioned in the center of bed during care prior to turning. The DON produced an employee signature log regarding proper bed positioning dated 10/9/18. The DON did not provide any evidence of re-education for NA #1. The DON stated it was her expectation that all residents who were dependent on staff for bed mobility and incontinence care include the correct number of staff assistance, proper bed positioning prior to turning the resident and staff not the leave a resident unattended during care.

Based on observations, record review, staff interviews, and law enforcement officer interview, the facility failed to provide supervision to prevent the elopement from the facility of 1 of 5 moderately cognitively impaired residents reviewed for accidents (Resident # 1). On 7/25/17, Resident # 1, unsupervised by staff, exited the facility by wheelchair and traveled approximately 440 feet (146 yards) to a convenience store behind the facility on a sidewalk. Resident #1 was located by law enforcement officer and was returned to the facility with no injuries after an undetermined amount of time outside of the facility. Immediate Jeopardy began on 7/25/17 when Resident #1 exited the facility unsupervised and was found outside by a law enforcement officer on the sidewalk a of a convenience store behind the facility after an undetermined amount of time. The Immediate Jeopardy was lifted on 9/14/17 when the facility's acceptable credible allegation of compliance was verified. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place and completion of employee training. The findings included: Resident #1 was admitted to the facility on [DATE] with a readmitted on 7/17/17. The resident's [DIAGNOSES REDACTED]. Review of the care plan dated 7/18/17 revealed focused area At risk for fall due to limitations secondary to hypertension, congestive heart failure, chronic kidney disease, osteoporosis, [DIAGNOSES REDACTED], left below knee amputation. The goal was to minimize the risk for fall. Interventions included to assist with transfer, assist to toilet at bedtime and reinforce need to call for assistance prior to going to the bathroom. Review of the comprehensive readmission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 1 had adequate hearing, vision, clear speech, and usually made self-understood. Per the MDS, Resident #1 had moderate cognitive impairment with Brief Interview for Mental Status (BIMS) score of 12. Resident #1 was assessed with [REDACTED]. The resident did not exhibit wandering behavior. The resident was assessed as needing supervision with one person assistance with bed mobility and transfer, limited one person assistance for locomotion on and off unit. The resident was coded as having no functional limitation in range of motion for upper extremities, and impairment on one side for the lower extremities. The resident used a wheelchair as mobility device. Resident #1 was assessed as receiving diuretics 7 out of 7 days in the look back period, and an antidepressant 6 days out of 7 days during the look back period. Review of an incident report, prepared by the facility, and dated 7/25/17 at 9:30 PM, revealed Resident #1 was brought in the building by a law enforcement officer who indicated that the resident was at The Store. The incident report also indicated that the resident informed the officer that someone carried him there and left him. On further questioning, Resident #1 could not describe the person who brought him or the mode of transport. Upon arrival to the facility, a complete head to toe assessment was completed and no injuries or bruises were noted. Fifteen minute checks and one to one observation was initiated. Physician (MD) and Responsible Party (RP) were notified at 11:00 PM. Review of the incident statement from the law enforcement officer dated 8/2/17 read in part: Law Enforcement Officer states that she was in her patrol car and visualized the resident sitting on the sidewalk in front of the store. She states she had observed him for 5 - 10 minutes before approaching him. She walked to him and initiated a conversation. Resident states that he was waiting to be picked up. She states she noticed that the resident was disabled so she offered to buy him something to eat or drink and he declined. Resident eventually gave her a telephone number that she called and spoke to his (family member). The (family member) tells the law enforcement officer that resident is a resident of Manor Care. She states that she pushed the resident's wheelchair to the facility. The front door was locked and a lady opened the door for them to come in. The lady directed her (the law enforcement officer) to the left, she (the law enforcement officer) pushed the resident to the nurse's station and spoke to the nurse. The nurse then took the resident into his room to assess him. The law enforcement officer stated that she never saw anyone with the resident other than the customers that he was speaking with and did not see how the resident got to the store. The law enforcement officer said that the incident occurred around 8:21 PM . A phone interview was conducted, on 9/13/17 at 8:20 AM, with the law enforcement officer who found the resident on 7/25/17. The officer indicated that she pulled at the store at 8:15 PM on 7/25/17 and noticed Resident # 1 sitting on the concrete sidewalk of the store. The law enforcement officer stated that she approached Resident #1, introduced herself and asked if the resident was hungry or thirsty. She indicated that Resident #1 refused any food or water. She indicated that Resident #1 informed her that someone had left him (the resident) at the store and he was waiting to be picked up. She stated that Resident # 1 provided her with a (family member's) phone number when she inquired about any contact information. The law enforcement officer stated she spoke with the resident's family member who informed her that Resident # 1 resided at Manor Care Nursing Home. The law enforcement officer indicated that she wheeled Resident #1 to the nursing home. She stated that upon reaching the nursing home, she informed a nurse (unsure of her name). The law enforcement officer also stated that the nurse indicated to her that she was about to go to the resident's room for night medications and was not aware the resident was not in his room. The officer indicated that it was around 8:30 PM when she brought Resident #1 to the nursing home. A phone interview was conducted with Resident #1's family member on 9/12/17 at 4:45 PM. Resident #1's family member indicated that a law enforcement officer had called her on the day of the incident (unsure of the time) and informed her that the resident had given the law enforcement officer her contact number. She stated that the law enforcement officer had informed her that Resident #1 indicated to the law enforcement officer that he was brought to the store by someone and had left him there. She further stated that she informed the law enforcement officer that the resident resided at Manor Care. She stated that the law enforcement officer indicated to her that the resident would be taken back to the facility. She further stated that the resident was able to self-propel his wheelchair. She also stated that the facility had taken precaution to make sure that the incident did not occur again by placing a device on the resident's ankle. She also stated that Resident# 1 had never eloped before and she was not sure why he went outside to the store. Review of investigation statement from the Store clerk dated 7/28/17 revealed Resident #1 had come to the store alone, was sitting outside on the sidewalk and talking to several people coming in and out of the store. The statement also indicated a law enforcement officer came over and started speaking with Resident #1. Later the law enforcement officer pushed the resident's wheelchair and took him back to the facility. The statement also indicated that Resident #1 never entered the store. During an interview with the store clerk on 9/12/17 at 7:50 PM, he stated he observed Resident #1 come down the sidewalk alone. He further stated that Resident # 1 was sitting on the concrete side walk outside the store beside the window and talking to his customers outside the store. He stated that he did not interact much with the resident. He stated he noticed one of his frequent customers spoke to the resident. He indicated after the law enforcement officer spoke with Resident #1, he took the resident back to the facility. The store clerk also indicated that he was unsure of the time, however as it was summer time there was daylight in the evening. Review of the investigation statement from NA #1 dated 7/26/17 revealed Resident # 1 was approached at around 8 PM or so and asked by NA #1 if he wanted a shower. Resident refused indicating he had a meeting to go to and proceeded toward the master hall nursing station. NA #1 indicated that she looked for the resident a little bit later and could not find the resident so NA #1 notified Nurse #1. The nurse was looking for the resident when the law enforcement officer brought the resident in the door. A phone interview was conducted with Nurse Aide (NA) #1 on 9/14/17 at 10:45 AM. NA #1 indicated that she no longer worked in the facility. She stated that she provided care to Resident #1 on the day of the incident. She stated that around 8 PM she had asked the resident if he would like to take a shower. She stated that Resident # 1 refused indicating that he had a meeting to attend. She stated that Resident #1 would go to a poker game in the activity room and she presumed he was going to the game. She stated that activities had poker games in the activity room some evenings. She stated that Resident # 1 was sitting in his wheelchair at the doorway of his room at that time. She stated that while she was leaving the resident room to attend to another resident, she noticed the resident was wheeling himself to the other end of the hallway towards room 135, opposite direction from the activity room. She also stated that Nurse #1 was in the hallway passing medications at room 126. She further stated that between 8:10 PM and 8:11 PM she had gone to Resident #1's room to ask about the shower again. She indicated that Resident #1 was not in the room and was not in the bathroom. NA# 1 indicated that she informed Nurse #1 about the resident. NA #1 stated that she was on her way towards the dining hall to look for the resident, when she noticed the law enforcement officer bringing in Resident #1. NA#1 stated that the law enforcement officer had informed Nurse #1 that Resident #1 was at the store behind the facility. NA #1 indicated that the nurse took the resident to his room and did a complete assessment. NA #1 also indicated that the front lobby door was locked after 8 PM. She stated that the front door could be opened from the nursing station at the Rehab unit, or a code could be entered at the door. NA # 1 stated that she did not hear any door alarms sound that night. During an interview with the Activity Director on 9/14/17 at 11 AM, she indicated that Resident #1 would participate in the poker game which was played once or twice a month from 6 PM to 6:30 PM. She further stated that no activities were usually scheduled after 6:30 PM. Review of the activity calendar for the month of July indicated that no poker activity was conducted on the day of the incident. Review of the investigation statement from Nurse # 1 dated 7/26/17 revealed Nurse #1 (who was taking care of Resident # 1 on the date of the incident) noticed the resident in his wheelchair in the hallway at start of her shift (7 PM - 7 AM) and during medication pass. Nurse # 1 indicated that she became busy with patient care. Resident #1 was wheeled down the hall by a law enforcement officer who stated that the resident was found at the store and resident had informed law enforcement officer that someone had taken him to the store and left him there. Resident was unable to provide more information as to who took him to the store. The law enforcement officer information was documented in the incident report. The resident was assessed and a shower was provided to the resident as it was his scheduled shower day. The front door was checked at around 9:30 PM and it was locked. 15 minutes checks and one to one observation began, and the resident was assisted to bed. A phone interview was conducted on 9/13/17 at 9:10 AM with the nurse (Nurse #1) who was assigned to Resident #1. Nurse #1 indicated that she no longer worked in the facility. Nurse # 1 stated that earlier in the shift (between 7:30PM - 8PM) she noticed Resident #1 sitting in his wheelchair at the nursing station. She indicated that she was passing medications to other residents at that time. She further indicated that 30 minutes later a law enforcement officer came in with the resident. Nurse # 1 stated that when she interviewed Resident #1, resident stated They took me to the store and now I am back. She indicated that Resident #1 was unable to elaborate on who they were, or elaborate further on the incident. Nurse #1 stated that a full body head to toe assessment was done and that no injuries or bruises were noted. Resident #1 did not appear confused and was his normal self. Nurse #1 indicated that after Resident # 1 was brought back to the facility by the law enforcement officer, Resident #1 was also provided a shower, placed on 15 minutes checks and later one on one observation. Nurse #1 also indicated that no code purple (a code called out in the facility by staff when a resident was missing) was called. However other nurses did a head count as they observed the resident being brought in the facility by a law enforcement officer. Nurse #1 also indicated that the Director of Nursing (DON) was informed sometime later that night (around 3 AM). Nurse #1 indicated that MD and RP were notified. Nurse # 1 further stated that Resident #1 did not exhibit exit seeking behaviors prior to the incident. Nurse #1 stated that she did not hear any door alarms sound that night. Review of nursing notes dated 7/25/17 at 9:15 PM read in part: routine medications administered upon resident's return to unit. Assessment completed in the shower no injuries or skin breakdown, tears or discolorations noted. No unusual odors noted. Mannerisms normal for resident. Fifteen (15) minutes checks were started. The resident was assisted to bed and he was resting quietly. During an interview with Nurse # 2 on 9/12/17 at 7:10 PM, she indicated that she was working on the opposite hallway and did not hear the exit door alarm sound. She further stated that resident was not exit seeking and usually sat in his room doorway in his wheelchair and observed residents and staff. She also indicated that the resident was able to propel his wheelchair throughout the facility. During an interview on 9/13/17 at 7:15 PM, NA #2 indicated that she was working on the opposite hallway and did not hear any door alarm sound the day of the incident. She further stated that she had not noticed the resident at all on the day of the incident as she was not assigned to him. Review of nursing notes dated 7/27/17 at 4:01 PM revealed that for the most part, Resident #1 had been alert and verbal until recently. He had a history of [REDACTED]. The resident was pleasant and joked with staff members as he frequently sat near the nurse's station people watching. He had no psychiatric issues and behaviors have been limited to occasional sexually inappropriate comments towards women. Resident's depression was being managed without medications and he had not exhibited symptoms of mood changes. Resident had declined recently resulting in one hospitalization and one emergency room (ER) visit in the past month related to cardiac issues. The resident appeared to be weaker than normal and noted to sleep more and sit with his head hanging down while in chair. The resident was exit seeking 7/25/2017 and had since received an order for [REDACTED]. One on one had continued to this point and will now be discontinued. While residing at the facility, there were no concerns related to exit seeking before the event on 7/25/17. Medical Doctor (MD) evaluated the resident the morning of 7/27/17 due to cognitive decline. MD ordered the discontinuation of Remeron, Neurontin, and Ultram. A CT (a computed tomography - a machine that makes detailed pictures of parts of human body) of the brain was scheduled. The resident continued to be observed every 15 minutes. No exit seeking behaviors were noted. Review of the Physician note dated 7/27/17 revealed Resident #1 tried to elope from the facility on 7/25/17 and was found on the sidewalk of the gas station next door. He had been having increasing confusion and disorientation over the last few days. Remeron (a medication prescribed to treat depression) was prescribed to the resident several weeks ago for appetite stimulant and possibly this could have caused an issue. Remeron was discontinued and will be followed up if no improvement or other changes occurred. Review of Physician note dated 8/1/17 read in part: Resident unfortunately was found to have elope(d) last week from the facility. He was gone for an undetermined period of time. It was my opinion, after evaluation and inability to find any kind of reversible etiology for his altered mental status, that Remeron was the agent added for appetite stimulant. This has been discontinued. Today patient (resident) states he feels a little better and not as confused. Altered mental status improving. Plan to continue meds as listed with follow if no improvement. During an interview with the Director of Nursing (DON) on 9/12/17 at 5:15 PM, DON indicated that she was informed about the elopement at 3 AM on 7/26/17. She stated that Nurse #1 was new to the facility and did not know to inform the administrator. The DON stated that Nurse #1 was made aware of the seriousness of the incident when she reported the incident to other nurses. Nurse #1 was made aware that she should call the DON. The DON also stated that there was a part time receptionist in the front lobby who worked till 8:30 PM. DON indicated that front door was locked after 8 PM when there was no receptionist in the lobby. The DON further stated that the residents could sit in the front lobby and porch as long as there was a receptionist watching them. She stated that all exit doors were checked weekly by the maintenance personnel. She stated that Resident #1 must have followed some family members exiting the facility and gone out of the building. DON stated that it was her expectation that the staff observe the residents and if any resident was not accounted for then staff should call a Code purple and follow appropriate procedure. She stated that Code purple was announced on the intercom when any resident was not accounted for. She stated that staff was to do a complete head count of all residents under their care at that time and document it, check for missing resident first inside of the facility including but not limited to resident room, closet, and bathrooms. She stated that if the resident was not found in the building, then few staff would check the entire outside perimeter of the building. She stated that the administration was informed immediately. She further stated that it was her expectation that she would be informed immediately if a resident eloped or was not accounted for. Review of a nursing notes dated 7/26/17 at 2:35 PM revealed the Director of Nursing (DON) was notified of the incident on 7/25/17. The DON gave instructions to provide one on one supervision for Resident #1 until further notice. A Wanderguard was placed on the resident which he was tolerating well. During an observation on 9/12/17 at 12 Noon, Resident #1 was observed sitting in a wheelchair in his room. Resident #1 indicated he was waiting for his lunch tray. Resident # 1 refused to talk about the incident on 7/25/17. During an observation on 9/12/17 at 3 PM, Resident #1 was observed sitting in a wheelchair near his room doorway and was watching staff and other residents. The observation revealed the resident had a Wanderguard to his right leg and had a below the knee amputation on the left side. Resident # 1 refused to be interviewed. During an observation of all the exit doors from the hallway on 9/12/17 at 10:00 AM, the observation revealed all exit doors including the front door had a signage that state Push until alarm sounds. Door can be opened in 15 seconds. There was a code pad near the doors. Employee exit door in the main hallway had a code pad on it. The door was closed and opened only with a code. The observation of the front door revealed that the front door consisted of 2 doors that were closed and needed to be pushed open. The observation also revealed that the doors had to be held to be kept open and would close when released. On 9/12/17 at 12:35 PM the alarm system of an exit door in the hallway was observed. The observation revealed that the door needed to be pushed hard for 15 seconds to open. It was also observed that while the door was pushed, the alarm sounded in the building. The alarm could be deactivated when the door closed properly and a code was entered on the code pad near the door. It was also observed that the door needed a code to open without the alarm. However, if the door was kept open for 15 seconds the alarm activated and the door needed to be closed to deactivate the alarm. On 9/12/17 at 12:45 PM, an observation of the dirty utility room door opposite to Resident # 1's room revealed the door had a code pad and opened only with a code. The observation revealed that when the door was opened and released, the door slammed shut immediately. The observation also revealed a door on the other side of the room had no code, but had a lever (handle). When the lever was lowered, the door opened to the loading hallway. The door was heavy and needed to be held to be kept open. The door had a key pad for code on the other side of the loading hallway. The loading hallway had an exit door that led to the employee parking lot. The door had no code. The door had a Wanderguard alert system placed. During an interview with the maintenance personnel on 9/12/17 at 5:30 PM, he indicated that the front entrance door automatically locked around 8:05 PM and automatically unlocked after 8:05 AM. He stated that the door needed a code to be opened during that time, if not the alarm was activated. He stated that when a resident with a Wanderguard approached the front door, the door would automatically be locked and the alarm would sound. He also stated that the door and alarms were tested and recorded weekly in Tactical Enterprising logistical System (TELS) report. During an interview with the evening receptionist on 9/12/17 at 6:49 PM, she indicated that she usually worked from 5 PM - 8:30 PM on the weekdays. She indicated that from 8:05 PM to around after 8:00 AM the front door was automatically locked and needed a code to open the door. She stated that she made sure no resident was sitting in the lobby or on the front porch before the end of her shift. She also indicated that on the day of the incident she did not see the resident near the front lobby. A walk to the store was completed on 9/12/17 at around 1:45 PM. The walkway around the building was well maintained and had no broken ground areas. The walkway passed through the entrance of employee parking lot and then crossed an open area with some trees and bushes towards the employee parking before reaching the store. The distance between the facility entrance and the store was approximately 400 - 450 feet. The street, usually had light traffic movement. Review of the official weather report for 7/27/17 revealed 93 degrees Fahrenheit recorded for high and 73 degrees Fahrenheit recorded for low temperatures. Weather report also indicated some clouds with no rain. On 9/14/17 at 11:50 AM, Corporate Personnel demonstrated the operation of the monitor at the front door from the rehab nursing station. The monitor displayed the picture of the person outside the front door. The monitor had an intercom that can be used to communicate with the person outside the facility. The monitor also had a key button that could open the locked front door. The corporate personnel indicated that this operation was done when the front door was locked at night (after 8 PM) and family member/ visitor needed to visit a resident after 8 PM. The corporate personnel indicated that the staff see who was at the front door at night before the door was opened. The Administrator, DON, corporate personnel were notified of Immediate Jeopardy on 9/13/17 at 4:28 PM. On 9/14/17 at 4:42 PM the facility provided the following credible allegation of compliance: The facility Quality Assessment and Assurance committee met on September 13, 2017 and implemented an internal plan of correction due to concerns identified through the complaint process and QA identification. On July 25, 2017 Resident #1 exited the facility at approximately between the hours of 8pm and 8:21pm. The resident was last seen at approximately 8pm when he was offered a shower and refused and was seen sitting at nursing station. At approximately between 8pm and 8:21pm, according to staff statements, they started looking for resident. When search was initiated Resident #1 was returned to center by police officer. The resident returned to his room and was reevaluated and a head to toe skin assessment was completed and care plan was updated on 7/26/2017. Resident #1 did not have any injuries upon assessment which is documented in progress notes on 7/25/2017. Investigation was initiated on 7/26/2017 and an internal plan of correction was developed on 7/26/2017 proactively to ensure wanderguard monitoring and door alarm system function and monitoring was in continued compliance. This included like residents that are at risk for elopement was in place and in compliance. During the investigation the root cause was identified as the resident exhibited a change in condition on the day of the event that he exited the facility. The facility could not identify which door Resident #1 exited, however it was determined based on staff interviews conducted on 7/26/2017 that no alarm was heard or silenced. Maintenance director checked all doors on 7/27/2017 and found none disarmed and all were working properly. Furthermore, the maintenance director went to each door to check system and found wanderguard system had no malfunction identified and was in working order. Current doors alarm and releases after 15 seconds of constant pressure as per Life Safety guidelines. Investigation found no issues in this area and doors and alarms functioning correctly requiring no outside intervention. Resident #1's care plan was updated to prevent reoccurrence. The facility's internal proactive plan of correction did not address like residents as this was considered isolated and not a systemic failure. However a plan of correction has been updated to include the following to address like residents who may experience a change in condition to ensure staff is prepared proactively to respond and prevent a reoccurrence or like incident. Immediate Corrective Action The Director of Nursing/ Unit Manager/ Maintenance director inserviced all staff on all shifts on code purple drills which was initiated on 7/26/2017 and completed on 7/27/2017 Exit seeking evaluations were completed on residents who wear wanderguards and this was completed on 7/26/2017 Log book documentation was in place for door alarms and wanderguards systems. The documentation reflects monitoring was completed on 7/25/2017 and has occurred weekly. Investigation of Resident #1 exiting the facility was completed on 7/27/2017 An Ad Hoc committee which included payroll, business office manager, unit manager's, social service director, admissions director, dietician, food service director, MDS, director of rehab, DON, Maintenance director, Administrator, and Housekeeping supervisor held 9/13/2017 to address additional plan of correction The facility will continue to monitor the wander guard system through our current Maintenance system which is checked weekly for functionality. The Identified Resident care plan and interventions were updated at the time of the incident and plan has been effective in preventing reoccurrence. The care plan included but not limited to the following: o Allow to wander inside the facility and redirect as needed o Check alert bracelet (Wanderguard bracelet) q shift and function q day o Escort to and from dining room and activities o wander guard bracelet o frequent checks of patient location o Provide directional cues to include name on Resident #1's door to assist him with location of room Department heads will educate starting 9/13/2017 facility staff (Nursing, Dietary, Housekeeping, Activities, Therapy, Administration) on the LOA (Leave Of Absence) policy and the Administrator will send on 9/14/17 a form letter to families to ensure all understand the LOA policy components. This is not a new policy and education is being done proactively for residents who leave the facility with or without family via doctor's orders. This policy is not relevant to the incident that occurred on 7/25/2017 but is being done proactively. Department Heads will educate starting 9/13/2017 facility staff (Nursing, Dietary, Housekeeping, Activities, Therapy, Administration) on behaviors that are indicative of potential changes and exit seeking behavior and steps to take to prevent unsafe exit from the facility. Door codes were changed by Maintenance Director proactively on 7/27/2017 and will be changed again proactively 9/13/17 Administrator or designee will educate facility staff starting on 9/13/2017 (Nursing, Dietary, Housekeeping, Activities, Therapy, Administration) not to share door codes proactively The Medical Director was notified on 9/13/2017 of citation and plan of correction that has been developed. Inservices started on 9/13/2017 and will continue until all staff is inserviced. This will be accomplished by staff that has not been educated will be educated before they start their shift ongoing until completed. An employee roster list was established and as people complete their inservicing they are highlighted off so facility clear system to manage completion of training. New hires will be inserviced as part of their orientation process. Any staff that has not been educated will be educated before they start their shift ongoing with new hires as well. The credible allegation was validated on 9/14/17 at 8:00 PM. The survey team confirmed the completion of wandering assessments for all resident with a potential for elopement. The MDS and care plans were verified for updates for residents with potential for elopement. The updated missing resident wandering/elopement notebook was verified. The survey team also verified the Treatment Administration Record (TAR) for monitoring of placement and functionality of wanderguard on every shift daily for residents with Wanderguard. Resident #1 had a medical procedure and was not in the facility at the time of verification to determine if the Wanderguard was in place, however other residents with Wanderguards were observed and their Wanderguards were in place and functioning. The alarms on all the exit doors were tested and were confirmed to be working properly. Wanderguard was tested near the front door to ensure the front door was locked when the Wanderguard was near the door. The observation revealed that the front door was locked and alarm activated. The alarm was deactivated with a code. Staff were interviewed to verified education on the Code purple (Missing resident) and procedure to follow when the missing resident code was announced.

Based on observations, record review, staff interviews, law enforcement officer interview, and the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the 2/03/17 recertification survey to correct a deficiency in the area of accidents (F323), which was subsequently recited on 9/14/17 on this complaint investigation. The continued failure of the facility during two federal surveys of record show a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance program. Immediate Jeopardy began on 7/25/17 when Resident #1 exited the facility unsupervised and was found outside, after an undetermined amount of time, by a law enforcement officer on the sidewalk at a convenience store behind the facility. The Immediate Jeopardy was removed on 9/14/17 when the facility's acceptable credible allegation of compliance was verified. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place and completion of employee training. The Findings Included: This tag is cross referenced to F 323 - Based on observations, record review, staff interviews, and law enforcement officer interview, the facility failed to provide supervision to prevent the elopement from the facility for 1 of 5 moderately cognitively impaired residents reviewed for accidents (Resident # 1). On 7/25/17 Resident # 1, unsupervised by staff, exited the facility by wheelchair and traveled approximately 440 feet (146 yards) to a convenience store behind the facility on a sidewalk. Resident #1 was located by a law enforcement officer and was returned to the facility with no injuries after an undetermined amount of time outside of the facility. During the recertification survey of 2/03/17, the facility was cited at F323 for failure to maintain a safe environment by allowing one sampled resident using oxygen via portal tank adjacent to another resident who was actively smoking. On the current complaint survey of 9/14/17 the facility was cited at F323 for failure to provide supervision to prevent elopement from the facility of a moderately cognitively impaired reviewed for accidents. An interview with the Administrator on 9/14/17 at 7:45 PM revealed the facility had a Quality Assurance and Performance Improvement (QAPI) program in place. Administrator indicated that the QAA committee consisted of himself, Director of Nursing, Minimum Data Set coordinator, Medical Director, Business Office Manager, Dietary Manager, All Department heads and the Admissions Coordinator. He indicated that team met during daily stand up meeting, monthly reviews and quarterly assessment. He indicated that the team discussed on-going issues, has an audit program, tracked and trended the problem and planned training and education process based on the trends. The Administrator, DON, corporate personnel were notified of Immediate Jeopardy on 9/13/17 at 4:28 PM. On 9/14/17 at 4:42 PM the facility provided the following credible allegation of compliance: The facility Quality Assessment and Assurance committee met on September 13, 2017 and implemented an internal plan of correction due to concerns identified through the complaint process and QA identification. On 9/13/2017 facility was notified that areas of concern would be cited as an Immediate Jeopardy. On July 25, 2017, Resident # 1 exited the facility at approximately between the hours of 8pm and 8:21pm. The resident was last seen at approximately 8pm when he was offered a shower and refused and was seen sitting at nursing station. At approximately between 8pm and 8:21pm, according to staff statements, they started looking for resident. When search was initiated Resident # 1 was returned to center by a law enforcement officer. The resident returned to his room and was reevaluated and a head to toe skin assessment was completed and care plan was updated on 7/26/2017. Resident #1 did not have any injuries upon assessment which is documented in the progress notes on 7/25/2017. Investigation was initiated on 7/26/2017 and an internal plan of correction was developed on 7/26/2017 proactively to ensure wanderguard monitoring and door alarm system function and monitoring was in continued compliance. This included like residents that are at risk for elopement was in place and in compliance. During the investigation the root cause was identified as the resident exhibited a change in condition on the day of the event that he exited the facility. The facility could not identify which door Resident # 1 exited, however it was determined, based on staff interviews conducted on 7/26/2017, that no alarm was heard or silenced. Maintenance director checked all doors on 7/27/2017 and found none disarmed and all were working properly. Furthermore, the maintenance director went to each door to check system and found wanderguard system had no malfunction identified and was in working order. Current doors alarm and release after 15 seconds of constant pressure as per Life Safety guidelines. Investigation found no issues in this area and doors and alarms were functioning correctly requiring no outside intervention. Resident #1's care plan was updated to prevent reoccurrence. The facility's internal proactive plan of correction did not address like residents as this was considered isolated and not a systemic failure. The facility has routine quality assurance meetings which include the Administrator, Director of Nursing, Medical Director and Department Heads. The facility quality assurance committee met on 7/26/2017 related to Resident #1 and developed an internal plan of correction. However a plan of correction has been updated to include the following to address our quality assurance process which will include additional monitoring by non-facility personnel to facilitate continuous quality improvement and give guidance to try to prevent adverse incidents. Immediate Corrective Action An Adhoc meeting will be held on 9/14/2017 which will include the Administrator, Director of Nursing, Activities, Therapy, Maintenance, and housekeeping to discuss additional plan of correction for our quality assurance program The Administrator will notify the Medical Director on 9/14/2017 on new area of concern and plan of correction to address quality assurance process The Department heads and quality assurance consultant will inservice all staff on all shifts on the quality assurance process and how to bring any concerns to the committee for review and consideration Inservices started on 9/14/2017 and will continue until all staff is inserviced. This will be accomplished by staff that has not been educated will be educated before they start their shift ongoing until completed. An employee roster list was established and as people complete their inservicing they are highlighted off so facility has a clear system to manage completion of training. New hires will be inserviced as part of their orientation process. The Quality assurance consultant ( assigned by corporate), Regional Director of Operations and or Senior Administrator will conduct monthly random audits weekly for 4 weeks and then monthly for 6 months to validate compliance with the Quality Assurance program which will include review of facility's self-identification, documentation and internal plan of corrections. Data collected by audits will be taken to QA for further review and recommendation. The Administrator is responsible for attaining and maintaining compliance, and will do this by submitting findings of audits and validation to the Quality Assurance Committee for further review and recommendations as needed, monthly times 6 months and as indicated thereafter. The credible allegation was validated on 9/14/17 at 8:00 PM. The survey team confirmed through interviews with the Administrator and all department heads for the QAPI program. Administrator indicated that the Medical director was informed of F520. Administrator stated that the Quality assurance consultant (assigned by corporate), Regional Director of Operations and or Senior Administrator will conduct random audits weekly for 4 weeks and then monthly for 6 months to validate compliance with Quality Assurance (QA) program. The survey team also validated the credible allegation for F323 with confirmation of the completion of wandering assessments for all resident with a potential for elopement. The MDS and care plans were verified for updates for residents with potential for elopement. The updated missing resident wandering/elopement notebook was verified. The survey team also verified the Treatment Administration Record (TAR) for monitoring of placement and functionality of Wanderguard on every shift daily for residents with Wanderguard. Resident #1 had a medical procedure and was not in the facility at the time of verification to determine if the Wanderguard was in place, however other residents with Wanderguards were observed and their Wanderguards were in place and functioning. The alarms on all the exit doors were tested and were confirmed to be working properly. Wanderguard was tested near the front door to ensure the front door was locked when the Wanderguard was near the door. The observation revealed that the front door was locked and alarm activated. The alarm was deactivated with a code. Staff were interviewed to verify education on the Code purple (Missing resident) and procedure to follow when the missing resident code was announced.

Based on observations, record review, staff interviews, and resident interviews, the facility failed to maintain a safe environment by allowing one of one sampled residents (Resident #25) using oxygen via portable tank adjacent to residents who were actively smoking. Immediate jeopardy began on 2/1/17 and was removed on 2/3/17 at 8:00 AM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to supervision to prevent accidents. Findings include: The facility's Smoking Guidelines, revised November 2013, included: Smoking is not permitted while oxygen is in use. Posted signage clearly states that no concentrated oxygen sources are permitted in smoking areas. The signage was posted outside smoking area entrances and inside smoking areas. The facility had a sign posted on the pillar in the designated resident smoking area that read, No oxygen use while smoking. The facility had the following scheduled daily smoking times: 9:00 AM to 9:15 AM, 11:15 AM to 11:30 AM, 1:45 PM to 2:00 PM, 4:00 PM to 4:15 PM, 6:15 PM to 6:30 PM and 8:15 PM to 8:30 PM. Resident #25 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #25 was cognitively intact. Resident #25 was coded as requiring supervision with one person to assist for bed mobility, independent with no setup or physical help for transfer and locomotion on the unit, requiring supervision when off the unit for locomotion, independent with setup help for eating, and supervision with one person physical assistance for toileting. Resident #25 was coded for Respiratory Failure. Resident #25 was coded as having received oxygen therapy, suctioning, and tracheostomy care. A review of Resident #25's care plan, which was last reviewed on 12/3/16, revealed that Resident #25 had the following focus areas: Chronic tracheostomy placement related to acute upper airway obstruction, noncompliant with as needed oxygen orders, request to wear oxygen at all times related to mood disorder, anxiety, and depression, and at risk for respiratory impairment related to aspiration potential secondary to eating PO foods and tracheostomy placement. Review of Resident #25's physician orders [REDACTED]. On 2/1/17 at 11:15 AM, Resident #25 was observed using oxygen via a tube connected to a green oxygen cylinder, which was turned on, connected to the back of his wheelchair. As measured by the Administrator, Resident #25 was 5 and a half feet from one of three residents that were smoking in the smoking area adjacent to where Resident #25 was sitting. The Activity Assistant was observed supervising the residents that were smoking. There was a sign posted in the smoking area that read, No oxygen use while smoking. The Activity Assistant was made aware that Resident #25 was observed using oxygen via a tube connected to a green oxygen cylinder, which was turned on, connected to the back of his wheelchair. The Activity Assistant, who was supervising the smokers on 2/1/17 at 11:18 AM, stated that Resident #25 needed to go inside because he was on oxygen. On 2/1/17 at 11:30 AM, the Administrator was informed that Resident #25 was using oxygen via a tube connected to green oxygen cylinder, which was turned on, connected to the back of his wheelchair, while sitting outside near residents that were actively smoking. The Administrator stated that Resident #25 was five and a half feet away from the residents that were smoking and he felt that Resident #25 was at a safe distance from the residents that were smoking. An interview that was conducted with the Activity Assistant on 2/1/17 at 11:50 AM revealed that she was aware that Resident #25 was outside using oxygen near the residents that were smoking that morning. She stated that she did not move Resident #25 because she felt that he was in a safe zone. An interview conducted with the Floor Technician on 2/1/17 at 12:44 PM revealed that he supervised the 9:00 AM smoking time and Resident #25 was not out there at that time. The Floor Technician stated that he had not known the distance Resident #25 had to be from the smokers. The Floor Technician stated that he thought it was 5-10 feet because of the oxygen. The Floor Technician stated that he had not had any training about oxygen and smoking prior to supervising residents that smoke. An interview that was conducted with the Activities Director on 2/1/17 at 1:54 PM revealed that she knew there should be a certain number of feet between smoking and oxygen and said it would be 5-10 feet. The Activities Director said that Resident #25 had been outside some days when she was out there. The Activities Director further clarified that Resident #25 normally sat in the sun at the round table. He was beyond the column in the smoking area. The Activities Director stated that he was there throughout the day and that she would normally let him out of the facility's locked exit door. The Activities Director stated that she did not feel that it was a safe practice to have someone with oxygen out with residents who were smoking. An interview conducted with Resident #25 on 2/1/17 at 2:14 PM revealed that Resident #25 was sitting outside near the designated smoking area. Resident #25 was using oxygen via a tube connected to green oxygen cylinder, which was turned on, connected to the back of his wheelchair. When Resident #25 was asked where he sat when other residents were smoking, he pointed to a table that was approximately 8-10 feet away from the columns or the smoking area. Resident #25 stated that he usually sat there when other residents were smoking. Resident #25 stated that he always wore his oxygen when he came outside. Resident #25 stated that no one had talked to him about sitting anywhere else until 2/1/17. Resident #25 stated that he had been sitting close to the smoking area since about 2 years ago. Resident #25 stated that he didn't think about being on oxygen near the smokers. Resident #25 stated that he was told to stay in the area that was adjacent to the resident smoking area. Resident #25 stated that he liked being in the area adjacent to the smoking area better than being out at the front entrance. Resident #25 stated that residents that smoked did not come over near him and that they were supposed to stay under the covered area, inside the columns. Resident #25 stated that as long as he was at the table, which was outside of the covered area and columns, facility staff had not told him to move. An interview conducted with NA #4 on 2/1/17 at 3:17 PM revealed that she did supervise smoking at times. NA #4 stated that smoking times that she supervised were the 11:00 AM or 1:00 PM times, during the week and on weekends. When NA #4 was asked about the training she had received regarding safe smoking, she stated that she did what she was told, everyone had an apron, cigarettes were kept in a locker, some got one cigarette, some got two cigarettes, some could use lighters too, and some had to have their cigarettes lit. NA #4 stated that there were no residents that were on oxygen that smoked. NA #4 stated that Resident #25 needed to be at least 20 feet away from the smokers. NA #4 stated that every day the sun was out, Resident #4 was out there. NA #4 stated that they tried to keep the resident on the opposite side of the courtyard. When NA #4 was asked if Administration was aware that Resident #25 was noncompliant with requests to move, NA #4 responded that Administration was aware that the resident did not want to move at times. NA #4 did not allow residents to smoke near Resident #25 with oxygen. NA #4 stated that Resident #25 could go out any time that he wanted to. NA #4 was told by an administrative staff that he could go outside any time that he would like, even if other residents were smoking. An interview that was conducted with Resident #25 on 2/3/17 at 10:05 AM. The resident stated that he used oxygen mostly when he was out of bed in his wheelchair and was out of his room. Resident #25 further clarified that he used the concentrator when he was in room and the tank when he was out of his room. Resident #25 added that he had been using the smoking area to sit for years now, he used to sit up front but he was told to move. Resident #25 stated that he was not told to not sit in the smoking area when other residents were smoking until yesterday. Resident #25 stated that 3 people told him (on 2/1/17) about the smoking policy and not to sit in the smoking area and also was told to use the T hall outdoor area to sit at and that's ok. Resident #25 was able to put the nasal cannula on to himself. An observation of Resident #25's room on 2/3/17 at 10:10 AM revealed an oxygen concentrator at the bedside and an oxygen tank attached to his wheelchair. The tank and concentrator set were observed to be set at 2 liters per minute. An interview with Nurse #6 on 2/3/17 at 10:20 AM revealed that she was the nurse assigned to Resident #25 on 2/3/17. Nurse #6 stated that Resident #25 was alert and oriented, he was able to apply and remove oxygen by himself, and he used oxygen when he needed it, but mostly when he was out of room. Nurse #6 confirmed that the resident was on oxygen and the order was for two liters per minute. The Administrator and DON were informed of Immediate Jeopardy on 2/1/17 at 6:15 PM. On 2/3/17 at 8:00 AM, the facility provided the following Credible Allegation of Compliance: The facility Quality Assessment and Assurance committee met on February 1st 2017 to address designated smoking areas for residents to ensure safety. Removal of Immediacy Resident #25, a non-smoker, was removed from the smoking area immediately and educated on courtyard areas he can utilize while utilizing oxygen. The Director of Nursing provided education on 2/1/17 to resident #25 and this was documented in resident's medical record with the resident agreeable to sit outside in the courtyard areas that were non-smoking. The Administrator immediately educated the employee supervising the smoking area that no patient may be in the smoking area while utilizing oxygen. Like Residents Audit was completed on February 1, 2017 by Director of Nursing and Unit Managers to determine current residents who utilize oxygen, and results showed no other residents observed sitting in the smoking area. 18 of 18 Residents who utilize oxygen have been educated by the Director of Nursing, Unit Manager, Minimum Data Set Nurse, Social Worker, and/or Administrator on February 1, 2017 that they cannot use the smoking area as a sitting area, and in addition educated to courtyard areas they can utilize, such as the T-Hall Courtyard (that is off the Heritage unit next to room 115), the Front Entrance Porch, and the Therapy Courtyard (off the Therapy Gym). In addition the center provided the education in writing to like residents. Systemic changes: All full-time and part-time staff will be educated by their Department Supervisor starting on February 1, 2017 and completed on February 2, 2017 on the facility smoking guidelines which includes that oxygen is not permitted in smoking area and to assist residents to another courtyard where no smoking is allowed. The education sign in sheets will be filed in Human Resources. Any Full-Time or Part-Time staff not educated on 2/1/17 will be educated by the Department Supervisor on 2/2/17. New hires will be educated during orientation by Department Supervisor or Human Resource Director. The facility smoking guidelines specifically addresses that smoking is not allowed while oxygen is in use and direct the staff to intervene when they see a resident with oxygen in the smoking area and that the resident with oxygen has a designated area to sit in. The door code for the smoking area was changed on February 1, 2017 by the Maintenance Director, to ensure continued safety and security of all residents. Signage has been posted on the door leading to the smoking area that states oxygen not permitted in smoking area. New admissions with oxygen orders, as well as current residents that receive orders for oxygen will be educated by the Director of Nursing, Unit Manager, or Social Worker that they cannot use the smoking area as a sitting area and in addition educated to courtyard areas they can utilize, with education being documented in the patient record. In addition the Director of Nursing, Unit Manager, or Social Worker will provide the education in writing to new admissions with oxygen orders and current residents that receive orders for oxygen. -Administrator is responsible for attaining and maintaining compliance. The credible allegation was verified on 2/3/17 at 10:00 AM as evidenced by staff interviews on the facility smoking guidelines which included that oxygen was not permitted in the smoking area and the locations of areas that residents wearing oxygen can go outside. All staff interviewed (nursing and non-nursing staff, administrative staff) stated any resident observed in the smoking area would be removed and redirected to any of the other three areas available. Observations were conducted of the smoking area and there were no residents in the smoking area with oxygen. Verification of verbal and written instructions that had been given smoking residents and all residents who wore oxygen was verified. Verification of education for all staff regarding the facility smoking guidelines was done 2/1/17. There were eight staff members who had received messages at home and Administrative staff stated those would receive in-servicing prior to working their shift. An observation completed of the smoking area on 2/3/17 at 10:35 AM revealed 2 doors with a sign on each door reading, smoking area only, no oxygen beyond this point, see staff for questions In the designated smoking area there was a sign on a column under the covered area that read, no oxygen use while smoking. An observation of the dining room on 2/3/17 at 10:38 AM revealed the front desk receptionist was seated at the 2 doors that exit to the resident smoking area. She stated that she had been assigned to sit and monitor the doors to ensure that no residents with oxygen went out in the smoking area.

Based on observations, record review, resident interviews, and staff interviews, the administration failed to maintain a safe environment by allowing one of one sampled residents (Residents #25) to use oxygen via portable tank adjacent to residents who were actively smoking. The findings included: Immediate jeopardy began on 2/1/17 and was removed on 2/3/17 at 8:00 AM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to supervision to prevent accidents. The findings included: Cross Refer to F323: Based on observations, record review, staff interviews, and resident interviews, the facility failed to maintain a safe environment by allowing one of one sampled residents (Resident #25) who was using oxygen via portable tank adjacent to residents who were actively smoking. During an interview with the Regional Director of Operations (RDO) on 2/3/17 at 8:46 AM he stated that he expected no resident using oxygen in the smoking area at all. The Administrator and Director of Nursing (DON) were informed of Immediate Jeopardy on 2/1/17 at 6:15 PM. On 2/3/17 at 8:00 AM, the facility provided the following Credible Allegation of Compliance: The facility Quality Assessment and Assurance committee met on 2/1/17 to address designated smoking areas for residents to ensure safety. The Quality Assessment and Assurance committee meeting was run by the Quality Assurance Team with oversight from the Licensed Nursing Home Administrator. Removal of Immediacy Resident #25, a non-smoker, was removed from the smoking area immediately and educated on courtyard areas he can utilize while utilizing oxygen. The Director of Nursing provided education on 2/1/17 to resident #25 and this was documented in resident's medical record with the resident agreeable to sit outside in the courtyard areas that are non-smoking. The Senior Administrator and Quality Assurance Consultant educated the Licensed Administrator on 2/1/17 on the facility smoking guidelines which includes that oxygen is not permitted in smoking area. Like Residents Audit was completed on 2/1/17 by Director of Nursing and Unit Managers to determine current residents who utilize oxygen, and results showed no other residents observed sitting in the smoking area. 18 of 18 Residents who utilize oxygen have been educated by the Director of Nursing, Unit Manager, Minimum Data Set Nurse, Social Worker, and/or Administrator on 2/1/17 that they cannot use the smoking area as a sitting area, and in addition educated to courtyard areas they can utilize, such as the T-Hall Courtyard (that is off the Heritage unit next to room [ROOM NUMBER]), the Front Entrance Porch, and the Therapy Courtyard (off the Therapy Gym). In addition the center provided the education in writing to like residents. Systemic changes: The Administrator with Interdisciplinary Team (Nursing Management, Therapy Representative, Activity Director, Social Services) will review smoking guidelines that includes the smoking evaluation has been completed, the resident is aware of the designated smoking area by interviewing the patient, there is no oxygen used in smoking area, smoking materials are secured by staff, staff supervises residents during smoking times, safety devices are available (i.e aprons, blankets, extinguisher, and ashtrays), review social service notes to show resident compliance, and validate care plans are in place by completing the Quality Assurance Performance Improvement Smoking tool weekly. Quality Assurance Consultant and Regional Director of Operations will validate compliance during monthly visits by reviewing the weekly Quality Assurance Performance Improvement Smoking tool and visually observe the courtyard areas for compliance. The Administrator will ensure that the Director of Nursing, Unit Manager, or Social Worker will provide the education in writing to new admissions with oxygen orders and current residents that receive orders for oxygen by reviewing the clinical record for documentation. The Administrator is responsible for attaining and maintaining compliance, and will do this by submitting findings and validation to the Quality Assurance Committee monthly. Quality Assurance Consultant and Regional Director of Operations will validate compliance during monthly visits. The credible allegation was verified on 2/3/17 at 10:00 AM as evidenced by staff interviews on the facility smoking guidelines which included that oxygen was not permitted in the smoking area and the locations of areas that residents wearing oxygen can go outside. All staff interviewed (nursing and non-nursing staff, administrative staff) stated any resident observed in the smoking area would be removed and redirected to any of the other three areas available. Observations were conducted of the smoking area and there were no residents in the smoking area with oxygen. Verification of verbal and written instructions that had been given smoking residents and all residents who wore oxygen was verified. Verification of education for all staff regarding the facility smoking guidelines was done 2/1/17. There were eight staff members who had received messages at home and Administrative staff stated those would receive in-servicing prior to working their shift. An observation completed of the smoking area on 2/3/17 at 10:35 AM revealed 2 doors with a sign on each door reading, smoking area only, no oxygen beyond this point, see staff for questions In the designated smoking area there was a sign on a column under the covered area that read, no oxygen use while smoking. An observation of the dining room on 2/3/17 at 10:38 AM revealed the front desk receptionist was seated at the 2 doors that exit to the resident smoking area. She stated that she had been assigned to sit and monitor the doors to ensure that no residents with oxygen went out in the smoking area. A review of the addendum to smoking guidelines revealed staff will intervene when they see a resident with oxygen in the smoking area. Staff will direct the resident with oxygen to an appropriate outside area. The smoking area is to be reviewed for anyone with oxygen prior to taking residents out to smoke. In the event someone is in the area with oxygen, resident smoking cannot start. The resident with oxygen should be offered a separate courtyard area. If a resident with oxygen attempts to come out during the resident smoking session they should be stopped and redirected to another courtyard area.