Every finding on record at The Healthcare Center at Buck Creek

Based on interviews, record review, and a review of the facility's policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, the facility failed to protect Resident Identifier (RI) #4 from being physically abused by RI #5. On 05/16/2024 Certified Nursing Assistant (CNA) #5 witnessed RI #5 slap RI #4 on the face in their room. This deficient practice affected RI #4 and RI #5, two of 19 residents sampled for abuse. Findings Include: A review of the facility's policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, with an effective date of January 2019, revealed: .Purpose: To prohibit and prevent abuse . Definitions: Abuse: The willful infliction of injury . resulting physical harm, pain, or mental anguish.Willful, as use in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 5. Identification . A resident to resident altercation will be reviewed as a potential situation of abuse. RI #4 was admitted to the facility on [DATE], readmitted on [DATE] and has diagnosis to include Unspecified Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. A review of RI #4's, most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/01/2024, documented a Brief Interview of Mental Status (BIMS) of 13 out of 15 which indicated RI #4's cognition was intact RI #5 was admitted to the facility on [DATE], readmitted on [DATE] and has diagnosis to include Vascular Dementia and Alzheimer's Disease. A review of RI #5's, most recent Quarterly MDS with an ARD of 02/21/2024 documented a BIMS of 7 out of 15 which indicated RI #5's cognition was moderately impaired. The Alabama Department of Public Health Online Incident Reporting System form, dated 05/16/2024 documented: . Incident Type . Abuse - Physical . Incident Detail . Name(s) of resident(s) involved: (RI #4 and RI #5) . Narrative summary of incident: Resident (RI #5) hit another resident (RI #4) . A review of the Investigation Template dated 05/23/2024 documented: . Description of the Allegation: On May 16, 2024 (RI #5) hit .another resident Investigation Summary: .body audit was performed on (RI #4) with no signs of injury. Based off interviews with the resident's roommate and staff physical abuse is substantiated. On 09/25/2024 at 1:54 PM an interview was conducted with CNA #5 who witnessed the incident on 05/16/2024 between RI #4 and RI #5. CNA #5 said, she was passing breakfast trays and entered RI #4's and RI #5's room. CNA #5 said she was removing RI #4's tray when RI #5 stood up from the bed and was unclothed. CNA #5 said she told RI #5 to wait, and she would take him/her to the restroom to get him/her cleaned up and dressed. CNA #5 said at that time RI #5 walked toward RI #4 and through the privacy curtain. CNA #5 said she responded by telling RI #5 she would take him/her to the restroom. CNA #5 said RI #5 responded by hitting her on the left side of her face. CNA #5 said she tried to move the privacy curtain back and RI #5 grabbed the curtain and slapped RI #4 across his/her face with his/her hand. CNA #5 said, the intensity of the hit was a five on a scale zero to ten. CNA #5 said she yelled for help and separated the residents. CNA #5 said CNA #8 was outside the door and she summoned LPN #7 for assistance. CNA #5 said, the incident was physical abuse. CNA #5 said, it was the resident's home, and it would not be a good feeling to be hit in your own home. CNA #5 further said this would make a reasonable person feel scared and upset. On 09/26/2024 at 2:30 PM an interview was conducted with LPN #7. During the interview, LPN #7 said she was at the nurses' desk when she heard CNA #5 call for help. LPN #7 said when she responded the residents were separated. LPN #7 said CNA #5 exited the room and CNA #8 entered the room to assist while she assessed both residents. LPN #7 said neither resident was injured. LPN #7 said RI #5 calmed down and was assisted to the nurses' station with CNA #8 for one-to-one observation. LPN #7 said the incident between RI #4 and RI #5 was resident to resident physical abuse. LPN #7 further said this would make a reasonable person feel scared, upset, and mad. On 09/25/2024 at 3:46 PM the Administrator (ADM) was asked about the alleged physical abuse on 05/16/2024 involving RI #4 and RI #5. The ADM said, RI #5 hit RI #4 and it was witnessed by a staff member. The ADM said, the incident was physical abuse. The ADM said, being slapped on the face would make a reasonable person upset in their home. F 600 was cited as a result of the investigation of complaint/report number #AL00047879. ************************************************************************** The facility took immediate actions to correct the non-compliance and prevent reoccurrence by: - On 05/16/2024 the residents were separated and assessed for injuries. No injuries noted. -On 05/16/2024 notifications were made to the residents' sponsor, the medical director, and local police department. - A report was made to the Alabama Department of Public Health (ADPH) on 05/16/2024. - Education for all staff, all departments was completed on 05/16/2024 on Abuse Education with a focus on resident to resident. - RI #5 immediately placed on one-on-one after incident on 05/16/2024. - RI #5 sent to Grandview Medical Center via EMS for Behavioral Disturbance on 05/16/2024. - 5-day investigation completed and submitted the results of the investigation to ADPH on 05/23/2024. - Root cause analysis completed 05/24/2024. - 4 Point Plan Created on 05/24/2024. - Began Weekly Audits (Weekly audit or embrace rounds to ensure any behaviors identified were discussed in clinical start up and plan of care updated to prevent resident to resident reoccurrence. Weekly for 4 weeks and monthly for 3 months until substantial compliance can be assured) started on 05/24/2024. - A QAPI meeting was held on 05/25/2024. Completed 05/25/2024. - Compliance has been met no further concerns identified. ************************************************************************** After review of documentation supporting the above corrective actions, including the facility's investigation file, in-service/education records, QAPI documentation, and staff interviews, the survey team verified the facility implemented corrective actions including ongoing monitoring from 05/16/2024 through 05/25/2024; thus, F 600 was cited at past non-compliance.

Based on record review, interview, the facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, and review of facility reported incidents (FRIs) information submitted to the Alabama Department of Public Health (ADPH) via the Online Incident Reporting System; the facility failed to submit their five-day investigative summary or results of their investigations for two of 18 FRIs concerning allegations of abuse, neglect, or misappropriation of resident property reviewed for timely reporting. This deficient practice affected Resident Identifier (RI) #6 and RI #22 two of 19 residents reviewed for abuse concerns. Findings Include: A review of a policy titled Abuse, Neglect, Misappropriation, Exploitation Policy with an effective date of January 2019. documented the following: .7. Reporting/Response .The results of all investigations must be reported to the Administrator, designee to the appropriate state agency, as required by state law, within five (5) working days of the alleged violation . RI #6 was readmitted to the facility on [DATE] with diagnoses to include Dementia. On 05/14/2024 the facility submitted an initial report of neglect to ADPH via the Online Incident Reporting System that alleged RI #6 had not received assistance with meals. On 05/22/2024 the facility submitted the printed initial report regarding the allegation, RI #6's face sheet, RI #6's care plan, Section C of RI #6's Minimum Data Set (MDS) assessment, and RI #6's order summary list to ADPH via the Online Incident Reporting System. The facility did not submit the results of their investigation. RI #22 was readmitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease. On 07/20/2024 the facility submitted an initial report of an allegation of sexual abuse to ADPH via Online Incident Reporting System that alleged a family member had their hands in RI #22's brief. On 07/29/2024 the facility submitted the printed initial report regarding the allegation, RI #22's face sheet, RI #22's care plan, Section C of RI #22's MDS assessment, and RI #22's order summary list to ADPH via the Online Incident Reporting System. The facility did not submit the results of their investigation. An interview was conducted with the Administrator on 09/27/2024 at 4:15 PM. The Administrator said that the investigation template included a summary and documented the investigation. She explained the form was scanned and submitted with the five-day reports to the State Agency. She said it was important to send the investigation template with the five-day report because it provided a summary of what was done during the investigation. When asked why the investigation template was not included in the five-day report concerning RI # 6 and RI #22, she stated she did not know. F 609 was cited as a result of the investigation of complaint/report numbers #AL00048672 and AL00048673.

Based on interviews, record review, review of a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, and review of information from the Alabama Department of Public Health (ADPH) Online Reporting System, the facility failed to protect the Resident Identifier (RI) #5's right to be free from verbal, mental, and physical abuse by a staff. On 04/25/2024 Certified Nursing Assistant (CNA) #9 observed Licensed Practical Nurse (LPN) #12 stand up and say she was going to go to RI #5's room and call his/her dead mother a bitch. On approximately 04/27/2024 or 04/28/2024 CNA #10 overheard LPN #12 on the phone during a break say she went in RI #5's room and called him/her an ugly bitch and called his/her dead mother an ugly bitch. On 04/26/2024 the Social Worker (SW) was informed by LPN #12 that RI #5 was wandering in other resident's room. The Social Worker started the process of having RI #5 moved to the secure/memory unit without informing RI #5 prior to the move. On 04/29/2024 RI #5 was moved to the secure/locked unit in the facility. The resident expressed he/she did not want to move and stated he/she felt LPN #12 had him/her moved because she did not like him/her. This failure affected RI #5, one of eight sampled residents reviewed for abuse prevention. This deficiency was cited as a result of the investigation of complaint/report number AL00047738. Findings Include: The ADPH Online Facility Report Incident dated 04/29/2024, identified . Incident Type .Abuse-Verbal .Incident Detail . CNA alleged the nurse (LPN #12) told the resident (RI #5) that his/her dead mother was a bitch . A review of the facility Abuse, Neglect, Misappropriation, Exploitation Policy, effective January 2019, revealed: Purpose: To prohibit and prevent abuse . Definitions: . Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . It includes verbal abuse .physical abuse, and mental abuse . Involuntary Seclusion: is defined as separation of a resident from other residents or from her/his room or confinement to her/his room (with or without roommates) against the resident's will . Mental Abuse: is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation . Physical Abuse: Includes, but is not limited to hitting, slapping, punching, biting and kicking . Verbal abuse: May be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability . RI #5 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia, without behavioral disturbance. A review of Resident #5's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/26/2024, revealed RI #5 had a Brief Interview for Mental Status (BIMS) score of 5 (five) of 15, which indicated the resident had severe cognitive impairment. A review of a progress note for RI #5 dated 04/26/2024 documented . alert and oriented . Resident has been redirected x3 attempts out of other residents' rooms. Resident's on the hallway has c/o (complained) to this writer (LPN #12) about being in their room while coughing. Resident has been wandering around the unit and is forgetful about where (his/her) room is as well as in the dining room asking where the dining room is . This was the only note in the RI #5's medical record that documented wandering behaviors. A review of a progress notes for RI #5 documented . 04/29/2024 . This resident was transferred from North Wing (he/she) is alert and oriented to person and place with some confusion noted . RI #5 was interviewed on 05/01/2024 at 5:30 PM. RI #5 said that LPN #12 had told him/her how ugly his/her mother was and had physically poked his/her shoulder with two fingers while saying this to him/her. RI #5 said this caused him/her to feel bad and he/she did not like what LPN #12 had said to him/her. RI #5 informed the surveyor that he/she was not supposed to be on the secured unit (Secure/Memory) and was only there because LPN #12 did not like him/her. RI #5 stated that LPN #12 had informed him/her that this unit would be a better fit, and he/she told LPN #12 they did not want to move. RI #5 said that LPN #12 had informed him/her that he/she had no choice in the matter. A second interview was conducted with RI #5 on 05/02/2024 at 12:46 PM. RI #5 said, LPN #12 had told him/her how ugly his/her mother was and had physically poked his/her shoulder with two fingers while saying this to him/her. RI #5 said this caused him/her to feel bad and he/she did not like what LPN #12 had said to him/her. RI #5 said this made him/her feel bad and she did not respond to the comment made by LPN #12. RI #5 said he/she was not doing good, because he/she did not belong on the secured unit. RI #5 stated LPN #12 had him/her moved because she (LPN #12) did not like him/her. RI #5 said he/she did not want to change rooms prior to being moved to the secure/locked unit. RI #5 further stated LPN #12 informed him/her of the move and said he/she had no choice. RI #5 said he/she missed his/her old room and his/her friends. On 05/02/2024 at 9:45 AM, an interview was conducted with CNA #9. According to CNA #9, on 04/25/2024, she observed RI #5 approach the nurse's desk where LPN #12 was sitting and inquired about the results of an x-ray. LPN #12 informed RI #5 that it was too early for the results as the x-ray technician had just left. CNA #9 stated that RI #5 then proceeded to call LPN #12 a bitch as he/she was walking away. After the resident walked away, CNA #9 said, LPN #12 stood up and said she would go to RI #5's room and call his/her dead mother a bitch. CNA #9 said, LPN #12 returned to her seat without going to RI #5's room or saying anything to RI #5. CNA #9 said she believed LPN #12 had RI #5 moved to the secure/memory unit related to the incident on 04/25/2024. On 05/02/2024 at 12:15 PM, an interview was conducted with CNA #10. According to CNA #10, on approximately 04/27/2024 or 04/28/2024, she overheard LPN #12 on the phone, during a break, saying she went to RI # 5's room and called him/her an ugly bitch and his/her dead mother an ugly bitch. CNA #10 said, she felt RI # 5 was moved to the secured unit because he/she made LPN #12 mad. When asked why she felt that way she explained it was based on what she heard LPN #12 say on the phone and it seemed likely to her that RI #5 had to move. CNA #10 stated she had never witnessed RI #5 wandering. CNA #10 said RI #5 questioned LPN #12 about the reason for the move and expressed she did not want to move. CNA #10 said, LPN #12 informed RI #5 he/she did not have a choice in the matter. On 05/03/2024 at 12:05 PM, a telephone interview was conducted with CNA #11. CNA #11 stated she had never observed RI #5 wandering, but rather observed RI #5 parking her wheelchair outside rooms and engaging in conversations with other residents who were friends. CNA #11 recalled that LPN #12 informed her that RI #5 would be moving, so she told RI #5 about the move. CNA #11 said RI #5 wanted to know the reason and initially refused to move. CNA #11 informed LPN #12 that RI #5 did not want to move but was told, by LPN #12, RI #5 did not have a choice in the matter. CNA #11 said LPN #12 walked RI #5 to the other (secured/memory) unit. On 05/02/2024 at 10:00 AM, an interview was conducted with the Social Worker (SW). The SW said that on 04/26/2024, LPN #12 informed her about RI #5's increased wandering in other residents' rooms. As a result, RI #5 was moved to the locked/secure unit. The SW said the process for RI #5's room change was she contacted RI #5's daughter, spoke with admissions, and confirmed the availability of a bed. The SW said the room change took place on 04/29/2024. The SW stated RI #5 had only one episode of wandering documented on 04/26/2024. The SW said that she did not have a conversation with RI #5 prior to the move. In addition, the SW said if the move was necessary, the resident would not be given a choice. On 05/02/2024 at 10:56 AM, an interview was conducted via telephone with LPN #12. LPN #12 said that during her shift on 04/29/2024, she received information from the Social Worker that RI #5 was approved to be moved to the locked unit. Upon informing RI #5 about the move, he/she became upset upon realizing it was to the locked unit and blamed LPN #12. LPN #12 explained to RI #5 that the administration believed the locked unit was a better fit, but RI #5 was dissatisfied with that response. According to LPN #12, RI #5 was transferred to the locked unit on 04/29/2024 and eventually calmed down. LPN #12 denied requesting the move of RI #5 to the locked unit. LPN #12 stated that on 04/26/2024, she informed the Social Worker about RI #5 wandering in the rooms of other residents. LPN #12 said RI #5 wandered into RI #6, RI #7, and RI #8's rooms. Upon review of RI #8's latest Quarterly MDS with ARD of 04/16/2024, RI #8's BIMS score was 11 out of 15, which indicated moderate impairment of cognition. An interview was conducted with RI #8 on 05/02/2024 at 5:15 PM. RI #8 confirmed he/she were friends with RI #5 and would see each other outside his/her room. RI #8 stated that RI #5 had never entered the room without permission to visit him/her. RI #8 also denied complaining about RI #5 wandering into his/her room. Upon review of RI #6's latest Significant Change MDS with ARD of 03/21/2024, it was found RI #6's BIMS score was 14 out of 15, which indicated that RI #6 was cognitively intact. An interview was conducted with RI #6 on 05/02/2024, at 5:20 PM. When asked if RI #6 knew RI #5, the response was yes, stating that they use to visit together. RI #6 was further questioned about RI #5 wandering into his/her room without permission, to which RI #6 replied that RI #5 would either come in to visit or sit outside the door to talk. RI #6 denied reporting to a nurse that RI #5 came in the room uninvited. Upon review of RI #7's latest Quarterly MDS with ARD of 02/29/2024, it was found RI #7's BIMS score was 11 out of 15, which indicated moderate impairment of cognition. An interview was conducted with RI #7 on 05/02/2024 at 5:25 PM. RI #7 confirmed remembering the RI #5 and said that RI #5 was a friend who had moved to a different hall. RI #7 stated that RI #5 had never wandered into his/her room without permission. Additionally, RI #7 denied reporting to a nurse about RI #5 entering the room without an invitation. On 05/02/2024 at 3:26PM, an interview was conducted with the Director of Nursing (DON). The DON said she became aware of an incident involving RI #5 and LPN #12 on 04/29/2024 when CNA #10 reported the incident. The DON explained that CNA #10 reported overhearing CNA #9 saying that LPN #12 had called RI #5's dead mother a bitch. The DON said after it was reported to her, she spoke with CNA #9, who shared that on 04/25/2024, she witnessed LPN #12 stand up and say she was going to RI #5's room and call his/her dead mother a bitch. The DON then interviewed RI #5, who she believed was interviewable. According to the DON, RI #5 said LPN #12 came in the room, saw a picture of his/her mother and told him/her she was ugly while poking his/her shoulder with two fingers. RI #5 also described LPN #12 as evil and sneaky, without providing further details. On 05/02/2024 at 6:19 PM, an interview was conducted with the Administrator/abuse coordinator. The Administrator said on 04/29/2024 when RI #5 was moved to the secure/memory unit she was on vacation. The Administrator stated that the move occurred due to the resident wandering in and out of rooms, and increased confusion. The Administrator said that it was normal to communicate with the resident before the move, if possible. If the resident expressed a desire not to move, questions should be asked to understand the reason behind for not wanting to move. The Administrator said she was not sure why someone had not spoken with RI #5 before the move. The Administrator also said, the consequences of not communicating with a resident prior to a move, would result in confusion, a lack of understanding regarding the move, and difficulties in adjusting to a new environment. The administrator said abuse should be reported immediately when it was received, heard, or witnessed. In addition, the administrator said the incident involving RI #5 and LPN #12, should have been first reported on 04/25/2024 when CNA #9 overheard LPN #12 saying she was going to go to RI #5's room and call his/her dead mother a bitch. The administrator said abuse should be reported immediately so an investigation could be started and for the protection of the residents from abuse.

Based on interviews, record review, review of a facility policy titled, Abuse, Neglect and Misappropriation, Exploitation Policy, and review of information from the Alabama Department of Public Health's (ADPH) Online Reporting System, the facility failed to ensure Resident Identifier (RI) #1 was free from misappropriation of funds from his/her personal funds. On 04/13/2024 the facility administrator was informed by the Business Office Manager (BOM) that she had been arrested for elder abuse. According to information received from local law enforcement detective the BOM used RI# 1's personal bank account information to pay her personal credit card in the amount greater than $16,000. The survey team applied the Reasonable Person Concept to determine the severity of psychosocial harm rose to the level of actual harm that was not immediate jeopardy. This deficient practice affected RI #1, one of eight sampled residents reviewed for abuse. This deficiency was cited as a result of the investigation of complaint/report number's and AL00047554. Findings Include: The ADPH Online Facility Report Incident dated 09/11/2023, identified . Incident Type .Misappropriation of Resident Property .The ADPH Incident Detail . Narrative summary of Incident: (RI #1's) daughter alleged the Business Office Manger stole $30,000 from (RI #1) . The ADPH Online Facility Report Incident dated 04/13/2024, identified . Incident Type .Abuse-Exploitation .The ADPH Incident Detail . Narrative summary of Incident: The Business Office Manger informed the Administrator on 04/13/2024 that she was arrested for Elder Abuse on 04/12/2024 . A review of the facility Abuse, Neglect, Misappropriation, Exploitation Policy, effective January 2019, revealed: Purpose: To prohibit and prevent abuse . Definitions: . Misappropriation of Resident Property: The deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the residents consent . The facility's job description, titled Position Description for Business Office Manager documented: .Accountability Objective: To perform and/or oversee the successful and timely completion of all business office functions . within the parameters established by state and federal regulation . Support an environment that promotes optimal efficiencies . and superior quality of business office employees . A review of a document provided by the facility for the BOM titled WORKSITE EMPLOYEE WARNING NOTICE documented: .Breach of Company Policy . Business office Manager (BOM) will allow the resident's to sign their own checks. If a resident is unable to sign a check then the facility will contact the family to assist with making financial arrangements. Any additional violation will result in termination . 10/26/23 .(dated) RI # 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Major Depressive Disorder and Cognitive Communication Deficit. A review of Resident #1's Significant Change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/29/2023, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13 of 15, indicating the resident had moderately cognitive intact. A review of RI #1's available Bank Statements for the month of June 2023 and August 2023 revealed mobile payments to Capital One in the amounts of $1725.99 on 06/22/2023, $640.81 on 08/02/2023, $1669.83 on 08/11/2023 and $1621.16 on 08/22/2023. A review of the Capital One statement's, obtained from the local detective, from June 2023 and August 2023 identified the BOM as an account holder. The statements identified payments made in the amounts of $1725.99 on 06/21/2023, $640.81 on 08/01/2023, $1669.83 on 08/10/2023, and $1621.16 on 08/21/2023 was applied to the BOM's Capital One credit card account. On 04/30/2024 at 3:00PM, an interview was conducted with RI # 1, who said that he/she did not have a Capital One credit card and had never set up payment through his/her bank account to pay a Capital One. On 04/30/2024 at 4:33PM, an interview was conducted with The Administrator (ADM). The ADM stated that the BOM had various responsibilities, including managing the finances for residents, handling insurance billing, collecting liability payments, and overseeing the resident trust account. The ADM said that RI #1 was a private pay resident who managed his/her own bank account. The ADM said that RI #1 had requested the former BOM's assistance in paying the monthly room and board, as well as the pharmacy bill. The ADM said, the former BOM kept RI #1's checkbook in the business office and would take it to RI #1's room, and help write out the check for payment. The ADM said, the BOM's job description would allow her to assist residents if the resident requested assistance. However, the ADM said it was not typical for the BOM to sign a check on behalf of residents. The ADM stated she investigated an allegation of misappropriation involving RI #1 and the former business office manager in September of 2023. The ADM said that in April of 2024, the BOM called her and reported she had been arrested for elder abuse. On 05/03/2024 at 3:15 PM, a second interview was conducted with the Administrator/Abuse Coordinator. During the interview, the Administrator said that she supervised the business office, which included the business office manager and receptionist. She explained that she provided daily supervision of the business office, and monthly audits were carried out by the corporate office. The Administrator said that she became aware in September 2023 during an investigation into the misappropriation of RI #1's funds that RI #1 's checkbook was kept in the business office by the BOM. The administrator stated the BOM could have contacted the family to assist with paying RI #1's monthly bills. An interview was conducted with the Regional Business Office Consultant (RBOC) on 05/01/2024 at 12:00PM. The RBOC said that she conducted an audit which involved reviewing all private pay transactions, payment postings, and examining the accounts of all residents who had funds with the facility. The audit results showed no misappropriation of funds. The RBOC said it was not acceptable for the BOM to sign checks for residents. She said that during the investigation in September, it was discovered that the former BOM had signed at least one check payable to the facility for room and board. The RBOC stated that the former BOM was reprimanded and received training when this issue came to light during the September 2023 investigation. The RBOC stated that she provided monthly supervision to the business office to ensure proper cash balancing and to address any concerns that may have occurred. She also stated that she had no knowledge of the former BOM using RI #1's personal funds to pay her personal credit cards. An interview was conducted with the facility's [NAME] President of Revenue Cycle (VPRC) on 05/01/2024 at 12:23 PM. The VPRC said that she conducted an audit of all private pay residents, checks that had been scanned, the resident trust fund, and RI #1's account. The VPRC confirmed that no missing funds were discovered during the audit. It was revealed in the audit that the former BOM had signed and written out checks for RI #1 for room and board payments in June, July, August, and September of 2023. The VPRC said following the investigation, the former BOM received in-service training and was issued a write up before returning to work. The VPRC stated she had no knowledge of the BOM using RI #1's personal funds to pay her personal credit card. On 05/08/2024 at 10:30AM, a local detective was interviewed regarding the misappropriation of funds linked to RI #1. The detective revealed that the Former BOM at the facility utilized RI #1's banking details to pay her personal credit card bill from June 2023 through September 2023. The cumulative amount of these payments equaled $16,705.00. He said, a payment of $1725.99 was made on 06/22/2023, payment of $640.81 was made on 08/02/2023, $1669.83 was made on 08/11/2023, and a payment of $1621.16 was made on 08/22/2023 to settle credit card payments for the BOM. The detective stated the BOM was arrested on 04/12/2024 for elder abuse (Misappropriation of resident's Property). On 05/17/2024 at 2:00 PM the Director of Nursing was interviewed via phone. The DON said it would be upsetting to a reasonable person, in a similar situation as RI #1 who had over 15 thousand of dollars misappropriated from her checking account by a staff member he/she entrusted with her checkbook and who aided writing checks.

Based on interviews, record review and facility policies titled Room & Roommate Change Policy, the facility failed to notify Resident Identifier (RI) #5 of a room change prior to the move. This affected Resident Identifier (RI) #5, one of one resident who expressed dissatisfaction with their room change. This deficiency was cited as a result of the investigation of complaint/report number AL00047738. Findings include: A review of an undated facility's policy titled Room and Roommate Change Policy documented: .PROCEDURE .The Resident has the right to refuse to transfer to another room in the Center if the purpose of the transfer is . c. Solely for the convenience of staff . RI #5 was admitted to the facility on [DATE], with diagnoses to include Unspecified Dementia. A review of a progress note for RI # 5 documented . 04/29/2024 . This resident was transferred from North wing (he/she) was alert and oriented to person and place with some confusion noted . On 05/01/2024 at 5:30 PM, an interview was conducted with RI #5. During the interview, RI #5 informed the surveyor that he/she was not supposed to be on that unit (secure/memory) and was only there because Licensed Practical Nurse (LPN) #12 did not like him/her. RI #5 said that LPN #12 had informed him/her that this unit (secure/memory) would be a better fit, and he/she told LPN #12 he/she did not want to move. RI #5 said that LPN #12 informed him/her that he/she had no choice in the matter. A second interview was conducted with RI #5 on 05/02/2024 at 12:46 PM. RI #5 said he/she did not belong on this unit (secure/memory), and LPN #12 had him/her moved because she did not like him/her. RI #5 said he/she did not want to change rooms. RI #5 further stated LPN #12 informed him/her of the move and no one else had spoken to him/her about the move. RI #5 said LPN #12 said he/she did not have a choice in the move. RI #5 said he/she missed his/her old room and his/her friends on the old unit (North wing). On 05/02/2024 at 10:00 AM, an interview was conducted with the Social Worker (SW). The SW said that on 04/26/2024, LPN #12 informed her about RI #5's increased wandering in other residents' rooms. As a result, RI #5 was moved to the locked/secure unit. The SW said the process for RI #5's room change was she contacted RI #5's daughter, spoke with admissions, and confirmed the availability of a bed. The SW said the room change took place on 04/29/2024. The SW stated RI #5 had only one episode of wandering documented on 04/26/2024. The SW said that she did not have a conversation with RI #5 prior to the move. In addition, the SW said if the move was necessary, the resident would not be given a choice. On 05/02/2024 at 6:19 PM, an interview was conducted with the Administrator/abuse coordinator. The Administrator said on 04/29/2024 when RI #5 was moved to the secure/memory unit she was on vacation. The Administrator stated that the move occurred due to the resident wandering in and out of rooms, and increased confusion. The Administrator said that it was normal to communicate with the resident before the move, if possible. If the resident expressed a desire not to move, questions should be asked to understand the reason behind not wanting to move. The Administrator said she was not sure why someone had not spoken with RI #5 before the move. The Administrator said the consequences of not communicating with a resident prior to a move, would result in confusion, a lack of understanding regarding the move, and difficulties in adjusting to a new environment.

Based on record reviews, interviews, and a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, and review of information from the Alabama Department of Public health's (ADPH) Online Reporting System, the facility failed to ensure staff implemented the facility's abuse policies and procedures when: staff failed to identify an allegation of abuse, protect residents from further potential abuse, and immediately report an allegation of verbal abuse on [DATE] involving Resident Identifier (RI) #5 and Licensed Practical Nurse (LPN) #12. Certified Nursing Assistant (CNA) #9, and CNA #10 became aware of the allegation, but did not report the incident for three days following the incident. On [DATE] Certified Nursing Assistant (CNA) #9 observed LPN #12 stand up and say she was going to go to RI #5's room and call his/her dead mother a bitch and she did not report the incident as LPN did not take any action only making a verbal threat. On either [DATE] or [DATE] CNA #10 overheard LPN #12 on the phone during a break say she went in RI #5's room and called him/her an ugly bitch and called his/her dead mother an ugly bitch. CNA #9 and CNA #10 did not identify the incident as abuse or suspected abuse, did not protect RI #5 from potential verbal abuse, and did not immediately report the incident. Due to the staff's failure LPN #12 continued to work on the hallway with RI #5 posing the likelihood of further harm. This failure affected RI #5; one of eight sampled residents reviewed for abuse prevention. This deficiency was cited as a result of the investigation of complaint/report number AL00047738. Findings Include: A review of the facility Abuse, Neglect, Misappropriation, Exploitation Policy, effective [DATE], revealed Purpose: To prohibit and prevent abuse . and to ensure reporting and investigation of alleged violations . Definitions: . Alleged Violation: A situation or occurrence that is observed or reported by team member . but has not yet been investigated . The following protocol has been established in the event of an allegation of abuse: 1. Protection First and foremost the resident/patient will be immediately assessed and removed from any potential harm. Examine the resident . for any sign of injury, including a physical assessment or psychosocial assessment . 4. Prevention. Establish a safe environment: Team members are required to report incidents of suspected abuse, neglect, or misappropriation of property without fear of reprisal . 5. Identification If actual violation or alleged violation occurs the resident will be immediately assessed and removed from any potential harm . 7. Reporting/Response Alleged violations/violations will be reported to the Administrator, designee immediately . RI #5 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia, without Behavioral Disturbance and Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. A review of Resident #5's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 5 (five) of 15, which indicated the resident had severe cognitive impairment. On [DATE] at 9:45AM, an interview was conducted with CNA #9. According to CNA #9, on [DATE], she observed RI #5 approach the nurses' desk where LPN #12 was sitting and inquired about the results of an x-ray. CNA #9 said, LPN #12 informed RI #5 that it was too early for the results as the x-ray technician had just left. CNA #9 said as RI #5 was walking away he/she called LPN #12 a bitch. CNA #9 said she witnessed LPN #12 stand up and say she would go to RI #5's room and call his/her dead mother a bitch. CNA #9 said she did not report what she heard because she believed that LPN #12 only made a threat and she did not witness anything being done. On [DATE] at 12:15 PM, an interview was conducted with CNA #10. According to CNA #10, on approximately [DATE] or [DATE], she overheard LPN #12 on the phone, during a break, say she went to RI # 5's room and called him/her an ugly bitch and his/her dead mother an ugly bitch. CNA #10 said she did not do anything because she thought it was not true and she did not see LPN #12 do anything to RI #5. CNA #10 said that when she returned to work on [DATE] she overheard CNA #9 talking about the incident and she then reported the incident to the Director of Nursing. On [DATE] at 3:26 PM, an interview was conducted with the Director of Nursing (DON). The DON said she became aware of an incident involving RI #5 and LPN #12 on [DATE] when CNA #10 reported the concern. After receiving the information an investigation was started. The DON said LPN #12, who had already left for day, was informed she would be on suspension. The DON said that CNA #9 should have reported the incident when she first heard the threat on [DATE]. On [DATE] at 6:19 PM, an interview was conducted with the Administrator/abuse coordinator. The Administrator said abuse should be reported immediately when it was received, heard, or witnessed. The Administrator said the abuse witnessed by CNA #9 should have been reported on [DATE] when CNA #9 overheard LPN #12 say she was going to go to RI # 5's room and call her deceased mother a bitch. The Administrator said abuse should be reported immediately so an investigation could be started and for the protection of the residents.

Based on an interview, review of facility personnel files, review of a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, the facility failed to ensure Certified Nursing Assistant (CNA) #6 and CNA #7 had initial Alabama Certified Nurse Aide Registry and criminal background checks completed before being hired by the facility. This deficient practice affected CNA #6 and CNA #7, two of six CNAs whose personnel files were reviewed. Findings include: Review of a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, with an effective date of 1/2019, revealed the following: Purpose: To prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property . 2. Screening Each center will follow any and all state specific requirements Potential team members shall, at a minimum, have the following screening checks conducted: . 2. Appropriate licensing board or registry check . 4. Criminal background check pursuant to company policy or state law . A review of personnel files for CNAs revealed CNA #6 was hired on 11/29/2022 and CNA #7 was hired on 11/02/2020, but neither of them had an initial CNA registry check or criminal background check done prior to working at the facility. A review of CNA #7's personnel file revealed CNA #7 was hired on 11/02/2020, but there was no initial CNA registry check or criminal background check done on CNA #7 before the CNA began work at the facility. On 01/25/2024 at 4:50 PM, the surveyor conducted an interview with the Human Resource Director (HRD). When asked who was responsible for checking the CNAs against their licensing registry, the HRD said the staff that was part of the initial interview process. The HRD said looking at the personnel files for CNA #6 and CNA #7 they did not have an initial registry check but they should have. The HRD also said the facility did criminal back ground checks and they should be completed before the employee worked the first day. The HRD said criminal back ground checks were mandatory.

Based on interviews, review of the facility's RECORD OF MEDICATION DISPOSAL sheets for the Non-Controlled Drugs, and review of a facility policy titled, RULES OF ALABAMA STATE BOARD OF HEALTH ALABAMA DEPARTMENT OF PUBLIC HEALTH CHAPTER 420-5-10 NURSING FACILITIES, the facility failed to ensure the required signatures were on the non-controlled medication destruction sheets. This deficient practice affected one of 12 months of non-controlled medication destruction sheets reviewed for 2023. Findings include: Review of an undated facility policy titled, RULES OF ALABAMA STATE BOARD OF HEALTH ALABAMA DEPARTMENT OF PUBLIC HEALTH CHAPTER 420-5-10 NURSING FACILITIES, revealed the following: 1. The nursing facility develops policies and procedures for the destruction of drugs and biologicals. 7. The pharmacist will verify that the list of drugs to be destroyed is accurate and with a Registered Nurse, will carry out destruction. 22 of 22 RECORD OF MEDICATION DISPOSAL forms reviewed for January 2023, marked for Non-Controlled Drugs disposal, contained only the Pharmacist's signature. On 01/25/2024 at 7:11 PM, the Director of Nursing (DON) verified the RECORD OF MEDICATION DISPOSAL sheets for the Non-Controlled Drugs had only one signature on 22 of the 22 sheets. The DON was asked how many signatures were required for non-controlled medications. The DON said, there should be two signatures to validate that destruction occurred. On 01/25/2024 at 7:22 PM, a telephone interview was conducted with the pharmacist. When asked how many signatures were needed on the non-controlled RECORD OF MEDICATION DISPOSAL sheets, the pharmacist said there were supposed to be two signatures.

Based on observations and an interview, the facility failed to ensure the DAILY ASSOCIATE POSTING form contained the name of the facility, the Resident Census at Start of Shift and the date for each shift. This was observed on 01/23/2024, one of four days of the survey, and had the potential to affect all 162 residents residing in the facility. Findings include: On 01/23/2024 at 9:15 AM, the surveyor observed the DAILY ASSOCIATE POSTING form in the front lobby. There was no facility name or Resident Census at Start of Shift for the 7:00 AM - 3:00 PM shift. On 01/23/2024 at 5:44 PM, the surveyor observed the DAILY ASSOCIATE POSTING form. There was no date or the Resident Census at Start of Shift for the 3:00 PM - 11:00 PM shift. On 01/25/2024 at 7:44 PM, the surveyor conducted an interview with the Workforce Management Coordinator (WMC). When asked what information should be on the DAILY ASSOCIATE POSTING form, the WMC said, the number of staff in the building and the census. WMC said, the name of the facility should also be on the form. The WMC said, when looking at the DAILY ASSOCIATE POSTING form, dated 01/23/2024, for the 7 AM - 3 PM shift, the census and the name of the facility was not on the form. The WMC said, looking at the DAILY ASSOCIATE POSTING form for the 3 PM -11 PM and the 11 PM - 7 AM shift, the date and the census was not on the form. The WMC said, she would be responsible for ensuring the the form was filled out with the correct information. When asked why it would be important to ensure the form was filled out completely, the WMC said, to ensure it was known how many staff and residents were in the building.

Based on interviews, record reviews and a review of a facility policy titled, Pain Assessment and Management, the facility failed to ensure Resident Identifier (RI) #11, a resident with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one of three residents sampled for pain concerns. Findings Include: A facility policy titled, Pain Assessment and Management, with an effective date of 05/2021, documented, . The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Implementing Pain Management Strategies: . 6. Implement the medication regimen as ordered, carefully documenting the results of the interventions. RI #11 was admitted to the facility on [DATE] and readmitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/14/2022 at 10:00 AM, RI #11 stopped the surveyor in the hallway and reported that he/she missed a dose of [MEDICATION(S)] on Wednesday night, 10/12/2022. The resident reported this never happened before. October 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #11's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/5/2022 indicated Pain Frequency as Occasionally and Pain Frequency as six out of 10. A review of RI #11's care plan revealed, . on pain medication therapy r/t (related/to) disease process CP ([CONDITION(S)]), chronic pain, dysphagia, [CONDITION(S)] . Administer medications as ordered by physician . A review of RI #11's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress Notes for RI #11 documented on 10/13/2022 at 6:56 AM by EI #3 revealed, . Pharmacy gave authorization number to pull from Omnicell back up. When charge nurse went to omnicell to pull the medication is not stocked in omnicell. Progress Notes for RI #11 documented on 10/13/2022 at 7:49 AM by EI #3 revealed, . DON and ADON (Director of Nursing and Assistant Director of Nursing) notified. MD called and gave order for Tylenol 650 mg now and it was given to resident. Resident offered [MEDICATION(S)], Volterm gel, laying down with calm music in dim lit room, and warm and cold treatments. Resident refused all but the Tylenol. Progress Notes for RI #11 documented on 10/13/2022 at 8:45 AM by EI #3 revealed, . [MEDICATION(S)] arrived from pharmacy and now dose is given for 6am that was not given. A review of a delivery receipt from Omnicare of Prattville indicated the facility received three orders of 30 [MEDICATION(S)] Sulfate 15 mg tablets (total 90 tablets) on 10/13/2022 for RI #11. In a follow-up interview on 10/14/2022 at 3:00 PM, RI #11 reported staff gave him/her Tylenol when he/she missed the [MEDICATION(S)] dose. The resident stated the Tylenol helped with the pain but not like the [MEDICATION(S)]. The resident reported he/she also took [MEDICATION(S)] for pain. The resident reported he/she had a hard time sleeping because he/she didn't have the [MEDICATION(S)] but was able to go to sleep. RI #11 reported staff offered a [MEDICATION(S)], voltern gel, calm music and warm and cold treatments. RI #11 stated he/she refused them because they do not work but he/she took the Tylenol but it did not provide the same relief as the [MEDICATION(S)]. In an interview on 10/14/2022 at 4:25 PM EI #3, LPN, reported she was notified 10/12/2022 at 10:56 PM that RI #11 did not have [MEDICATION(S)]. The resident had reported that he/she brought two prescriptions from the pain clinic in August. The nurse had attempted to use a code from pharmacy for the omnicell in the building but [MEDICATION(S)] was not in the machine because the machine did not stock [MEDICATION(S)]. EI #3 stated she called the doctor who instructed them to give RI #11 Tylenol 650 mg and offer alternative pain relief until [MEDICATION(S)] arrived. RI #11 was offered Tylenol, [MEDICATION(S)], voltern gel, calm music and warm and cold treatments. The resident accepted Tylenol and refused all other alternatives because he/she preferred the [MEDICATION(S)]. EI #3 stated when she observed the resident on Thursday morning, the resident did not appear to be in pain but he/she was emotional, which was not out of character, and upset because the [MEDICATION(S)] had not been delivered. EI #3 stated the [MEDICATION(S)] should not have run out. EI #3 stated she called the pharmacy on Wednesday after she did an audit. EI #3 stated the [MEDICATION(S)] should have been ordered a day or two sooner. EI #3 stated she completed audits on medications on Mondays, Wednesdays and Fridays. EI #3 stated she should have noticed on Monday that it needed to be reordered and it would not have been missed if ordered on Monday. When asked about the potential negative outcome of someone not getting an ordered a dose of [MEDICATION(S)], EI #3 stated the resident received [MEDICATION(S)] for pain so pain could be an issue when it was missed. In a follow-up interview on 10/14/2022 at 6:06 PM, EI #3 reported there was seven [MEDICATION(S)] pills left on Monday, 10/10/2022 on the three times a week narcotic audit sheet. EI #3 stated the [MEDICATION(S)] should have been ordered on 10/10/2022 after the audit. EI #3 stated the resident was down to seven pills and the medication would have been received prior to the last pill being used. EI #3 stated she did not recall why she did not reorder the [MEDICATION(S)] on 10/10/2022. EI #3 stated the next audit was 10/12/2022 and the resident had one [MEDICATION(S)] pill left. EI #3 stated she reordered the [MEDICATION(S)] by phone on 10/12/2022. A review of RI #11's medication audit sheets completed by EI #3, LPN on 10/10/2022 indicated the resident had seven [MEDICATION(S)] pills left. The medication audit sheet competed by EI #3 on 10/12/2022 indicated the resident had one [MEDICATION(S)] pill left.

Based on observation, interviews, review of resident records, review of a facility policy titled Physician Medication Orders the facility failed to ensure medications were reordered from the pharmacy in a timely manner to have the medication available for administration to RI #55 on 10/13/2022 and RI #11 on 10/12/2022 and 10/13/2022. This had the potential to affect two of 28 sampled residents. Findings include: A facility policy titled Physician Medication Orders with an effective date of 5/2022 documented the following: . 9. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy per community protocol. 1.) RI #55 was readmitted to the facility on [DATE]. RI #55's physician orders documented an order dated 9/5/2022 for [MEDICATION(S)] 600 mg one tablet to be given twice a day. On 10/13/2022 at 8:55 AM EI #5 Licensed Practical Nurse (LPN) was observed preparing medications to administer to RI #55. EI #5 said, [MEDICATION(S)] 600 mg was not in the medication cart and she had reordered some medications yesterday (10/12/2022). EI #5 administered other medications to EI #5 without the [MEDICATION(S)]. EI #5 notified EI #3 LPN unit manager of the [MEDICATION(S)] not being available. On 10/13/2022 at 9:24 AM EI #3 went to look for RI #55's [MEDICATION(S)] in medication supply. Review of RI #55's October 2022 Medication Administration Record (MAR) revealed [MEDICATION(S)] 600 mg tablet was due at 8:00 AM and 8:00 PM every day. RI #55's dose due on 10/13/2022 at 8:00 AM was documented as 3 by EI #5. RI #55's MAR documented 3 meant the supply had been reordered. A checkmark would have been used to document the medication had been administered. Review of a REFILL REORDER FORM with a fax date and time stamp of 10/12/2022 at 6:08 PM revealed EI #5 faxed the form to the pharmacy to reorder medications for residents to include RI #55's [MEDICATION(S)] 600 mg tablets. On 10/14/2022 at 4:15 PM EI #3 LPN unit manager for Building Two, was asked how many doses of [MEDICATION(S)] RI #55 missed. EI #3 said, one. When asked what the system was for reorders of routine medications, EI #3 said, they were to pull stickers from the pharmacy card as early as seven days. When asked what the system was to make sure that was done, EI #3 said, it was supposed to be on night shift, order any low medications, but every nurse who notices medications were low could pull the sticker and order. When asked who was responsible to ensure the medications were ordered in time for filling, EI #3 replied, the nurses on the cart. When asked what the reason was the medication was not available for medication administration on 10/13/2022 for the AM dose, EI #3 said it was a cutoff issue about the time it was ordered since it was not ordered until after 6:00 PM on 10/12/2022. When asked when the medication should have been ordered in time for refill delivery, EI #3 said, by 3:00 PM. On 10/14/2022 at 4:36 PM EI #2 Director of Nursing (DON), was asked when non-controlled medications should be ordered. EI #2 said, when they were down to about a week supply. EI #2 was asked what the importance was of medications being available for administration as ordered. EI #2 responded, to ensure the treatment plan was followed and the medication was available. 2.) RI #11 was admitted to the facility on [DATE] and readmitted [DATE] with diagnosis that included [CONDITION(S)], Unspecified [CONDITION(S)], Other Chronic Pain and Dysphagia. In an interview on 10/14/2022 at 10:00 AM, RI #11 stopped surveyor in the hallway and reported that he/she missed a dose of [MEDICATION(S)] on Wednesday night, 10/12/2022. The resident reported this never happened before. A review of October 2022 physician orders for RI #11 documented, with a start date of 9/19/2022, [MEDICATION(S)] Sulfate Tablet 15 MG (milligrams) Give 1 (one) tablet by mouth three times a day for pain related to OTHER CHRONIC PAIN. A review of RI #11's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/5/2022 indicated Pain Frequency as Occasionally and Pain Frequency as six out of 10. A review of RI #11's care plan revealed, . on pain medication therapy r/t (related/to) disease process CP ([CONDITION(S)]), chronic pain, dysphagia, [CONDITION(S)] . Administer medications as ordered by physician . A review of RI #11's Medication Administration Record (MAR) for October 2022 documented a pain level of six for night shift on 10/12/2022 and a pain level of eight for day shift on 10/13/2022. The MAR also indicated a dose of [MEDICATION(S)] Sulfate Tablet was not administered at 10:00 PM on 10/12/2022 nor at 6:00 AM on 10/13/2022 due to a code of 3 which meant the supply was reordered. Progress Notes for RI #11 documented on 10/13/2022 at 6:53 AM by Employee Identifier (EI) #3 Licensed Practical Nurse (LPN) unit manager, revealed, . Unit manager was informed at 1056 pm that resident's [MEDICATION(S)] was not delivered. Charge nurse informed unit manager that she called pharmacy and that it was being stat delivered. When unit manager arrived at 630 am again pharmacy was called due to medication not being delivered. Pharmacy informed charge nurse it was on the way. Progress Notes for RI #11 documented on 10/13/2022 at 6:56 AM by EI #3 revealed, . Pharmacy gave authorization number to pull from Omnicell back up. When charge nurse went to omnicell to pull the medication is not stocked in omnicell. Progress Notes for RI #11 documented on 10/13/2022 at 7:49 AM by EI #3 revealed, . DON and ADON notified. MD called and gave order for Tylenol 650 mg now and it was given to resident. Resident offered [MEDICATION(S)], Volterm gel, laying down with calm music in dim lit room, and warm and cold treatments. Resident refused all but the Tylenol. ADON called and spoke with pharmacy concerning delivery. will continue to follow up with pharmacy and plan or care as directed. Progress Notes for RI #11 documented on 10/13/2022 at 8:45 AM by EI #3 revealed, . [MEDICATION(S)] arrived from pharmacy and now dose is given for 6am that was not given. In a follow-up interview on 10/14/22 at 3:00 PM, RI #11 reported staff gave him/her Tylenol when he/she missed the [MEDICATION(S)] dose. The resident stated the Tylenol helped with the pain but not like the [MEDICATION(S)]. The resident reported he/she also took [MEDICATION(S)] for pain. The resident reported he/she had a hard time sleeping because he/she did not have the [MEDICATION(S)] but was able to go to sleep. RI #11 reported staff offered a [MEDICATION(S)], voltern gel, calm music and warm and cold treatments. RI #11 stated he/she refused them because they do not work but he/she took the Tylenol, but it did not provide the same relief as the [MEDICATION(S)]. The resident reported he/she received two doses of [MEDICATION(S)] on 10/14/2022, a dose the morning of 10/13/2022 as well as two other doses on 10/13/2022. In an interview on 10/14/2022 at 4:25 PM EI #3, LPN, reported she was notified 10/12/2022 at 10:56 PM that RI #11 did not have [MEDICATION(S)]. The nurse had attempted to use a code from pharmacy for the omnicell in the building but [MEDICATION(S)] was not in the machine because the machine did not stock [MEDICATION(S)]. EI #3 stated she called the doctor who instructed them to give RI #11 Tylenol 650 mg and offer alternative pain relief until [MEDICATION(S)] arrived. RI #11 was offered Tylenol, [MEDICATION(S)], voltern gel, calm music and warm and cold treatments. The resident accepted Tylenol and refused all other alternatives because he/she preferred the [MEDICATION(S)]. EI #3 stated when she observed the resident on Thursday morning, the resident did not appear to be in pain but he/she was emotional, which was not out of character, and upset because the [MEDICATION(S)] had not been delivered. EI #3 stated the [MEDICATION(S)] should not have run out. EI #3 stated she called the pharmacy on Wednesday after she did an audit. EI #3 stated the [MEDICATION(S)] should have been ordered a day or two sooner. EI #3 stated she completed audits on medications on Mondays, Wednesdays and Fridays. EI #3 stated she should have noticed on Monday that it needed to be reordered and it would not have been missed if ordered on Monday. When asked about the potential negative outcome of someone not getting an ordered dose of [MEDICATION(S)], EI #3 stated the resident received [MEDICATION(S)] for pain so pain could be an issue when it was missed. In a follow-up interview on 10/14/2022 at 6:06 PM, EI #3 reported there was seven [MEDICATION(S)] pills left on Monday, 10/10/2022 on the three times a week narcotic audit sheet. EI #3 stated the [MEDICATION(S)] should have been ordered on 10/10/2022 after the audit. EI #3 stated the resident was down to seven pills and the medication would have been received prior to the last pill being used. EI #3 stated she did not recall why she did not reorder the [MEDICATION(S)] on 10/10/2022. EI #3 stated the next audit was 10/12/2202 and the resident had one [MEDICATION(S)] pill left. EI #3 stated she reordered the [MEDICATION(S)] by phone on 10/12/2022. EI #3 stated the [MEDICATION(S)] was delivered to the facility on [DATE] ay 8:44 AM. EI #3 stated RI #11 missed one dose of [MEDICATION(S)] on 10/13/2022. A review of a delivery receipt from Omnicare of Prattville indicated the facility received three orders of 30 [MEDICATION(S)] Sulfate 15 mg tablets (total 90 tablets) on 10/13/2022 for RI #11. A review of RI #11's medication audit sheets completed by EI #3, Licensed Practical Nurse (LPN) on 10/10/2022 indicated the resident had seven [MEDICATION(S)] pills left. The medication audit sheet competed by EI #3 on 10/12/2022 indicated the resident had one [MEDICATION(S)] pill left. In an interview on 10/14/2022 at 4:54 PM, EI #2, Director of Nursing (DON) reported controlled medications can be ordered up to three days in advance.

Based on observation, interviews, and review of the facility policy titled Controlled Substances, the facility failed to ensure controlled medications were stored in the Building Two refrigerator in a permanently affixed compartment. This was observed on 10/14/2022 in one of four unit medication refrigerators observed. Findings include: A facility policy titled Controlled Substances with an effective date of 9/2022, documented the following: . The facility shall comply with all laws, regulations, and other requirements related to handling, storage, . of Schedule II and other controlled substances. On 10/14/2022 at 3:00 PM, the Building Two medication refrigerator was observed containing a controlled medication emergency kit, a small box with a lock from the pharmacy, with a label description of a [MEDICATION(S)] Injection two milligrams (mg) per milliliter (ml) and a [MEDICATION(S)] [MEDICATION(S)] (ORAL) two mg/ml with 30 mls quantity, not in a permanently affixed compartment in the refrigerator. Employee Identifier (EI) #3 Building Two unit manager and EI #4 Rehabilitation unit manager both explained, the refrigerator on Building Two stopped working and all the medications in the refrigerator were transferred to the Rehabilitation refrigerator. Building Two got a new refrigerator and everything was brought back. There was a clear canister attached inside the previous refrigerator. EI #3 and EI #4 further explained, it was previously in a small counter top refrigerator that had an affixed compartment. They were not sure who had moved the emergency kit with controlled medications back to the Building Two refrigerator that did not have a permanently affixed compartment for locking controlled medications.

Based on observation, record review, interviews and review of a facility procedure guide titled Perineal Care, the facility failed to ensure a staff member changed gloves and performed hand hygiene to prevent the spread of infection. On 03/16/2022, during incontinent care, Employee Identifier (EI) #3, a Certified Nursing Assistant (CNA), removed a dirty incontinent brief from Resident Identifier (RI) #15. The CNA failed to perform hand hygiene and put on clean gloves before placing a clean brief on the resident. This deficient practice affected RI #15, one of two residents observed for incontinent care. Findings Include: An undated facility procedure guide titled Perineal Care documented, . Hand Hygiene. Perform hand hygiene. Apply clean gloves . Prevents transmission of microorganisms. RI #15 was readmitted to the facility on [DATE] and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] A review of RI #15's quarterly Minimum Data Set assessment with an Assessment Reference Date of 03/08/2022 revealed RI #15 was totally dependant on staff for toileting, required extensive assistance with personal hygiene and was always incontinent of bowel and bladder. On 03/16/2022 at 10:11 AM, the surveyor observed EI #3 remove RI #15's soiled brief and clean RI #15's perineum. EI #3 placed a clean brief on RI #15, without performing hand hygiene and applying a clean set of gloves. An interview was conducted with EI #3/CNA on 03/16/2022 at 10:15 AM. EI #3 was asked when should she change her gloves. EI #3 replied gloves should be changed when going from dirty to clean and she should wash her hands in between. EI #3 was asked if she changed gloves when providing incontinent care for RI #15. EI #3 replied, no. EI #3 was asked why did she not change gloves when going from dirty to clean. EI #3 replied, she was not thinking. EI #3 was asked, what was the harm in not changing gloves. EI #3 replied, cross contamination. On 03/16/2022 at 4:57 PM, EI #1/Director of Nursing was interviewed. EI #1 confirmed staff should perform hand hygiene after performing something dirty, before performing something clean, as with placing the clean brief on the resident.

Based on interviews, review of the facility's investigation file and policy titled, Abuse, Neglect, and Exploitation, the facility failed to report to State Agency an allegation of misappropriation of residents funds, as outlined in their abuse policy, when they were made aware of the allegation. Employee Identifier (EI) #2, the facility's Interim Administrator and EI #3, the Former Administrator were notified that a Business Office Manager (BOM), Employee Identifier (EI) #4, made unauthorized Automatic Teller Machine (ATM) withdrawals and unauthorized electronic withdrawals from Resident Identifier (RI) #3's account, totaling $13,857.23. Both EI #2 and EI #3 failed to immediately report this incident to the State Agency. This deficient practice affected RI #3; one of the eleven sampled residents reviewed for misappropriation of resident property. Findings include: The facility's policy titled, Abuse, Neglect and Exploitation with a revised date of 11/30/2020, revealed Policy It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions . Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. Policy Explanation and Compliance Guidelines . The components of the facility abuse prohibition plan are discussed herein: .VII. Reporting/Response . 1. Reporting of all alleged violations to the . state agency . as is required within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . RI #3 was admitted to facility on 6/12/2019. On 8/18/2021 at 8:48 AM, a telephone interview was conducted with a Special Agent in the Medicaid Fraud Control Unit, Office of Attorney General. The Special Agent stated EI #4, the facility's BOM, has two felony warrants for theft of property in the first degree, a Class B felony for unauthorized ATM withdrawals and unauthorized electronic withdrawals from a checking account. The Special Agent stated warrants were issued on 8/10/2021 and EI #4 turned herself in and was released on bond. The charges involved EI #4 making unauthorized withdrawals from an ATM for a total of $13,857.23, from RI #3's account. The Special Agent stated video surveillance from the ATM, was used to verify the incidents. In a follow-up telephone interview on 9/7/2021 at 9:20 AM, the Special Agent in the Medicaid Fraud Control Unit, Office of Attorney General. stated he had made the former Administrator, EI #3, aware of the misappropriation of RI #3's funds. The Special Agent stated, he spoke with EI #3 in person and showed him a picture of EI #4, the BOM at the ATM for EI #3 to confirm EI #4's identify. When asked when this was, the Special Agent stated he was unsure of the exact date but recalled it was sometime in May (2021). In a telephone interview on 9/2/2021 at 1:53 PM, EI #3, the facility's Former Administrator was asked why was the allegation of misappropriation of RI #3's property not reported to the State Agency. EI #3 replied that he never knew of RI #3's funds being misappropriated. On 9/3/2021 at 4:15 PM, an interview was conducted with EI #2, the facility's Interim Administrator. EI #2 was asked what the facility's abuse policy said about misappropriation. EI #2 replied, It states that anytime we have misappropriation of funds it should be reported. According to EI #2, the former Administrator, EI #3, should have reported it. EI #2 acknowledged she did not report the allegation of misappropriation of resident property to the State Agency when she became aware of it on 8/18/2021. When asked did she follow the facility's policy, EI #2 answered, no. According to State Agency's Online Incident Reporting System Report on 9/3/2021 at 4:51 PM, EI #2 reported an allegation of Misappropriation of Resident Property regarding RI #3 perpetrated by EI #4, the facility's BOM. This deficiency was cited as a result of the investigation of complaint/report number AL 056 and AL 113.

Based on interviews, record review, and review of the facility's policy titled, Abuse, Neglect and Exploitation, and review of the facility's investigation files, this facility failed to ensure residents were free from verbal abuse, physical abuse, and neglect. On 5/23/2021, two Emergency Medical Technicians (EMTs) arrived at the facility to transport Resident Identifier (RI) #36 to the hospital. The EMT's witnessed an Licensed Practical Nurse (LPN)/Employee Identifier (EI) #16, yelling in RI #36's ear, telling him/her to shut-up multiple times, placing her hand over the resident's mouth to silence him/her while she provided a status report to the EMTs. After RI #74 sustained [CONDITION(S)] to his/her skin from a spill of hot tea on 6/13/2021, there was no documentation of an assessment of the injuries sustained by the resident, or an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the facility's documentation, RI #74 had reddened areas on his/her right side with clear fluid filled blisters along the outside of the reddened area. These deficient practices affected RI #36 and RI #74, two of 17 sampled residents reviewed for abuse and neglect. On 7/14/2021 at 7:05 PM, the facility's Administrator, Director of Nursing Services, and the Regional Director of Clinical Operations were notified of findings of immediate jeopardy at F 600, Free from Abuse and Neglect. The deficient practice of the facility failing to assess, document the assessment, and obtain and initiate treatment orders for RI #74 had the potential to result in serious injury, harm or impairment and was likely to affect all 150 residents in the facility. Findings include: The facility's Abuse, Neglect and Exploitation policy with an effective date of 11/09/2020, stated Policy It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, . Definitions . 'Abuse' means the willful infliction of injury, .resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being . It includes verbal abuse, physical abuse . .Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking, It also includes controlling behavior through corporal punishment . 'Neglect' means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 1) RI #36 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #36's Quarterly Minimum Data Set (MDS) Assessment, with an assessment reference date of 4/13/2021, indicated he/she had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. An Alabama Uniform Incident/Offense Report dated 5/28/2021, includes a narrative which states, May 28, 2021, EI #92 (facility social worker) called to file a report about a situation at Ahava Health Care. She (EI #92) stated they (the facility) was notified by RPS (Regional Paramedical Services) of the situation that occurred on May 23, 2021. They (the facility) that one of the care givers (EI #16) and a current tenant (resident) (RI # 16) were the individuals involved. (EI #92) stated that (RI #36) was being put into an ambulance and (EI #16) told him/her to shut up. (EI #92) stated, EI #16 was trying to talk to the ambulance personnel and (RI #36) would not stop talking. She stated that (EI #16) then put her hand over his/her mouth and told him/her to shut up again. (EI # 92) stated they have interviewed RI #36 since he/she returned from the hospital and he/she told them he/she was fine. (EI #92) also stated that (EI #16) has been suspended and the board of nursing was made aware of the situation. On 6/29/2021, at 11:00 AM, an interview was conducted with RI #36. RI #36 was asked to tell the surveyor what happened regarding an incident with him/her and a nurse and paramedics (EMTs). EI #36 stated he/she was in his/her room with the LPN and two paramedics (EMTs). RI #36 stated the nurse popped him/her in the mouth while the ambulance staff was in the room and they saw her do it but got me out of there. When RI #36 was asked if he/she felt this was abuse, RI #36 said yes, the nurse should not have done this. On 6/29/2021, at 08:58 AM, an interview was conducted with EMT #2. This EMT said that herself, her partner, the patient/resident and the nurse were present when asked about the incident occurring on 5/23/2021. This EMT stated the resident was blind and hard of hearing. EMT #2 stated the resident kept asking for the nurse for things while she was trying to give report. This EMT said the nurse told RI#36 to shut up, then she placed her hand over the residents mouth and yelled in his/her ear to shut-up. On 06/29/2021, at 5:09 PM, an interview was conducted with EMT #1, who was present during this incident. When asked about the incident occurring on 5/23/2021, EMT #1 stated the nurse (EI #16) was attempting to give report and the resident was asking for his/her wallet. EMT #1 said the nurse (EI #16) told the resident to shut up 3 times and placed her hand around his/her (RI #36's) mouth. On 6/30/2021, at 09:31 AM, an interview was conducted with EI #16, an LPN. When asked to tell the surveyor about an incident that occurred between she and RI #26, EI #16 stated that nothing happend out of the ordinary, then a couple of days later she was notified she was being accused of yelling at a resident. This nurse denied that she placed her hands over EI #36's mouth and told him/her to shut up. When asked if placing your hands on a resident and telling them to shut up and yelling in their ear is abuse, EI #16 replied yes, that is physical and verbal abuse. EI #16 stated she was terminated from the facility because after the facility conducted interviews it was determined she had to be let go. On 6/30/2021, at 10:45 AM, an interview was conducted with the facility's Administrator/EI #1. He stated he was informed on 5/26/2021 of the incident regarding RI #36 and EI #16. EI #1 stated he interviewed EI #36 and EI #36 said the incident did occur. EI #1 said that RI #36 said he was trying to explain something to the nurse and the nurse told him to shut up and let her talk and she put her hands over his mouth. EI #1 stated EI #16 was terminated because the facility had to protect the residents and facility and that this behavior was was out of line. When asked about the corrective actions for this incident, EI #1 stated that first, the plan was to ensure the safety of the resident, that's why we (the facility) terminated her (EI #16). Second, EI #1 said to establish psychosocial needs and third, reeducation was initiated on abuse and prevention and customer service standards to employees. When asked if this was followed up through the facility's QAPI (Quality Assurance and Performance Improvement), EI #1 said yes. 2) A review of the facility's policy titled, Wound Care Management with an effective date of 10/25/2018 revealed the following: . Each resident receives the care and service necessary to retain or regain optimal skin integrity to the extent possible . RI #74 was admitted on [DATE], with diagnosess to include Acute Respiratory Failure with [CONDITION(S)], Type 2 Diabetes without complications, abnormal posture, and weakness. On 6/18/2021, at 6:10 p.m., the Alabama State Agency received a Facility Reported Incident (FRI). The category/incident type selected by the facility is listed as Neglect. The report states that on 6/18/2021, RI #74 sustained a burn from hot tea on 6/13/2021. The adverse outcome to the resident is listed as Redness and scabbed area to right side. The report states that an investigation was initiated, family and MD (Medical Doctor) were notified, staff interviews and reeducation were initiated, and a 100 percent skin sweep was done. The facility's Investigative Summary and Conclusion dated 6/25/2021, states, The question of neglect came about on 6.18.21 (6/18/2021) when the Administrator was made aware of a hot liquid burn involving (RI #74). At the time, it was not known exactly how the incident occurred or if treatment was initiated. Additionally, the facility's Investigative Summary and Conclusion dated 6/25/2021 states: On 5/28/2021 the Certified Registered Nurse Practitioner (CRNP) visited (RI #74) and observed that (he/she) spilled hot tea. After assessment there were no injuries or new orders given. LPN (EI #21) was aware of the incident. On 6/13/2021, the report states, EI # 25, a Certified Nursing Assistant (CNA) prepared hot tea for the resident according to his/her preference. EI #25 reheated the tea in a microwave for RI #74 because he/she complained it was not hot enough. The report states a short while later, RI #74 pressed his/her light for assistance. EI #25 responded and observed RI #74 spilled the tea. The LPN (EI #21) was made aware of the incident and assessed the area. The report states there was no injuries at that time. The facility's investigative summary states that on 6/16/2021, EI #21 noted an area developed where the hot liquid spilled. The report, under Characteristics of Injury states Chest redness with small area scabbed measuring L (length) 3.5 X 2 ¾ CM (Centimeter); Right front iliac crest redness with scabbed area to the side measuring 7 X 3.2 CM and 2.5 X 1 CM. On 6/16/2021, the summary states that the CRNP was in the facility and was asked to look at the area. The CRNP noted it to be a burn from the incident that occurred on 5/28/21 because she was not aware of the 6/13/21 incident. The CRNP spoke with the ADON (EI #26) and Treatment Nurse (EI #27) about implementing a treatment plan. Review of the documented Progress Notes for RI #74 dated 6/16/2021 at 10:00 AM, by the CRNP revealed, PT (PATIENT) SITTING IN WC (WHEELCHAIR) AT BS (BEDSIDE). PT (RI #74) REPORTED TODAY TO NP (NURSE PRACTITIONER) THAT (HE/SHE) HAD A PLACE ON (HIS/HER) SIDE FROM 'WHEN THE TEA SPILLED ON ME' TEA SPILLED ON (RI #74) ON 05/28/2021 . RI #74's Progress Notes dated 06/18/2021, at 09:00 AM, written by the CRNP documented, . PATIENT SITTING IN WC (Wheelchair) GETTING CLEANED UP. ASKED (HIM/HER) IF WOUND NURSE CAME TO SEE (HIM/HER) ABOUT AREA TO SIDE AND (HE/SHE) STATED 'NO' On 06/30/2021, at 4:27 p.m., the surveyor conducted an interview with the CRNP. When asked if she saw RI #74 on 6/16/2021, the CRNP said that when she rounded on RI #74, the resident told her about the area (burn). The CRNP said that is how she found out. The CRNP said the resident had experienced another spill on 5/28/2021 then RI #74 had a spill on 6/13/2021, but she (CRNP) was not told about that spill. The CRNP said it looked as if it (the burned area) may have had blisters that may have already burst. When asked if there were any orders written, the CRNP said she informed the EI #23, Assistant Director of Nursing (ADON) who was training a treatment nurse. The CRNP said that she wanted them to go in and put a treatment plan in place. CRNP stated she did not find out there was not a treatment plan until she came back on Friday (6/18/2021). The CRNP said the facility should have assessed and staged (the burned area). The CRNP, when she returned on Friday 6/18/2021, asked the resident (RI #74) if anybody came into see her area. The resident told her they had not. The CRNP said she then went to the computer and did not see a treatment plan so she put one in herself. On 6/30/2021, at 7:52 p.m., the surveyor conducted an interview with EI #12, LPN. EI #12 stated she became aware of the burn on 6/18/2021 when she was working with RI #74. EI #12 stated RI #74 asked her to rub something over it. EI #12 stated she observed the area and it was scabbed. EI #12 said RI #74 did not specify what he/she wanted rubbed on it just that it was burning and wanted her to rub something on it. EI #12 stated she looked in the computer and did not see an order. EI #12 stated she reported it to the CRNP and asked if she would evaluate RI #74. EI #12 said she told the CRNP the resident was complaining of burning to the right side. EI #12 said there were no new orders in the computer system at that time. On 7/03/2021, at 12:06 p.m., an interview was conducted with EI #24, Unit Manager. EI #24 stated she saw the wound on 6/16/2021, before the morning clinical meeting. EI #24 stated she took no action because she was new to the facility and was unsure where to document. EI #24 stated she reported this to the EI #2, Director of Nursing (DON) on the way to the morning clinical meeting on 6/16/2021. EI #24 stated she informed EI #2 that she had not taken any action because she was unsure what to do. On 6/30/2020 at 2:34 PM, the surveyor conducted an interview with the DON (EI #2). The DON was asked why had the incident not been identified. She stated that there was no documentation, no risk assessment, no skin assessment or no progress notes nursing notes to identify that something had occurred. The DON said that on 6/17/2021 in the clinical meeting, the unit manager said she heard RI #74 had an open area. The DON said the next morning she was reviewing documentation and identified a late entry for 6/13/21. The DON said that the entry said that the resident spilled hot tea at breakfast and there was a skin assessment done, with no redness or blisters and that a cold pack was applied. On 7/01/2021, at 11:55 a.m., the surveyor conducted an interview was with EI #21, an LPN. EI #21 said she failed to report the tea spill the resident had on 6/13/2021. EI #21 said that day after RI #74 spilled the hot liquids he/she did not complain that whole afternoon. EI #21 stated she was off the next two days and when she returned on that Wednesday (6/16/2021) after the incident, she forgot to look at the area until the CRNP made rounds. EI #21 said she walked into the room and RI #74 was asking the CRNP about some cream for the area. The CRNP said she would order some cream. The CRNP stated this when RI #74 indicated the burn was on his/her side. EI #21 said RI #74 had a two cm diameter area on the right upper side of the chest area to the end of the rib cage. EI #21 said RI #74 had tiny intact clear fluid filled blisters along the outside of the reddened area. On 07/01/2021, at 2:59 p.m., an interview was conducted with EI #23, the ADON. EI #23 said that she learned about RI #74's burn in a clinical meeting on 6/16/2021. EI #23 said that this had to be on Wednesday 6/16/2021. The ADON said she heard EI #24, the RN (Unit Manager) say to the Director of Nursing (DON) that a CNA (EI#24) had reported to the LPN (EI #21) that a resident (RI #74) had spilled tea or coffee on him/herself. The DON said that EI #21 said, it happened on 06/13/2021 or 06/14/2021. EI #23 stated, that the DON said in the meeting a risk assessment report needed to be done. EI #23 said the DON spoke with her later that morning and said if you all get a chance look at RI #74. EI #23 said, she called EI #24, the Unit Manager who stated, the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #23 said, that she never checked the order to verify what EI #24 said was true and she just took her word to be correct. EI #23 said, she was training the wound treatment nurse and doing rounds. EI #23 stated, she did not check behind EI #24 to see if she was telling the truth. EI #23 said on Thursday (June 17,) EI #24 told her there was blisters but, that treatment would not have been provided unless the blister burst. EI #23 stated, she was off Friday, Saturday, and Sunday, but the DON called her and EI #24 in to assess all residents on 6/19/2021. EI #23 said RI #74's blisters had burst blisters and that EI #24 told her RI #74 had an order now for [MEDICATION(S)] cream. EI #23 said, the area was consistent with a burn and had started granulation/healing. The facility's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Once [MEDICATION(S)] comes in dc (discontinue) this order. one time a day for open area to right side -Start Date-6/18/2021 . -D/C Date 6/22/2021. Staff of the facility documented the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficiency was cited as a result of the investigation of complaint/report AL 428. On 07/14/2021 at 7:05 PM, the facility submitted their corrective action plan and the steps they took to address the non-compliance at F 600. The corrective actions taken included: .06.18.21 Adhoc QAPI (Quality Assurance Program Improvement) Meeting 06.18.21 Reeducation for Staff Initiated: Hot liquid safety Abuse and Neglect Timely notification of change Timely notification of DON/ADMN Reporting skin conditions timely Hot liquid (re)heating All food and beverage from kitchen Weekly skin audits, assessments, etc. 06.21.21 Involved nurse disciplined and reeducated 06.18.21 Involved CNA disciplined and reeducated 06.22.21 Administrator reeducated IDT (Interdisciplinary Team) on meetings agendas and goals, communication, and importance of following up on issues Daily Clinical Morning Meeting o Discuss any critical events, such as accidents/incidents that occurred since previous meeting to review and/or implement intervention o Orders Review o Lab/Diagnostic o Risk Management o Weight/Vitals o Documentation in last 24 hours. o Clinical Dashboard for any new alerts and POC/MAR documentation Afternoon Clinical Resolution Meeting o A brief resolution meeting in the afternoon to confirm assigned items from the morning meeting have been resolved and/or status updates are received. This meeting also is to facilitate that pertinent information and follow-up items are communicated to the next shift as needed. 06.22.21 Refocus and Continuation of Weekly risk meeting Identify residents at risk for or that have experienced unwanted outcomes to discuss their progress in deciding to start, continue, modify, or discontinue current interventions and/or treatments 06.23.21 Reminder provided to residents of methods to voice concerns/complaints related to care/abuse/neglect 06.25.21 Administrator updated Angel Round assignments for department managers to audit 06.25.21 Facility reviewed provider agreement to affirm 24 hour provider availability for medical guidance and oversight 06.25.21 CRNP and MD (Medical Doctor) reminded of ability to initiate orders directly in medical record 06.25.21 Administrators personnel cell phone available at desk for staff to call whenever questions or incidents arise 06.26.21 Staff reeducation completed . After a review of the documented allegation of compliance presented to the survey team, the team verified that corrective actions taken to correct F 600 for the delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficiency is cited at past non-compliance.

Based on interviews, record review, review of the facility's policy titled, Accidents and Supervision, the Food Temperature policy, review of the facility's investigative file as well as the Facility Reported Incident (FRI), this facility failed to ensure staff implemented measures for the safe heating of liquids in a microwave for residents, resulting in RI (Resident Identifier) #74 sustaining [CONDITION(S)] to the chest and abdomen area on two different occasions. Staff were allowed to utilize microwave ovens, located on each unit's nourishment rooms to heat items for residents. Facility staff had received no instruction or monitoring to be sure that items heated were at a safe temperature, therefore ensuring that accidents, specifically [CONDITION(S)] did not occur. On 05/28/2021, around 9 am, EI (Employee Identifier) #17 heated liquid (water) in the microwave and served it to RI #74. EI #17 stated she then left the resident's room. Upon returning to resident's room RI #74 informed staff he/she had spilled the hot liquids on him/herself. EI #17 said she did not use any type of device to measure the temperature of the liquid nor did she use any assistive devices to prevent spilling. RI #74 had redness along his/her abdomen starting beneath his/her chest down to his/her waistline, a couple inches wide as a result of this spill. On 6/13/2021, EI #25 heated liquids in the microwave and placed the heated liquid on RI #74's meal tray. EI #25 said as she was returning to pick up the resident's tray, RI #74 informed her he/she spilled the hot liquid burning him/herself. EI #25 stated she took no precautionary measures to test the temperature of the liquids before serving them to RI #74. As result of this second spill, RI #74 received injuries to include redness and multiple blisters to his/her right side. This deficient practice affected RI #74, one of 13 sampled residents reviewed for accidents. The failure of the faciltiy to ensure that there were systems in place to prevent adverse outcomes resulted in an immediate jeopardy placing residents at risk for serious injury or harm and had the potential to affect the remaining 12 residents the facility identified at at risk for hot liquid spills. On 07/10/2021 at 5:15 PM, the facility's Administrator, Director of Nursing Services, and the Regional Director of Clinical Services were notified of the findings of immediate jeopardy in the area of Accidents at F689. Findings Included: The facility's Food Temperature policy with a revised date of 01/01/2014, states Foods should be served at proper temperature to insure food safety and palatability. This policy also states that acceptable serving temperatures for coffee, tea, and hot beverages are greater than or equal to 140 degrees and no higher than 140-155 degrees F (Fahrenheit). The facility's policy titled, Accidents and Supervision with an effective date of 11/09/20 (2021), revealed the following: The resident environment remains as free of accidentnhazards as is possible; and each resident receives supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. Definitions: Accident refers to any unexpected or unintentional incident, which results in injury . Hazards refers to elements of the resident environment that have the potential to cause injury or illness. Risk refers to any external factor, facility characteristic (e.g., staffing or physical environment) or characteristic of an individual resident that influences the likelihood of an accident. Identification of Hazards and Risks-the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. RI #74 was admitted on [DATE], with diagnoses to include Acute Respiratory Failure with [CONDITION(S)], Type II Diabetes Mellitus withouth complications, abnormal posture and weakness. On 6/18/2021 at 6:10 p.m., EI #1, the Administrator of Ahava Healthcare of Alabaster reported an allegation of neglect which stated that it was reported that on 6/18/2021, RI #74 sustained a burn from tea on 6/13/2021. Through review of the facilty's 5 day report and investigative summary dated 6/25/2021, the facility identified that there were two separate instances, 5/28/2021 and 6/13/2021, where hot tea was spilled by RI #74 onto his/her skin after staff heated water in the microwave. *Spill of 5/28/2021 The facility's Investigative Summary and Conclusion dated 6/25/2021, identified that RI #74 first spilled hot tea on 5/28/2021. The summary states that on 5/28/2021, the Certified Registered Nurse Practitioner (CRNP) visited RI #74 and observed that RI #74 spilled hot tea. The summary and conclusion also states that after an assessment there were no injuries or new orders given and that EI #21, LPN (Licensed Practical Nurse) was aware of the incident. On 7/02/2021, at 3:59 p.m., an interview was conducted with EI #17, a Certified Nursing Assistant (CNA) regarding the spill on 5/28/2021. EI #17 said that during meal service, she took RI #74 coffee but RI #74 reported the he/she drank tea. EI #17 stated she went to the nursing desk and asked EI #21, LPN where the tea was. EI #17 said EI #21 told her where to find the tea and to heat the water in the microwave. EI #17 stated she found the tea and heated the water in the microwave for about 15 seconds, and she let the tea steep in the nourishment room for about 5-6 minutes. EI #17 said she placed her hand over the top of the cup and checked the temperature and it was not smoking. EI #17 said she took the tea and placed it on RI #74's table and the resident said he/she was ok. EI #17 said the resident was in the bed in an upright position. EI #17 said she left the room and about 10 minutes later she went back to check on RI #74 and RI #74 had spilled the tea on the front of his/her clothing. EI #17 said RI #74 denied having pain and being burned and it was okay. EI #17 said she got RI #74 cleaned up and reported it to EI #21. EI #17 stated EI #21 then went and assessed the resident. EI #17 said RI #74 had an area of redness along his/her abdomen starting beneath his/her chest down to his/her waistline, a couple inches wide where the tea spilled. EI #17 said EI #21 said to her, Let me go start an incident report. EI #17 said the same day, EI #21 gave her an Incident Report/paper to write down what happened. EI #17 stated she completed the form and returned it to EI #21 but does not know what EI #21 did with it. When EI #17 was asked if she had received any training on heating liquids she said there was an in-service on heating liquids but it occurred after the second spill. On 7/02/2021 at 3:06 p.m., an interview was conducted with the CRNP. The CRNP said when she and EI #5 (Medical Records personnel) walked into the room of RI #74, had spilled the tea. The CRNP said EI #21 came in and began cleaning the resident. The CRNP stated this occurred on 5/28/2021. When asked who was responsible for communicating to others that the resident spilled hot tea, the CRNP answered EI #21. The CRNP stated that she did not know what had caused the spill. During an interview on 7/02/2021, at 4:43 p.m., EI #5 said she remembered going into the room and the resident was wet. EI #5 said she saw wetness on the resident' clothes and the floor. EI #5 said the CRNP told EI #21 the resident had spilled hot tea on him/herself and that EI #21 closed her computer laptop, medication cart and walked toward the resident's room as she and the CRNP were leaving the area. EI #5 said EI #21 should have assessed the resident and if it was hot liquids that spilled, EI #21 should have reported it to the Administrator and done an incident report. On 07/02/2021, at 6:09 p.m., an interview was conducted with EI #21, an LPN. EI #21 stated she did not recall the CRNP notifying her of RI #74 spilling hot tea on him/herself. EI #21 said she did not remember giving an Incident Report to EI #17 on 05/28/2021 and she did not remember EI #17 completing and returning and Incident Report to her. EI #21 stated she did not know what happened to the Incident Report. When EI #21 was told that the CRNP stated she witnessed her cleaning RI #74 after he/she spilled the tea on 05/28/2021, EI #21 said she does not remember that happening. EI #21 was asked when she is informed a resident has spilled a hot liquid, what should be done. EI #21 said an incident report and notification of the physician and family. EI #21 also said, if a resident spills hot liquid and it spills on the floor the resident would be assessed and notification given to the (ADON) Assistant Director of Nursing) or (DON) Director of Nursing to make sure everything that needed to be addressed was addressed. On 06/30/2021, at 2:34 p.m., an interview was conducted with EI #2, Director of Nursing (DON) regarding the 5/28/2021 spill of hot tea. When asked why the tea was at a temperature that would cause a burn to the resident, EI #2 said it had been microwaved by a CNA per the residents request. EI #2 said that there was no temperature taken on the liquids served RI #74 and no one could validate the temperature of the hot tea. *Spill on 6/13/2021 The facility's Investigation Summary and Conclusion dated 6/25/2021 revealed on 6/13/2021, that EI # 25, CNA prepared hot tea for the resdient (RI #74) according to his/her preference. The CNA reheated the item in the microwave for RI #74 because the resident complained it wasn't hot enough. The summary states that EI #25 attests that RI #74's head of the bed was raised high enough to see over his/her tray'. A short while later RI #74 pressed his/her light for assistance. EI #25 responded and observed RI #74 spilled the tea. EI #21, the LPN was made aware of the incident and assessed the area. At that time there were no injuries. The summary continues to say that on 6/18/21 it was reported that the resident sustained a burn from hot tea on 6/13/21 . Characteristics of Injury: Chest redness with small area scabbed measuring (Left) L 3.5 X 2 ¾ CM (Centimeter); Right front iliac crest redness with scabbed area to the side measuring 7 X 3.2 CM and 2.5 X 1 CM. On 06.16.2021 (three days later) EI #21 noted an area developed where the hot liquid spilled. The CRNP was in the facility and asked to look at the area. The CRNP noted it to be a burn from the incident that occurred on 5/2/21 because she was not aware of the 6/13/21 incident. The CRNP spoke with the ADON (EI #26) and Treatment Nurse (EI #27) about implementing a treatment plan. This investigative summary states, Based upon the investigative findings, it is substantiated the facility did not ensure the tea was less than 140 degrees according to its policy. On 07/01/2021, at 8:07 a.m., an interview was conducted with EI #25, CNA regarding the spill of the hot tea on 06/13/2021. EI #25 stated she was passing trays and took RI #74 his/her tray. EI #25 stated RI #74 asked her if he/she could have some hot tea. EI #25 stated she got a coffee cup, put water in it and warmed the water up. EI #25 said she did not recall how much water she put into the cup and not sure of how much water the cup would hold. EI #25 said she warmed the water for not more than a minute. EI #25 said the most she has warmed up anything was minute. EI #25 stated she put the tea bag into the cup and RI #74 added his/her own sugar. EI #25 said, she then walked out of the room and started feeding. EI #25 stated when she returned to get RI #74's tray, his/her light was on. EI #25 stated RI #74 said he/she had wasted his/her tea and burned him/herself and then ask her for cold wet rag. EI #25 said the area was a light reddish pink. The CNA (EI #25) said after she cleaned him/her up she went and got the nurse (EI #21) and after her assessment she said RI #74 was fine. On 07/02/2021 at 3:08 p.m., a second interview was conducted with EI #25, CNA. EI #25 stated a thermometer was not in the area to check the water's temperature and there were no other measures taken to check the temperature. On 07/01/2021, at 11:55 a.m., an interview was conducted with EI #2, LPN. EI #21 stated EI #25, CNA came to her during morning med. (medication). EI #21 stated EI #25 said RI #74 had spilled some tea on him/herself. EI #21 stated she went to look at RI 74. EI #21 said RI #74 said he/she was drinking his/her hot tea and not sitting up in bed at the time. EI #21 said RI #74 sometimes get confused because his/her saturation will drop. EI #21 said she asked EI #24 how this could happen when you are sitting up in the bed at the time. EI #21 stated that when RI #74's head of bed is at 30-45 degrees angle, he/she will get confused and when this occurs, he/she don't remember to hold the cup. EI #21 said she saw redness inside of RI #74's right antecubital and to the right upper arm. EI #21 stated she was off the next two days and when she returned on that Wednesday (June 16) after the incident, she forgot to look at the area until the CRNP made rounds. EI #21 said she walked into the room and RI #74 was asking the CRNP about some cream for the area. The CRNP said she would order some cream. This is when RI #74 said it was his/her side. EI #21 said she observed RI#74 had a 2 cm diameter area on him/her right upper side at the end of his/her chest area at the end of the rib cage. EI #21 said he/she had tiny intact, fluid filled blisters along the outside of the reddened area. Review of the Progress Notes in RI #74's medical record revealed a Late Entry dated 6/16/2021 at 10:00 a.m. which states, PT (PATIENT) (RI 74) SITTING IN WC (Wheel Chair) AT BS (BEDSIDE) PT (RI #74) REPORTED TODAY TO NP (NURSE PRACTITIONER) THAT (HE/SHE) HAD A PLACE ON . SIDE FROM 'WHEN THE TEA SPILLED ON ME.' .Plan: AREA TO SIDE LOOKS AS IF IT HAD BEEN BLISTERED AT SOME POINT. THERE IS LIGHT PEELING OF SKIN NOTED. INFOMED TREATMENT NURSE AND ADON OF AREA SO TREAEMENT (TREATMENT) PLAN CAN BE PUT IN PLACE. TOLD THAT IT WOULD BE LOOKED AT TODAY. On 06/30/2021, at 2:34 p.m., an interview was conducted with EI #2/DON. EI #2 stated there was an incident where RI #74 was burned from hot liquid spilling. EI #2 stated she assessed the area on Friday (6/18/2021). EI #2 stated it was an uneven edged red area with three of what looked like ruptured blisters inside. EI #2 stated RI #74 told her that he/she had spilled his/her hot tea. EI #2 was asked why the tea was at a temperature that would cause a burn. EI #2 responded by saying, it had been heated in the microwave by a CNA and that there was no temperature done on the liquid, so no one could validate the temperature of that tea. On 07/01/2021, at 10:14 a.m., an interview was conducted with EI #1/Administrator. EI #1 stated he was informed on 06/18/2021 of the incident that RI #74 had been burned from spilling hot tea on him/herself. When asked what the policy was on warming liquids for residents, EI #1 said there was not an active policy on warming hot liquids. EI #1 stated the water got hot enough to burn RI #74 because the water was warmed in the microwave. When asked what measures were in place for staff to verify the temperature of the water before giving it to RI #74, EI #1 said that the facility has thermometers in place to verify the temperature but at the time, he was not sure if one was at the area (where the water was heated). This deficiency was cited as a result of the investigation of complaint/report AL 428. On 07/10/2021 at 5:15 PM, the facility submitted an Allegation of Compliance (AOC) which documented: Initial interviews and investigation initiated Notification to family and physician Treatment orders received Call with Corporate Staff and Regional team Burn Incident Uploaded to ADPH Adhoc QAPI Meeting Hot liquid policy developed Removed microwaves from units All food and drink from the kitchen IDT initiate Identification of residents most at risk for liquid burn event 100% Skin sweep initiated to ensure all skin injuries are identified and treated Care plan added for impaired skin related to hot liquid spill Involved nurse interviewed and suspended Education/Reeducation Initiated for all staff Education/Reeducation continued 100% Skin sweep continued Education/Reeducation continued Regional Staff in facility for oversight of corrective action Affected resident and at risk residents' care plan updated Care plan added for Injury related to my inability to safely handle hot liquids Education/Reeducation continued Regional Staff in facility for oversight of corrective action Affected resident and at risk residents' care plan updated Education/Reeducation continued IDT Identify residents most at risk for liquid burn event Regional Staff in facility for oversight of corrective action Education/Reeducation continued Completed on 6/26/2021 After review and verification of the facility's corrective actions and steps to address Accidents, F 689 was found to be corrected as of 6/26/2021 and is cited at past noncompliance. Surveyor: [NAME], [NAME] V.

Based on identified deficient practices cited during the survey of 6/28/2021 to 7/16/2021, the administration of this facility failed to ensure that the facility did not have deficient practices higher than an E level in order to graduate from the Special Focused Facility (SFF) program. This survey found that deficient practices existed at Immediate Jeopardy at F 600, Abuse and Neglect; F 656, Comprehensive Care Plans; and F 689, Accidents. On 06/28/2021 at 8:35 PM, the facility's Administrator, Director of Nursing Services, and Regional Director of Clinical Services were notified of the findings of immediate jeopardy in the area of Administration, F835. On 05/28/2021 and 06/13/2021, two Certified Nursing Certified (CNA) heated water in a microwave for Resident Identifier (RI) #74 to have hot tea. On both occasions, RI #74 spilled the hot tea onto his/her skin, sustaining [CONDITION(S)] to the his/her right side and abdomen. The CNAs, involved in the two incidents, confirmed they had not been made aware of interventions and trained on how to safely provide hot liquids to residents until 06/18/2021, after RI #74 suffered his/her second burn. According to the Accident and Supervision policy dated 11/9/2020, the facility should have identified potential hazards, evaluated risk factors, and implemented preventive interventions to reduce hazards, but failed to implement this policy until after RI #74 suffered the second burn on 6/18/2021. An interview with the Director of Nursing (DON) revealed facility staff members were aware RI #74 desired hot tea since his/her admission and stated she too should have been aware of staff heating liquids in a microwave to serve to resident. In addition, on 06/16/2021, after staff failed to provide care to RI #74's [CONDITION(S)]. RI #74 made a request to the Certified Registered Nurse Practitioner (CRNP) for treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to implement the Abuse, Neglect, and Exploitation policy resulting in staff neglecting to provide care to RI #74's [CONDITION(S)] until 5 days after RI #74's request for treatment. The Administrator, Director of Nursing and Regional Director of Clinical Services confirmed staff delayed providing care to RI #74. These deficient practices affected Resident Identifier (RI) #74, one of 14 sampled residents reviewed for accident hazardous and abuse/neglect; and placed these residents at an immediate risk for serious injury, harm or death. Findings included: Refer to F580 F600, F656, and F689. A review of the undated job description for Employee Identifier (EI #2), the Director of Nursing Service documented, . Major Duties and Responsibilities Plans, develops, organizes, implements, evaluates and direct the overall operation of the Nursing Service department, as well as programs and activities, in accordance with the current state and federal laws and regulation. Interprets and communicates policies and procedures to nursing staff, and monitor staff practices and implementation . Act in an administrative capacity in the absence of the Administrator A review of the job description for EI #1, the Administrator documented, .Major Duties and Responsibilities Plans, develops, organizes, implements, evaluates and direct the overall operation of the facility as well as its programs and activities. In accordance with current state and federal laws and regulations. Plan, develops, organizes, implements, evaluates, and direct the facility's programs and activities in accordance with guidelines issued by the governing body. Leads and coordinates daily, weekly, bi-monthly or monthly management team meeting to discuss priorities and develop solutions with facility leaders.Know and understand general nursing practices and procedure.Identifies and collaborates with members of the interdisciplinary team, physicians, consultants .to identity opportunities to enhanced services to the resident and/or resolve issues. On 06/30/2021, at 4:27 p.m., an interview was conducted with the CRNP who said she did her round on 6/16/2021, and the resident informed her of the [CONDITION(S)]. The CRNP said RI #74 informed her that he/she had experienced another spill. The CRNP said the first spill was on 5/28/2021 and the second spill occurred on 06/13/2021, but she was not made aware of the second spill. The CRNP said she looked at it and it look like it had blister that already had burst. The CRNP said she instructed the Assistant Director of Nursing (ADON)/EI #23 and the Treatment nurse/EI #27 to go in and put a treatment plan in place. The CRNP stated she did not find out the ADON and Treatment Nurse did not implement a treatment plan until Friday (06/18/2021). The CRNP said the treatment nurse should have assessed, measured and staged the wound and afterward informed them of RI #74's burned area. The CRNP stated she put an order in place to treat the blister on Friday 06/18/2021 on the right side of abdomen. On 07/01/2021 at 2:59 p.m., an interview was conducted with EI #23, the Assistant Director of Nursing (ADON). EI #23 said the CRNP asked if she had a chance to look at RI #74's skin. EI #23 said she called EI #24, the Unit Manager who stated RI #74 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #23 said she never checked the order to verify what EI #24 said was true and she just took EI #24's word to be correct. EI #23 said she was training a wound treatment staff and completing rounds. EI #23 stated she did not check behind EI #24 to see if she was telling the truth. EI #23 said on Thursday (06/17/2021), EI #24 told her there were blisters but the treatment would not have been provided unless the blister burst. EI #23 stated she was off Friday, Saturday, and Sunday but EI #2 called her and EI #24 in to assess all residents on 06/19/2021. EI #23 said RI #74's blisters had burst and that EI #24 told her RI #74 had an order now for [MEDICATION(S)] cream. EI #23 said, the area was consistent with a burn and had started granulation/healing. On 06/30/2021, at 2:34 p.m., an interview was conducted with EI #2, the DON, who said there were no temperatures done on the liquids so no one could validate the temperature of the hot liquids served to RI #74 on 05/28/2021. The DON said the staff in service started on 06/18/2021. On 07/03/2021, at 1:38 p.m., a follow-up interview was conducted with EI #2. EI #2 revealed she was not aware of the staff heating liquids in the microwave until an investigation was started on RI#74 regarding his/her [CONDITION(S)]. EI #2 stated she should have known staff would use the microwaves to heat liquids because . we had microwaves . On 07/01/2021, at 10:14 a.m., an interview was conducted with EI #1, the Administrator. EI #1 stated he was informed on 06/18/2021 of the incident that RI #74 had been burned from spilling hot tea on him/herself. EI #1 stated the water got hot enough to burn RI #74 because the water was warmed in the microwave. A follow-up interview with EI #1 was conducted on 07/03/2021, at 3:48 p.m. The administrator states we have learned several things. EI #1 said the first incident of the hot liquid spill on 05/28/2021 there were no mechanism in place to assure temps did not reach certain levels and that we have certain residents at risk for hot liquids spills/[CONDITION(S)]. EI #1 said the most important thing that has been learned through this process is communication. We learned that we must take actions and follow up on information when we receive it. The Administrator said, looking back on both spills, the facility had staff that observed the events. On the 05/28/2021 incident, the CRNP observed it and she spoke to the nurse. EI #1 said the CRNP states she followed up but there was no full communication or documentation for the observation. The administrator stated the nurse and the CNA knew about the 06/13/2021 spill but there was no follow up. EI #1 said, the CRNP saw the burn so did the nurse and there was communication with Assistant Director of Nursing (ADON), but nothing was executed. The Administrator said the CRNP communicated the need for treatment, but this should be a situation where the provider goes ahead and initiates treatment themselves in the records. EI #1 stated ideally, the incident should have been discussed during the Clinical Meeting on 06/14/2021 and absolutely should have been discussed on 06/17/2021. An interview with EI #29/Regional Director of Clinical Services on 07/03/2021, at 3:48 p.m., identified on 06/18/21, during the morning meeting the issue of the hot spill was identified. EI #29 said as a team we identified the spills were entered as a late entry. EI #29 stated documentation by the CRNP revealed she identified the area before the management team knew and did not report to nursing management. During the CRNP interview, she revealed she asked the ADON to look at the wound and there was a delay in treatment because there was no evidence the wound care was started. EI #29 stated it was determined a CNA had heated hot water for tea in the microwave and no evidence she temped the hot water. EI #29 stated on 06/21/21, she went and assessed the wound with the DON and the resident denied pain at that time. EI #29 said the DON had already seen the area and on the date of discovery on 06/18/2021 hot liquid spill, the DON immediately contacted her and the Vice-President (VP) of Clinical Services. EI #29 stated based on their discussion of the finding related to the incidents and the delay from the incident occurring and the incident being discovered by management, they decided it was a major incident and self-reported this incident. EI #29 stated there was a discussion with the entire governing body. EI #29 stated they developed a plan to conduct body assessments on all residents to ensure all skin injuries were identified and treated; reviewed the incident report template and added hot liquid burn as an option type; ensured notification of family and physician (both were already aware, but was not documented); completed a pain assessment; care planned the skin injury; completed hot liquid assessment to identify all residents at risk and care planned all residents at risk for hot liquids; created audit tools; began auditing the usage of secure lid cups; conducted ad-hoc Quality Assessment Performance Improvement meetings; began interviewing all staff; removed microwaves from units; discussed changes with resident council; created a Hot Liquid Policy on 06/18/2021 (included temp check of hot liquid); and began educating staff. EI #29 stated staff members were educated on the Hot Liquid Policy; educated on timely notification of change in condition, notification of family/physician, documentation of incidents and change of condition including nursing notes and incident report, reporting abuse/neglect training, timely notification to DON and supervisor, resident incidents and what type of incidents should be reported, when skin injuries occur, what should be done including notification, assessment, incident report, documentation in medical record, order to treat if indicated, and timely care planning, staff should notify primary charge nurse, food and drink to be heated in kitchen and temped and not delivered hotter than 140 degrees. EI #29 stated the facility added on the tray card an item for which residents were at risk for hot liquids and care plan fires to the CNA Kardex and staff have copies of the list of residents at risk for hot liquids. This deficiency was cited as a result of the investigation of complaint/report AL 428. On 07/10/2021 at 5:15 PM, the facility submitted an acceptable Allegation of Compliance (AOC) which documented: Initial interviews and investigation initiated Notification to family and physician Treatment orders received Call with Corporate Staff and Regional team Burn Incident Uploaded to ADPH Adhoc QAPI Meeting Hot liquid policy developed Removed microwaves from units All food and drink from the kitchen IDT initiate Identification of residents most at risk for liquid burn event 100% Skin sweep initiated to ensure all skin injuries are identified and treated Care plan added for impaired skin related to hot liquid spill Involved nurse interviewed and suspended Education/Reeducation Initiated for all staff Education/Reeducation continued 100% Skin sweep continued Education/Reeducation continued Regional Staff in facility for oversight of corrective action Affected resident and at risk residents' care plan updated Care plan added for Injury related to my inability to safely handle hot liquids Education/Reeducation continued Regional Staff in facility for oversight of corrective action Affected resident and at risk residents' care plan updated IDT Identify residents most at risk for liquid burn event Education/Reeducation continued Regional Staff in facility for oversight of corrective action Completed on 6/26/2021 After conducting a review and verifying the steps taken by the facility in their submitted Allegation of Compliance (AOC), F 835 is corrected as of 6/26/2021.

Based on interview, record review, and a review of a facility policy titled, Care Plan - Comprehensive, the facility failed to ensure a comprehensive care plan was developed for Resident Identifier (RI) #74 to include resident specific safety interventions for when this resident was served hot liquids for making tea. On 05/28/2021, RI #74 spilled hot tea causing a reddened area to the right side of his/her body. After licensed staff became aware of this incident, there were no specific care plan interventions put into place to ensure that when hot liquids were served, what measures would be taken to ensure for this resident's safety. On 06/13/2021, RI #74 had a second spill from hot tea. This spill resulted in blisters and reddened areas to the right side of the body. The facility, still at the time of the second spill did not have a care plan in place for this resident to ensure that there were no injuries when the resident was served hot liquids. After the second incident, a care plan was developed on 6/18/2021, 21 days after the initial spill on 05/28/2021. This deficient practice affected RI #74, one of 13 sampled residents reviewed for comprehensive resident centered care plans and had the potential to affect the additional 12 residents identified to be at risk for accidents with hot liquids. On 07/10/2021 at 5:15 PM, the facility's Administrator, Director of Nursing Services, and the Regional Director of Clinical Services were notified of the findings of immediate jeopardy in the area of Comprehensive Care Plans, F656. Finding Include: RI #74 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #74 has an Admission Minimum Data Set (MDS) with a Reference Date of 05/11/2021. RI #74 has a Brief Interview of Mental Status (BIMS) score of 15, indicating his/ her cognition to be intact. This assessment identified RI #74 as being independent in eating requiring set up help only. A review of the facility's policy titled, Care Plans - Comprehensive, dated 10/2017, states the policy is for an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Under General Guidelines, #5 states, Care plans are revised as changes in the resident's change in condition dictate. During an interview with the CRNP (Certified Registered Nurse Practitioner) on 6/30/2021, the CRNP was asked if she assessed RI #74 on 5/28/2021 where he/she spilled hot liquid on him/herself. The CRNP said that she did, but at the time, there were no abnormalities and nothing manifested after the first spill. The CRNP said the resident made her aware of another spill that occurred on 6/16/2021. The CRNP said that when she looked at the resident's area where the liquid spilled on 6/16/2021, it looked like there may have been blisters that may have already burst. Based on review of RI #74's medical records/care plans, it was determined that care plan interventions were not put into place once the incident of 5/28/2021 occurred to ensure that further incidents did not recur and result in serious injury. On 6/18/2021, a care plan was developed with measures put into place for how this resident would safely be served liquids and a spill of hot liquids to the skin would not result in serious injury to the resident. An interview with Employee Identifier (EI) #2, Director of Nursing (DON) on 07/04/2021 at 9:17 a.m., identified on 06/18/2021, RI #74's care plan was updated, and interventions added for impaired skin integrity to include a problem of RI #74 having a hot liquid spill. Also, added to the plan of care was the resident's injury to skin with interventions that included positioning, treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #2, said the care plan was not updated until 06/18/2021. The DON said RI #74's care plan was updated to reflect risk for hot liquid spills on 06/21/2021 which included resident specific intervention for hot liquids. EI #2 said it took some time with investigating, educating staff, and performing skin sweeps (skin check/body audit) which delayed the development of RI #74's care plan. This deficiency was cited as a result of the investigation of complaint/report AL 428. On 07/10/2021 at 5:15 PM, the facility submitted to the survey team an Allegation of Compliance (AOC) which included the following steps taken to address the development of a care plan to address the identified non-compliance. Initial interviews and investigation initiated Notification to family and physician Treatment orders received Call with Corporate Staff and Regional team Burn Incident Uploaded to ADPH Adhoc QAPI Meeting Hot liquid policy developed Removed microwaves from units All food and drink from the kitchen IDT initiate Identification of residents most at risk for liquid burn event 100% Skin sweep initiated to ensure all skin injuries are identified and treated Care plan added for impaired skin related to hot liquid spill Involved nurse interviewed and suspended Education/Reeducation Initiated for all staff Education/Reeducation continued 100% Skin sweep continued Education/Reeducation continued Regional Staff in facility for oversight of corrective action Affected resident and at risk residents' care plan updated Care plan added for Injury related to my inability to safely handle hot liquids Education/Reeducation continued Regional Staff in facility for oversight of corrective action Affected resident and at risk residents' care plan updated IDT Identify residents most at risk for liquid burn event Education/Reeducation continued Regional Staff in facility for oversight of corrective action Education/Reeducation continued Completed on 6/26/2021 After review and verification of the facility's allegation of compliance submitted by the facility, it was determined tht F 656 was found corrected as of 6/26/2021 and is cited at past noncompliance.

Based on interviews, record review, review of a facility policy titled, Notification of Changes, and review of the facility's investigation revealed this facility failed to ensure Resident Identifier (RI) #74's physician was promptly notified after RI #74 spilled hot tea onto his/her skin resulting in a burn to the skin. This deficient practice affected RI #74, one of one residents sampled for notification of changes. Findings Include: The facility's policy titled, Notification of Changes with an effective date of 03/30/2021, revealed the following: Policy . The purpose of this policy is to ensure the facility promptly . consults the resident's physician. Definitions: .''Clinical Complications: Examples - .The facility must consult with the resident's physician . when there is a change requiring such notification. Circumstances requiring notification include: 1. Accidents a. Resulting in injury. b. Potential to require physician intervention . 3. Circumstances that require a need to alter treatment. This may include a. New treatment . Additional considerations: 1. Competent individuals: a. The facility must still contact the resident's physician . RI #74 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's 5 day Follow-up Report dated 6/25/2021 revealed ., On 06/18/21 it was reported that the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Characteristics of Injury: Chest redness with small area scabbed measuring L 3.5 X 2 ¾ CM (centimeters); Right front iliac crest redness with scabbed area to the side measuring 7 X 3.2 CM and 2.5 X 1 CM. On 06/30/2021 at 2:34 p.m., an interview was conducted with EI #2, Director of Nursing (DON). EI #2 stated that on 06/13/2021, RI #74 spilled a cup of hot tea. EI #2 stated RI #74's skin was intact with no blisters, but the area was red and warm. EI #2 stated the Licensed Practical Nursing (LPN)/EI #21 said she did not complete a risk assessment, make a nursing note, or notify anyone. On 06/30/2021 at 4:27 p.m., the CRNP was interviewed. The CRNP stated she was not notified of this spill occurring on 6/13/2021. On 07/01/2021 at 11:55 a.m., an interview was conducted with EI #21, an LPN regarding the hot liquid spill on 06/13/2021. EI #21 stated EI #25, a CNA informed her that RI #74 had spilled tea on him/herself. EI #21 stated she saw redness inside of the resident's right antecubital and to the right upper arm. EI #21 stated the facility's protocol for reporting an incident was to notify the Certified Registered Nurse Practitioner (CRNP) on call, the Director of Nursing (DON) and the family. EI #21 stated she did not notify anyone. EI #21 stated she was aware of this protocol for reporting before the incident with RI #74 happened. EI #21 stated she hated it happened, she dropped the ball, and she did not report it. On 07/03/2021 at 1:38 p.m., a second interview was conducted with EI #2. EI #2 stated when a resident develops a wound or skin injury, the physician should be notified immediately. On 07/03/2021 at 4:04 p.m., RI #3, Medical Director (MD) was interviewed. RI #3 stated he was not aware of this incident. This deficiency was cited as a result of the investigation of complaint/report AL 428.

Based on observation, interview, record review, and review of a facility document titled CLINICAL COMPETENCY EVALUATIONS the facility failed to ensure nebulizer administration sets were properly stored in a plastic bag. This was observed on Resident Identifier (RI) #95 and RI #126. This deficient practice affected two of three residents sampled for respiratory care. Findings include: A review of a facility document titled CLINICAL COMPETENCY EVALUATIONS, with no effective date, revealed PROCEDURE: Handheld Nebulizer . 16. Disassembles equipment, stores cleaned tubing and bagged for next treatment. Disposes of equipment every 7 days or if soiled . 1. RI #95 was admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #95's Order Summary Report, dated Jul (July) 2,2021 revealed .[MEDICATION(S)]-[MEDICATION(S)] Solution 0.5-2.5 (3) MG/3ML 1 application inhale orally four times a day . Start Date 5/22/2021 . On 6/29/21 at 12:15 PM, an observation was made of RI #95's nebulizer administration set setting on top of the nebulizer machine. The administration set was not in a plastic bag. On 6/30/21 at 7:53 AM, a second observation was made with Employee Identifier (EI) #8, a Licensed Practical Nurse (LPN) and interview conducted. The surveyor observed RI #95's nebulizer administration set setting on top of the nebulizer machine. The administration set was not in a plastic bag. EI #8 was asked how should the nebulizer administration set be stored. EI #8 picked up the administration set and placed it in the empty plastic bag dated 6/20. EI #8 was asked why should the nebulizer administration sets be stored in a plastic bag. EI #8 replied, so it would not get dirty or infected. On 7/1/21 at 6:11 PM, an interview was conducted with EI #7 an LPN. EI #7 was asked who gave RI #95 the nebulizer treatment at 8 AM on 6/29/21. EI #7 replied, that would have been her. EI #7 was asked where she put the nebulizer administration set after the treatment was finished. EI #7 replied, the administration set is supposed to be unscrewed from the nebulizer and put in a plastic bag, but RI #95 was always telling the nurses to leave, and he/she would turn it off when finished. EI #7 was asked how should the administration set be stored. EI #7 replied, the administration set should be unscrewed and put in the plastic bag. EI #7 was asked what was the harm when a nebulizer administration set was not stored properly. EI #7 replied, it could grow bacteria and cause an infection. 2. RI #126 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #126's Order Summary Report, dated Jun (June) 30,2021 revealed . [MEDICATION(S)]-[MEDICATION(S)] Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally every 4 hours for shortness of breath . On 6/29/21 at 10:56 AM, the surveyor observed RI #126's nebulizer administration set sitting on the bedside table. The administration set was not being stored in a plastic bag. On 6/30/21 at 8:10 AM, the surveyor observed RI #126's nebulizer administration set sitting on the bedside table. The nebulizer administration set was not stored in a plastic bag. 6/30/21 at 8:12 AM, an interview was conducted with EI #10, an LPN in RI #126's room. The surveyor showed EI #10 where the nebulizer administration set was sitting. EI #10 was asked what should the administration set be stored in. EI #10 replied, it should be in a bag EI #10 was asked, why were nebulizer administration sets kept in a plastic bag. EI #10 replied, because of germs. EI #10 was asked, what should a nurse do if the nebulizer administration set not changed or being stored properly. EI #10 replied, change it, and put in a bag. On 6/30/21 at 3:54 PM, an interview was conducted EI #2, Registered Nurse (RN), Director of Nursing (DON). EI #2 was asked how should nebulizer administration sets be stored at the resident's bedside. EI #2 replied, in a bag of some sort. EI #2 was asked, a paper bag or a plastic bag. EI #2 replied, usually plastic, like a zip lock bag. EI #2 was asked what should a nurse do when they notice a nebulizer administration set was not being stored properly at the bedside or has not been changed. EI #2 replied, discard it, and get a new one and date it. EI #2 was asked what was the risk to the resident when nebulizer administration sets were not stored in a plastic bag. EI #2 replied, they can get dirty and a chance of infection. On 7/2/21 at 7:59 AM, an interview was conducted with RI #126. RI #126 was asked how often did he/she receive nebulizer treatments. RI #126 replied, four times a day. RI #126 was asked when the treatment was finished where was the administration set placed. RI #126 replied, exactly where it was setting. The surveyor observed the nebulizer administration set sitting on top of an empty zip lock bag which was dated 6/27. RI #126 was asked how long did the administration set lay on top of the bedside table. RI #126 replied, until the next treatment was due.

Based on interviews, review of Resident Identifier (RI) #362's medical record, the 24 HOUR REPORT/CHANGE OF CONDITION REPORT, Contract Agency #1's FACILITY STAFFING AGREEMENT, Contract Agency #2's CLIENT AGREEMENT FOR HEALTHCARE PROFESSIONAL SERVICES and personnel files, the facility failed to train the Licensed Nurses of Contract Agency #1 and Contract Agency #2 on the facility's policies and the computerized charting system. On 11/30/2019 at 1:00 PM, RI #362 was found on the floor by Employee Identifier (EI) #25, a Certified Nursing Assistant. The CNA informed the Registered Nurse (RN), EI #15. After continued complaints of pain, on 12/1/2019, EI #15 called the physician and an x-ray was ordered at 3:33 PM. On 12/1/2019 at 11:36 PM, RI #362's x-ray results were released to the facility's computerized charting system, which revealed the resident had sustained a recent left [MEDICATION NAME] radius, with soft tissue swelling. The RN, on duty and assigned to care for the resident when the x-ray results were sent to the facility, was an employee of Contract Agency #1. The RN stated she did not get the results of the x-ray for RI #362 because the fax machine was not working, and she had not been trained on where x-ray results would come. The facility's Director of Nursing (DON) stated the facility utilized licensed nurses from different agencies and they were not provided the same training on the facility's computerized charting system as the licensed staff employed through the facility. This failure led to the Ordering Physician and the resident's responsible party not being made aware of the results of the resident's x-ray. Furthermore, the resident received no treatment or further evaluation of the left distal radius fracture before being discharged home on[DATE]. Once the resident arrived home, RI #362's family member noticed swelling, bruising and guarding of the left arm. The resident complained of pain when the left arm was touched. When the change in the resident's condition was not improving, RI #362's family member called the physician and was asked to call an ambulance to have the resident transferred to the local hospital. RI #362 presented to the emergency room of the local hospital with mild to moderate swelling of the left wrist, minimal bruising, mild redness on the dorsal side of the wrist, and pain with attempted range of motion of the left wrist. The x-ray reports revealed the resident had sustained a Left distal radius fracture. RI #362's wrist fracture was treated with immobilization, given pain medication, and asked to follow up with an orthopedic physician for further evaluation and treatment of [REDACTED]. Refer to F 6[AGE] and F [AGE]7. This deficient practice affected RI #362, one of 35 sampled residents, with the potential to affect the remaining 161 residents who reside in the facility being cared for by Licensed Staff of Contract Agency #1 and Contract Agency #2. This deficient practice placed RI #362 in immediate jeopardy as it was likely to cause serious injury, harm, impairment or death. On 1/31/2020 at 9:30 PM, the Administrator and Director of Nursing were given a copy of the Immediate Jeopardy (IJ) template and notified of the findings of immediate jeopardy in the area of Nursing Services, F [AGE]6; Findings include: The Contract Agency #1's FACILITY STAFFING AGREEMENT with an effective date of 7/10/2019, documented . ARTICLE 3. RESPONSIBILITIES OF FACILITY Section 3.1 Orientation. FACILITY will promptly provide (contract agency #1) Personnel an adequate and timely orientation to FACILITY. FACILITY shall review instructions regarding confidentiality (including patient and employee), and orient (Contract Agency #1) Personnel to . any of the FACILITY'S specific policies and procedures . The Contract Agency #2's CLIENT AGREEMENT FOR HEALTHCARE PROFESSIONAL SERVICES with an effective date of 7/22/2019, documented . 7. ORIENTATION POLICIES . It is the responsibility of the Client ([STAFFING CO]) to orient (Contract Agency #2) Professional to Client's facility and Client specific rules and regulations, all policies and procedures, all Client equipment, and to validate competency . RI #362 was admitted to the facility on [DATE]. RI #362 has a medical history to include [DIAGNOSES REDACTED]. During a telephone interview with EI #15, a RN on 1/16/2020 at 8:28 PM, the RN stated after being informed of the resident's continued complaints of pain, EI #15 stated he called the physician and got an order for [REDACTED].>RI #362's physician orders [REDACTED]. The 24 HOUR REPORT/CHANGE OF CONDITION REPORT dated 12/1/2019 indicated RI #362 had a left wrist and shoulder x-ray ordered during the day shift. There was no documentation listed for the evening and night shift for 12/1/2019. The [STAFFING CO] Radiology Results Report for RI #362 revealed on 12/1/2019 at 11:36 PM, the results of RI #362's wrist and shoulder x-ray was released to the facility. According to the report, . Reason for Study: . PAIN IN LEFT WRIST . Results: Recent. [MEDICATION NAME] fracture distal radius. Not displaced. [CONDITION]. Soft tissue swelling with [MEDICAL CONDITION] changes Conclusion: Fracture distal radius . In an interview on 1/17/2020 at 2:19 PM, EI #13, the DON was asked, what the facility's system was for receiving and reviewing x-ray results. EI #13 stated, once the x-ray results are completed, they were automatically uploaded in the facility's computerized charting system. The licensed nurse would then go into the computerized charting system and review the x-ray results. When asked whose responsibility it was to ensure the x-ray results had been received and reported to the physician, EI #13 replied, the ideal way was for the ordering nurse to report to the oncoming nurse that an x-ray had been ordered, so the oncoming nurse could be on the lookout for the results. EI #13 was asked how she ensured all the licensed nurses were aware of the facility's system. EI #13 answered, all the [STAFFING CO] licensed staff go through training on the facility's computerized charting system as part of orientation. However, [STAFFING CO] utilizes licensed nurses from different agencies and they are not provided the same training on the facility's computerized charting system as the licensed staff employed through the facility. In an interview on 1/29/2020 at 2:03 PM, EI #8, the Staff Development Coordinator (SDC) stated she has been the SDC for about a year. When asked what her job responsibilities were, EI #8 stated she did new hire orientation, periodic in-service education/training with [STAFFING CO] staff, but not with any staff from an agency. EI #8 was asked if the facility utilized licensed nursing staff from a contract agency and she said yes. When asked what was discussed in orientation regarding the facility's computerized charting system as it relates to diagnostic tests. EI #8 stated it was explained to the staff where in the computerized charting system the results are found. When asked how the facility ensured the licensed nurses from the contract agencies are oriented to the facility's computerized charting system, EI #8 answered, no one at the facility had sent a contact agency nurse to teach them about the facility's computerized charting system. EI #8 stated she assumed whoever the contract agency was placed with on the floor, would teach them what they needed to know about the computerized charting system. When asked who orientated the contact agency licensed nursing staff on the facility's policies and procedures, EI #8 stated no one, they get that orientation when they are placed on the floor to work. EI #8 was asked how a licensed nurse would look for the results of an x-ray and she stated, one should look in the computerized charting system because the facility no longer receives results by way of fax. On 1/29/2020 at 6:11 PM, an interview was conducted with Contract Agency #1 RN #2, the RN assigned to care for RI #362 during the 6:00 PM to 6:00 AM shift on 12/1/2019. RN #2 said facility nurses normally communicate about resident care from shift to shift on the 24-hour report. RN #2 said she did not get the results of the x-ray for RI #362 because the fax machine was not working. RN #2 said she had not been trained on where x-ray results would come, she just assumed they would come by way of fax. In a follow-up interview on 1/30/2020 at 6:49 PM, RN #2 stated she couldn't recall if she informed the oncoming shift nurse about RI #362's x-ray. When asked whose responsibility was it to ensure RI #362's x-ray results were received, and the physician was notified, RN #2 stated it was hers. RN #2 explained she didn't know the results were coming by way of the facility's computerized charting system; she thought the results would be faxed to the facility. When asked if she followed up on the results of RI #362's x-ray that was ordered on [DATE], RN #2 said she did not because she didn't know how to. During an interview on 1/31/2020 at 10:19 AM, Contract Agency #1 LPN #5 was asked if she had been orientated/trained on the facility's policy titled Clinician Notifications of Lab and Diagnostic Results. LPN #5 said no. A telephone interview was conducted on 1/31/2020 at 10:30 AM, with Contract Agency #2 LPN #2. When asked what system the facility had in place to receive x-ray results, LPN #2 stated, the facility received x-ray results by way of the fax. LPN #2 stated she has never looked or been told to look for x-ray results in the facility's computerized charting system. When asked if she had been orientated/trained on the facility's policy titled Clinician Notifications of Lab and Diagnostic Results, LPN #2 said no. In a follow up interview on 1/31/2020 at 1:15 PM, EI #8, the SDC stated the facility's agreement with Contract Agency #1 and Contract Agency #2 indicated the facility was responsible for orientating the agency staff on the facility's policies and procedures. EI #8 commented that she was not responsible for ensuring the licensed contract agency staff were familiar with the facility's policies and procedures. On 1/31/2020 at 1:40 PM, an interview was conducted with EI #19, the Human Resource/Payroll Director. EI #19 was asked did she give the licensed contract agency nurses anything in their new hire packet about the facility's policies and procedures or what to do concerning labs/x-ray results. EI #19 said no. EI #19 stated she guessed this would come from the House Supervisor. During an interview on 1/31/2020 at 2:09 PM, EI #18, the Assistant DON was asked who was responsible for ensuring the licensed contract agency staff followed the facility's policies and procedures. EI #18 replied, she would assume the SDC, the DON, Human Resources and herself. EI #18 stated she talked with licensed contract agency nurses to see if they had any questions or concerns. When asked which nurse she had spoken with, EI #18 replied, she couldn't think of any names. When asked if there was an evaluation or check system in place to ensure the contract agency staff was provided and trained on the facility's policies and procedures, EI #18 replied, she was sure that was discussed when the contract agency staff started. EI #18 acknowledged the facility's agreement with Contract Agency #1 and Contract Agency #2 indicated the facility was responsible for orientating the agency staff on the facility's policies and procedures. In an interview on 1/31/2020 at 2:33 PM, EI #11, a Licensed Practical Nurse (LPN) Unit Manager stated the licensed nurses from the contract agencies are to know the facility's policies and procedures just as if they are [STAFFING CO] nurses. EI #11 commented, we expect them to operate as if they are an [STAFFING CO] employee. EI #11 acknowledged the facility's agreement with Contract Agency #1 and Contract Agency #2 indicated the facility was responsible for orientating the agency staff on the facility's policies and procedures. In a follow up interview with the DON, EI #13, on 1/31/2020 at 5:50 PM, she was asked according to the facility's agreement with Contract Agency #1 and Contract Agency #2, who was responsible for orientating the agency staff on the facility's policies and procedures. EI #13 answered, the facility. When asked if anyone at the facility ever went back to see if the licensed staff from the contract agencies were adhering to the facility's policies and procedures, EI #13 replied, she didn't know if anyone had been following up to see if the agency nurses were following the facility's policies and procedures, but from here on out someone will. A review of the Personnel files for licensed nurses of Contract Agency #1 and Contract Agency #2, revealed no information in the files pertaining to staff being trained on the policies and procedures of the facility. ************************* On 2/1/2020 at 6:20 PM, the facility submitted an acceptable Removal Plan which documented: [STAFFING CO] Removal Plan for F[AGE]6 RI #362 was discharged from the facility on 12/2/19. The facility at this time has contracts with (Contract Agency #1) and (Contract Agency #2). We currently employ 2 nurses from (Contract Agency #2) and 5 from (Contract Agency #1). Beginning 01/31/20 Licensed Nurses including agency nurses were inserviced by Staff Development Coordinator on where to locate diagnostic results in the Medical Record on PCC. Inservicing will continue until all licensed staff, including agency nurses have been inserviced. No nurse will be allowed to work until this inservice has been attended. All new hires, including agency staff will receive this training/education on hire by the Staff Development Coordinator. Documentation of completed training will be kept in the Agency Nurses personnel file in the Human Resources Office. The Administrator or designee will audit agency nurse files to ensure compliance of training/education weekly for two months. Any identified issues will be addressed immediately. Results of the audits will be brought to the weekly QAPI meeting for the next month to review for trends and any changes needed. Any identified trends or concerns will be addressed immediately. Alleging removal on 2/1/20. ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F [AGE]6 was lowered to a F level on 2/1/2020, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as the result of the investigation of complaint/report number AL 402.

Based on interviews and review of Employee Identifier (EI) #13, the Director of Nursing, the DON failed to oversee the activities of the Nursing Department when she failed to ensure the Licensed Nurses from Contract Agency #1 and Contract Agency #2 were trained on the facility's policies and procedures and the facility's computerized charting system. On 11/30/2019 at 1:00 PM, Resident Identifier (RI) #362 was found on the floor by Employee Identifier (EI) #25, a Certified Nursing Assistant. The CNA informed the Registered Nurse (RN), EI #15. After continued complaints of pain, on 12/1/2019, EI #15 called the physician and an x-ray was ordered at 3:33 PM. On 12/1/2019 at 11:36 PM, RI #362's x-ray results were released to the facility's computerized charting system, which revealed the resident had sustained a recent left [MEDICATION NAME] radius, with soft tissue swelling. The RN, on duty and assigned to care for the resident when the x-ray results were sent to the facility, was an employee of Contract Agency #1. The RN stated she did not get the results of the x-ray for RI #362 because the fax machine was not working, and she had not been trained on where x-ray results would come. The facility's Director of Nursing (DON) stated the facility utilized licensed nurses from different agencies and they were not provided the same training on the facility's computerized charting system as the licensed staff employed through the facility. This failure led to the Ordering Physician and the resident's responsible party not being made aware of the results of the resident's x-ray. Furthermore, the resident received no treatment or further evaluation of the left distal radius fracture before being discharged home on[DATE]. Once the resident arrived home, RI #362's family member noticed swelling, bruising and guarding of the left arm. The resident complained of pain when the left arm was touched. When the change in the resident's condition was not improving, RI #362's family member called the physician and was asked to call an ambulance to have the resident transferred to the local hospital. RI #362 presented to the emergency room of the local hospital with mild to moderate swelling of the left wrist, minimal bruising, mild redness on the dorsal side of the wrist, and pain with attempted range of motion of the left wrist. The x-ray reports revealed the resident had sustained a Left distal radius fracture. RI #362's wrist fracture was treated with immobilization, given pain medication, and asked to follow up with an orthopedic physician for further evaluation and treatment of [REDACTED]. Refer to F 6[AGE], F [AGE]6 and F [AGE]7. This deficient practice affected RI #362, one of 35 sampled residents, with the potential to affect the remaining 161 residents who reside in the facility being cared for by Licensed Staff of Contract Agency #1 and Contract Agency #2. This deficient practice placed RI #362 in immediate jeopardy as it was likely to cause serious injury, harm, impairment or death. On 1/31/2020 at 9:30 PM, the Administrator and Director of Nursing were given a copy of the Immediate Jeopardy (IJ) template and notified of the findings of immediate jeopardy in the area of Administration, F [AGE]5. Findings include: The job description for the Director of Nursing with a revised date of June 2006, documented . General Purpose: To manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of the residents' needs . Personnel Functions * Interview, orient, train, evaluate and supervise nursing department personnel . In an interview on 1/17/2020 at 2:19 PM, EI #13, the DON was asked, what the facility's system was for receiving and reviewing x-ray results. EI #13 stated, once the x-ray results are completed, they were automatically uploaded in the facility's computerized charting system. The licensed nurse would then go into the computerized charting system and review the x-ray results. When asked whose responsibility it was to ensure the x-ray results had been received and reported to the physician, EI #13 replied, the ideal way was for the ordering nurse to report to the oncoming nurse that an x-ray had been ordered, so the oncoming nurse could be on the lookout for the results. EI #13 was asked how she ensured all the licensed nurses were aware of the facility's system. EI #13 answered, all the [STAFFING CO] licensed staff go through training on the facility's computerized charting system as part of orientation. However, [STAFFING CO] utilizes licensed nurses from different agencies and they are not provided the same training on the facility's computerized charting system as the licensed staff employed through the facility. In a follow up interview with the DON, EI #13, on 1/31/2020 at 5:50 PM, she was asked according to the facility's agreement with Contract Agency #1 and Contract Agency #2, who was responsible for orientating the agency staff on the facility's policies and procedures. EI #13 answered, the facility. When asked if anyone at the facility ever went back to see if the licensed staff from the contract agencies were adhering to the facility's policies and procedures, EI #13 replied, she didn't know if anyone had been following up to see if the agency nurses were following the facility's policies and procedures, but from here on out someone will. ************************* On 2/1/2020 at 6:20 PM, the facility submitted an acceptable Removal Plan which documented: [STAFFING CO] Removal Plan F [AGE]5 RI # 362 was discharged from the facility on 12/2/19. (Name of Diagnostic Service Provider) contract was reviewed on 01/31/20 by the Administrator and it was determined that labs/xrays will continue to be scanned directly into the facilities PCC (Point Click Care) system. On 1/31/20 DON, Administrator, and UM's were inserviced by the administrator on ensuring when a resident is discharged from the facility the resident/RP is made aware of the residents condition upon discharge, and ensuring the physician/family are notified of new orders, results of labs/xrays, and on ensuring staff are documenting continuity of care in the residents chart. The administrative staff were also inserviced on why it is important to train/educate agency nurses at the beginning of their contract on the facilities PCC system for obtaining lab/xray results. The Administrator will audit to ensure the DON and UM's are reviewing resident charts to ensure discharge documentation has been completed weekly for two months. QA was held on 01/31/20 with Administrator, DON, UM's, and MDS to discuss cited deficiencies. (Name), Medical Director notified by phone. Results of the audits will be brought to the weekly QAPI meeting for the next month to review for trends and any changes needed. Any identified trends or concerns will be addressed immediately. Alleging removal 2/1/20 ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F [AGE]5 was lowered to a D level on 2/1/2020, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as the result of the investigation of complaint/report number AL 402.

Based on interviews and review of Resident Identifier (RI) #362's medical and hospital records, the facility failed to provide treatment for [REDACTED]. On 11/30/2019 at 1:00 PM, RI #362 was found on the floor by Employee Identifier (EI) #25, a Certified Nursing Assistant. The CNA informed the Registered Nurse (RN), EI #15. When EI #15 assessed the resident, the resident complained of left arm pain. After continued complaints of pain, on 12/1/2019, EI #15 called the physician and an x-ray was ordered at 3:33 PM. RI #362's x-ray results were released to the facility's computerized charting system on 12/1/2019 at 11:36 PM. During a planned discharge scheduled for [DATE], RI #362 was discharged home, without notification to the resident's representative that an x-ray had been ordered or the results had been received that indicated the resident had sustained a [MEDICATION NAME] distal radius. While the facility was made aware of the resident's x-ray results, the resident received no treatment or further evaluation of the left distal radius fracture before being discharged home. Once the resident arrived home, RI #362's family member noticed swelling, bruising and guarding of the left arm. The resident complained of pain when the left arm was touched. When the change in the resident's condition was not improving, RI #362's family member called the physician and was asked to call an ambulance to have the resident transferred to the local hospital. RI #362 presented to the emergency room of the local hospital with mild to moderate swelling of the left wrist, minimal bruising, mild redness on the dorsal side of the wrist, and pain with attempted range of motion of the left wrist. The x-ray reports revealed the resident had sustained a Left distal radius fracture. RI #362's wrist fracture was treated with immobilization, given pain medication, and asked to follow up with an orthopedic physician for further evaluation and treatment of [REDACTED]. RI #362's family stated if they been notified the resident was ordered an x-ray after the fall and the results of the x-ray, they would have requested the resident be sent to the local hospital for further evaluation and treatment rather than being discharged home on[DATE]. The facility also failed to ensure RI #362 was provided pain medication for the resident's continued complaints of pain. The direct care staff and physical therapy staff indicated the resident complained of pain on 12/1/2019. The physical therapy staff indicated during the resident's therapy session on 12/1/2019, the resident's complained of pain that was rated as a nine out of 10, with movement; the resident's arm was swollen, and he/she couldn't raise the left arm up. RI #362's therapy session was limited due to the resident's complaints of pain and the pain limited the resident's ability to reach, stand and walk. The direct care staff indicated the resident's left arm was swollen. After continued complaints of pain, the direct care staff informed the RN that the resident was in pain and requested pain medication. There is no evidence within RI #362's medical record the resident was ordered and/or was administered any pain medication. This deficient practice affected RI #362, one of six sampled residents reviewed for accidents and placed this resident in immediate jeopardy as it was likely to cause serious injury, harm, impairment or death. On 1/31/2020 at 9:30 PM, the Administrator and Director of Nursing were given a copy of the Immediate Jeopardy (IJ) template and notified of the findings of immediate jeopardy in the area of Quality of Care, F 6[AGE]. Findings include: RI #362 was admitted to the facility on [DATE]. RI #362 has a medical history to include [DIAGNOSES REDACTED]. RI #362's incident report prepared by EI #15, a RN dated 11/30/2019 1:00 PM, documented . Notified by CNA that patient was on the floor. Went to assess patient. Sitting on floor facing the door, with legs straight and back against the left side of her bed. Patient stated (he/she) attempted to get up and then went to the floor. Assessed patient. Complaining of left arm pain, 3/10. No change noted in ROM to upper or lower extremities. No apparent injury noted. Assisted patient to bed . RI #362's AHAVA PAIN assessment dated [DATE], completed by EI #15, a RN indicated the resident had acute mild pain, that occurred less often than daily and the non-medication interventions used were relaxation and a cool compress. The [STAFFING CO] Progress Notes for RI #362 written by EI #15, a RN and dated 11/30/2019 1:07 PM, documented . Complained of left hand pain after incident. Applied ice. Effective. In an interview on 1/16/2020 at 6:35 PM, EI #25, a CNA acknowledged that she was the CNA who found RI #362 on the floor on 11/30/2019. EI #25 stated she notified the nurse, EI #15, who came in and assessed RI #362. After being assessed, the resident was placed in bed with the call light within reach. EI #25 stated on the next day, 12/1/2019, when the resident complained of pain in the left wrist, she notified the nurse, EI #15, again. According to EI #25, the nurse, EI #15, came to RI #362's room and said the resident's wrist didn't look broke or swollen but he would get an x-ray. During a telephone interview with EI #15, on 1/16/2020 at 8:28 PM, the RN acknowledged that he worked 11/30/2019 during the 6:00 AM to 6:00 PM shift. EI #15 also confirmed that he was the nurse who assessed RI #362 after the resident was found on the floor on 11/30/2019. EI #15 stated he did not see the resident fall, but a CNA informed me the resident had fallen. When asked if the resident was injured after the fall, EI #15 stated he didn't see any injuries but did recall the resident complaining of wrist pain. When asked if the resident was administered any pain medication for his/her complaints of pain, EI #15 stated he couldn't remember without looking at the resident's medical record. EI #15 stated he was again assigned to care for the resident on 12/1/2019 during the 6:00 AM to 6:00 PM shift. When asked if resident complained of pain during his shift, EI #15 stated yes, the resident complained of wrist pain. EI #15 stated he looked at RI# 362's wrist and didn't see any bruising or swelling. After being informed of the resident's continued complaints of pain, EI #15 stated he called the physician and got an order for [REDACTED].>RI #362's physician orders [REDACTED]. In a follow-up interview on 1/17/2020 at 10:57 AM, EI #25, the CNA assigned to care for RI #362 during the first shift on 12/1/2019, stated when the resident continued to complain of pain to the left wrist, she notified the nurse, EI #15. RI #362's Physical Therapy Treatment Encounter Note(s) documented Date of Service: 12/1/2019 . Precautions / Contraindication: fall risk, shaky, anxiety . Noted that pt (patient) had a fall yesterday and is complaining of left wrist pain. Noted pt's left wrist appeared to be swollen and pt inconsistantly stated (he/she) couldn't raise (his/her) arm up. Nurse notified and present to assess . Pain = Present, assessment indicated; Pain Assessment Method = Patient verbalized pain level; Does pain limit patient's functional activities? = Yes, Pain limits the following functional activities: reaching, standing, and walking; What relieves pain? = Sitting down, Remaining still; What exacerbates pain? = Reaching, Prolonged Activity . Pain at Rest = 0/10 . Pain with Movement = 9/10; Frequency = Intermittent; Location: left wrist; Pain Description/Type: Aching and Discomforting . Response to Session Interventions: . Limited session due to left wrist pain post fall yesterday . Complexities/Barriers Impacting Session: . Pain levels . A review of RI #362's Physician order [REDACTED]. In an interview on 1/17/2020 at 2:19 PM, EI #13, the Director of Nursing (DON) acknowledged that RI #362 was not ordered medication for pain. EI #13 stated if she would have received RI #362's x-ray results, she would have notified the physician and if they were unable to notify the physician, she would have sent the resident to the emergency room before sending the resident home on [DATE]. When asked how she became aware of the results of RI #362's x-ray results, EI #13 stated when the State Agency surveyors asked about the x-ray report. According to EI #13, the facility should have known prior to 1/16/2020, that RI #362 has sustained a distal radius fracture. When asked if RI #362's family should have been notified when an x-ray was ordered and the results of that x-ray before taking the resident home, EI #13 said yes. The [STAFFING CO] Radiology Results Report for RI #362 revealed on 12/1/2019 at 11:36 PM, the results of RI #362's wrist and shoulder x-ray were released to the facility by way of the facility's computerized charting system. According to the report, . Reason for Study: . PAIN IN LEFT WRIST . Results: Recent. [MEDICATION NAME] fracture distal radius. Not displaced. [CONDITION]. Soft tissue swelling with [MEDICAL CONDITION] changes Conclusion: Fracture distal radius . During a telephone interview with a family member of RI #362 on 1/16/2020 at 5:21 PM, the family member stated that she picked RI #362 up from the facility on [DATE] around 11:00 AM/12:00 PM. The family member observed that the resident's balance seemed a little off but attributed this to the resident being anxious to go home. When asked if she observed any injuries to the resident's arm when she transported the resident from the facility on 12/2/209, the family said no but she did notice RI #362's arm was bruised and swollen when the resident got home. On 12/3/2019, an ambulance was called to the family's home to transport RI #362 to a local hospital, where the family member stated the resident was diagnosed as having a broken left arm. After notifying the hospital staff that RI #362 had just been discharged from [STAFFING CO], the hospital staff telephoned the nursing facility and was informed by facility staff that the resident had a fall and that an x-ray was done which revealed a fractured radius. RI #362's family member stated she was not notified the resident had fallen, or that an x-ray was done or the results of the x-ray. The family member stated she called the facility on either 12/5/2019 or 12/6/2019 and left a message with the Unit Manager for someone to call her back, but the family member never received a return call from the facility staff. In a follow-up telephone interview on 1/17/2020 at 11:41 AM, RI #362's family member stated the resident was treated in the ER for a compound left arm fracture. According to the family member, because of the resident's age, surgery was not done. The resident's arm was placed in a temporary cast, RI #362 was referred to an orthopedic doctor and informed to follow up with the physician in two weeks for a permanent cast. At the two-week follow-up on [DATE], it was decided to keep the resident in the temporary cast for another two weeks. RI #362's family member stated the resident will follow up with the physician again on [DATE]20. The local hospital records for RI #362 revealed the resident arrived in the emergency roiagnom on [DATE] at 9:15 AM with a chief complaint of multiple falls and weakness. The report documented, . Pt. was dc'd (discharged ) from rehab yesterday and has been falling since, l (left) wrist swelling noted, pt reports no pain but unable to lift left arm . Physical Examination . There is mild to moderate swelling of the left wrist. There is very minimal bruising present. There is also pain with attempted range of motion of the left wrist. There is also some very mild [DIAGNOSES REDACTED] noted to the skin on the dorsil (dorsal) side of the wrist . Radiology results: X-ray, interpretation: X-ray of the left forearm shows an impacted distal radius fracture . Impression and Plan Distal radius fracture, left . Plan . Patient was given the following educational materials: Wrist Fracture Treated With Immobilization . Follow up with: (Name of Doctor) Within 1 to 2 days; Follow-up with orthopedics in 1 to 5 days for further evaluation and treatment of [REDACTED]. [MEDICATION NAME] as needed for pain . During an interview on 1/29/2020 at 11:34 AM, with EI #25, the CNA assigned to care for RI #362 on 12/1/2019, EI #25 was asked if the resident complained of pain. EI #25 replied, yes and that she informed the nurse, EI #15, of the resident's complaints of pain. When asked to describe the resident's complaint of pain, EI #25 stated the resident would flinch and say ouch when the left arm was touched. When asked if the resident requested some pain medication for the pain, EI #25 said yes. Around lunch time, the resident requested something for pain and EI #25 stated she informed the nurse, EI #15, of the resident's request for pain medication. EI #25 also stated she informed the nurse of the swelling of RI #362's arm on 12/1/2019; however, the nurse stated it was swelling from the fall. In an interview on 1/29/2020 at 2:03 PM, EI #8, the Staff Development Coordinator was asked what information should be documented that a resident has been ordered an x-ray. EI #8 replied, the x-ray has been ordered, the family has been informed of the new order for the x-ray, and the family and physician has been notified when the results are received. On 1/30/2020 at 9:47 AM, Contract Agency #1 Licensed Practical Nurse (LPN) #1 was asked what information would she expect to be documented in the resident's medical record once the resident has been ordered an x-ray. LPN #1 answered, the x-ray had been ordered, the reason for the x-ray, and notification of the family. During an interview on 1/30/2020 at 11:27 AM, EI #26, an LPN was asked should a nurse document in a resident's medical record when an order has been received for an x-ray. EI #26 replied, yes, there should be documentation the resident and/or their responsible party was notified of the new order for the x-ray. On 1/31/2020 at 10:30 AM, Contract Agency #2 LPN #2 was asked what information she would expect to the documented in the resident's medical record once the resident has been ordered an x-ray. LPN #2 stated that the physician had given an order for [REDACTED]. On 1/31/2020 at 2:09 PM, an interview was conducted with EI #18, the Assistant Director of Nursing. EI #18 was asked who was responsible for ensuring the resident's family was notified of x-ray results. EI #18 explained, if there was an order for [REDACTED]. This information should also be communicated to the Unit Manager from the Charge Nurse. When the x-ray results come in, the physician and resident's family are notified of the results and there should be documentation within the progress notes of such notifications. When asked who was responsible for ensuring there is follow up to the items listed on the 24 hours report, EI #18 answered, the Charge Nurse and Unit Manager. When asked what should be documented in the resident's medical record of a resident who has had an x-ray ordered, EI #18 replied, there should be documentation that an x-ray was ordered, the resident's family has been informed of the order for the x-ray and both physician and family notification of the results of the x-ray, along with any new orders the physician may have requested. A review of RI #362's medical record revealed documentation of the physician's orders [REDACTED]. There was no documentation to indicate the resident and/or the resident's representative had been notified of the new order for an x-ray. There was no documentation in the resident's medical record to indicate why an x-ray was ordered or of the resident's continued complaints of pain. During an interview on 1/31/2020 at 2:27 PM, EI #13, the DON was asked who was the House Supervisor during the time RI #362's x-ray was ordered on [DATE]. EI #13 replied, EI #21. During a telephone interview on 2/1/2020 at 5:55 PM, EI #21, the RN Supervisor stated he worked the 11:00 PM to 7:00 AM shift and weekends as the RN Supervisor. When asked if reviewed the 24 hours report dated 12/1/2019, EI #21 stated he couldn't remember if he reviewed the report or not. When asked if he was aware of RI #362's x-ray results, EI #21 stated he did not even know the resident had an order for [REDACTED].#21 was asked, what should have happened before the resident was sent home on [DATE]. EI #21 replied, the resident should have been sent to the hospital. When asked what the nurses were required to do once an x-ray has been ordered, EI #21 answered, notify the Supervisor, the resident's family and the physician when the results are received. During a telephone interview with EI #14, the facility's Medical Director and RI #362's Primary Physician on 1/17/2020 at 1:30 PM, he acknowledged that he didn't recall being informed of the left wrist and shoulder x-ray results for RI #362. When asked should he have been informed of the results of the resident's x-ray, EI #14 answered yes. When asked how soon he would have liked to be informed, EI #14 replied, on a finding such as the results of the resident's x-ray results, at the time the facility becomes aware. EI #14 was asked, if a wrist fracture was an emergency situation. EI #14 replied, a wrist fracture was urgent but not an emergent situation. When asked would it have been necessary to send the resident to the hospital for further evaluation before discharging the resident, EI #14 answered, given the resident was being discharged , he would have asked the resident's family what they wanted the facility to do; being sent to the hospital would have been an option because it needed to be dealt with urgently, but the resident could have also been seen by an orthopedic doctor. In a follow-up interview with RI #362's family member on 1/29/2020 at 9:11 AM, she was asked did RI #362 complain of pain on [DATE]. The family member stated the resident didn't complain of pain, but the resident guarded the left arm and would say ouch when it was touched. The family member noticed the left arm was swollen and bruised when the resident arrived home from [STAFFING CO]. The resident guarded the left arm and used the right arm to pick up the left arm. When asked if the facility informed her prior to the resident being discharged that an x-ray had been ordered, RI #362's family member stated the facility said nothing about an x-ray or the resident's arm. The nurse only went over the resident's medications and the need to follow up with the primary care doctor. When asked had she been notified of that RI #362's x-ray results revealed the resident had sustained a distal radius fracture, what would have wanted the facility to do, RI #362's family member stated inform the family and send the resident to the hospital before letting RI #362 be discharged from the facility. ************************* On 2/1/2020 at 6:20 PM, the facility submitted an acceptable Removal Plan which documented: [STAFFING CO] Removal Plan for F6[AGE] RI # 362 was discharged from the facility on 12/2/19. All residents having labs/xrays since 12/2/19 were reviewed and no lab/xrays revealed any resident has had a delay in treatment. Beginning 01/31/20 Licensed Nurses including agency nurses were inserviced by the Staff Development Coordinator on following the facility's policy and procedures related to informing the physician and family or responsible party of diagnostic results to ensure appropriate treatment is provided without delay. Inservicing will continue until all licensed staff, including agency nurses have been inserviced. No nurse will be allowed to work until this inservice has been attended. All new hires, including agency staff will receive this inservice on hire. Unit Managers and DON will audit diagnostic reports in the a.m. 5 x a week and the House Supervisor will audit diagnostic reports in the a.m. on weekends to ensure there has been no delay in treatment and services of residents. Any identified issues will be addressed immediately. Results of the audits will be brought to the weekly QAPI meeting for the next month to review for trends and any changes needed. Any identified trends or concerns will be addressed immediately. Alleging removal on 2/1/2020 ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F 6[AGE] was lowered to a D level on 2/1/2020, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as the result of the investigation of complaint/report number AL 402.

Based on interviews and review of Resident Identifier (RI) #362's medical and hospital records, the facility's policy titled Clinician Notifications of Lab and Diagnostic Results and the 24 HOUR REPORT/CHANGE OF CONDITION REPORT, the facility failed to notify Employee Identifier (EI) #14, the facility's Medical Director and RI #362's Ordering/Primary Physician of the results an x-ray of the resident's left wrist and shoulder that was ordered on [DATE]. On 12/1/2019 at 11:36 PM, the facility was made aware of the results of RI #362's wrist and shoulder x-ray, which revealed the resident had sustained a recent left [MEDICATION NAME] radius, with soft tissue swelling. While the facility was made aware of the resident's x-ray results, the Ordering Physician was not and the resident was discharged home from the facility on [DATE] around noon. Once the resident arrived home, RI #362's family member noticed swelling, bruising and guarding of the left arm. The resident complained of pain when the left arm was touched. When the change in the resident's condition was not improving, RI #362's family member called a physician and was instructed to call an ambulance to have the resident transferred to the local hospital. RI #362 presented to the emergency room of the local hospital with mild to moderate swelling of the left wrist, minimal bruising, mild redness on the dorsal side of the wrist, and pain with attempted range of motion of the left wrist. The x-ray reports revealed the resident had sustained a Left distal radius fracture. RI #362's wrist fracture was treated with immobilization, given pain medication, and asked to follow up with an orthopedic physician for further evaluation and treatment of [REDACTED]. This deficient practice affected RI #362, one of six sampled residents reviewed for accidents and placed this resident in immediate jeopardy as it was likely to cause serious injury, harm, impairment or death. On 1/31/2020 at 9:30 PM, the Administrator and Director of Nursing were given a copy of the Immediate Jeopardy (IJ) template and notified of the findings of immediate jeopardy in the area of Laboratory, Radiology, and Other Diagnostics Services, F [AGE]7. Findings include: The facility's policy titled Clinician Notifications of Lab and Diagnostic Results dated November 2017, documented Policy The faclity is to ensure the prompt notification to the clinician of lab and diagnostic results. Purpose To ensure prompt notification of laboratory values and diagnostic results that are outside o clinical reference ranges based on the physician's orders [REDACTED]. 8. Results outside the average range parameters will be placed in the clinicians's communcation book for the next business day review by the clinician, unless otherwise specified in the clinician's orders i.e. (for example) notify me of results as soon as available. 9. Any results deemed critical, will be phoned to the facility with a licensed staff member receiving the results. The licensed staff will promptly phone the results to the clinician for further orders. 10. The results of any orders following a critical lab or diagnostic result will be noted in the medical record either in the progress notes, lab results or order received following critical results. RI #362 was admitted to the facility on [DATE]. RI #362 has a medical history to include [DIAGNOSES REDACTED]. RI #362's incident report prepared by EI #15, a RN dated 11/30/2019 1:00 PM, documented . Notified by CNA that patient was on the floor. Went to assess patient. Sitting on floor facing the door, with legs straight and back against the left side of her bed. Patient stated (he/she) attempted to get up and then went to the floor. Assessed patient. Complaining of left arm pain, 3/10. No change noted in ROM to upper or lower extremities. No apparent injury noted. Assisted patient to bed . In an interview on 1/16/2020 at 6:35 PM, EI #25, a CNA acknowledged that she was the CNA who found RI #362 on the floor on 11/30/2019. EI #25 stated she notified the nurse, EI #15, who came in and assessed RI #362. After being assessed, the resident was placed in bed with the call light within reach. EI #25 stated on the next day, 12/1/2019, when the resident complained of pain in the left wrist, she notified the nurse, EI #15, again. According to EI #25, the nurse, EI #15, came to RI #362's room and said the resident's wrist didn't look broke or swollen but he would get an x-ray. During a telephone interview with EI #15, on 1/16/2020 at 8:28 PM, the RN acknowledged that he worked 11/30/2019 during the 6:00 AM to 6:00 PM shift. EI #15 also confirmed that he was the nurse who assessed RI #362 after the resident was found on the floor on 11/30/2019. EI #15 stated he did not see the resident fall, but a CNA informed me the resident had fallen. When asked if the resident was injured after the fall, EI #15 stated he didn't see any injuries but did recall the resident complaining of wrist pain. EI #15 stated he was again assigned to care for the resident on 12/1/2019 during the 6:00 AM to 6:00 PM shift. When asked if resident complained of pain during his shift, EI #15 stated yes, the resident complained of wrist pain. EI #15 stated he looked at RI# 362's wrist and didn't see any bruising or swelling. After being informed of the resident's continued complaints of pain, EI #15 stated he called the physician and got an order for [REDACTED].>RI #362's physician orders [REDACTED]. The 24 HOUR REPORT/CHANGE OF CONDITION REPORT dated 12/1/2019 indicated RI #362 had a left wrist and shoulder x-ray ordered during the day shift. There was no documentation listed for the evening and night shift for 12/1/2019. In an interview on 1/17/2020 at 2:19 PM, EI #13, the Director of Nursing (DON) acknowledged she became aware of the results of RI #362's x-ray results, EI #13 stated when the State Agency surveyors asked about the x-ray report. According to EI #13, the facility should have known prior to 1/16/2020, that RI #362 has sustained a distal radius fracture. When asked when was RI #362's x-ray ordered, EI #13 replied on 12/1/2019 at 3:00 PM. When asked when did the facility receive the results of the x-ray, EI #13 stated she didn't know. EI #13 was asked, what was the facilty's system for receiving and reviewing x-ray results. EI #13 stated, once the x-ray results are completed, they were automatically uploaded in the facility's computerized charting system. The licensed nurse would then go into the computerized charting system and review the x-ray results. When asked whose responsibility it was to ensure the x-ray results had been received and reported to the physician, EI #13 replied, the ideal way was for the ordering nurse to report to the oncoming nurse that an x-ray had been ordered, so the oncoming nurse could be on the look out for the results. EI #13 was asked how did she ensure all the licensed nurses were aware of the facility's system. EI #13 answered, all of the [STAFFING CO] licensed staff go through training on the facility's computerized charting system as part of orientation. However, [STAFFING CO] utilitizes licensed nurses from different agencies and they are not provided the same training on the facility's computerized charting system as the licensed staff employed through the facility. When asked if there was a system to ensure the physician was notified of the x-ray results, EI #13 answered, the nurse that received the results is supposed to notify the physician. EI #13 stated if she would have received RI #362's x-ray results, she would have notified the physician and if they were unable to notify the physician, she would have sent the resident to the emergency room before sending the resident home on [DATE]. The [STAFFING CO] Radiology Results Report for RI #362 revealed on 12/1/2019 at 11:36 PM, the results of RI #362's wrist and shoulder x-ray were released to the facility by way of the facility's computerized charting system. According to the report, . Reason for Study: . PAIN IN LEFT WRIST . Results: Recent. [MEDICATION NAME] fracture distal radius. Not displaced. [CONDITION]. Soft tissue swelling with [MEDICAL CONDITION] changes Conclusion: Fracture distal radius . On 1/29/2020 at 6:11 PM, an interview was conducted with Contract Agency #1 RN #2, the RN assigned to care for RI #362 during the 6:00 PM to 6:00 AM shift on 12/1/2019. RN #2 said facility nurses normally communicate about resident care from shift to shift on the 24-hour report. RN #2 said she did not get the results of the x-ray for RI #362 because the fax machine was not working. RN #2 said she had not been trained on where x-ray results would come, she just assumed they would come by way of fax. In a follow-up interview on 1/30/2020 at 6:49 PM, RN #2 stated she couldn't recall if she informed the oncoming shift nurse about RI #362's x-ray. When whose responsibility was it to ensure RI #362's x-ray results were received and the physician was notified, RN #2 stated it was hers. RN #2 explained she didn't know the results were coming by way of the facility's computerized charting system; she thought the results would be faxed to the facility. When asked if she followed up on the results of RI #362's x-ray that was ordered on [DATE], RN #2 said she did not because she didn't know how to. In an interview on 1/30/2020 at 7:17 PM, EI #24, acknowledged she was the LPN who discharged RI #362 home on [DATE]. When asked if she was informed RI #362 had been ordered an x-ray of the wrist due to complaints of pain, EI #24 stated she was not aware of this. EI #24 stated she only knew the resident had fallen a couple of days ago and was being discharged home on[DATE]. The 24 HOUR REPORT/CHANGE OF CONDITION REPORT dated [DATE] indicated RI #362 was discharged home in the afternoon. During a telephone interview with a family member of RI #362 on 1/16/2020 at 5:21 PM, the family member stated that she picked RI #362 up from the facility on [DATE] around 11:00 AM/12:00 PM. The family member observed that the resident's balance seemed a little off but attributed this to the resident being anxious to go home. When asked if she observed any injuries to the resident's arm when she transported the resident from the facility on 12/2/209, the family said no but she did notice RI #362's arm was bruised and swollen when the resident got home. On 12/3/2019, an ambulance was called to the family's home to transport RI #362 to a local hospital, where the family member stated the resident was diagnosed as having a broken left arm. After notifying the hospital staff that RI #362 had just been discharged from [STAFFING CO], the hospital staff telephoned the nursing facility and was informed by facility staff that the resident had a fall and that an x-ray was done which revealed a fractured radius. The local hospital records for RI #362 revealed the resident arrived in the emergency roiagnom on [DATE] at 9:15 AM with a chief complaint of multiple falls and weakness. The report documented, . Pt. was dc'd (discharged ) from rehab yesterday and has been falling since, l (left) wrist swelling noted, pt reports no pain but unable to lift left arm . Physical Examination . There is mild to moderate swelling of the left wrist. There is very minimal bruising present. There is also pain with attempted range of motion of the left wrist. There is also some very mild [DIAGNOSES REDACTED] noted to the skin on the dorsil (dorsal) side of the wrist . Radiology results: X-ray, interpretation: X-ray of the left forearm shows an impacted distal radius fracture . Impression and Plan Distal radius fracture, left . Plan . Patient was given the following educational materials: Wrist Fracture Treated With Immobilization . Follow up with: (Name of Doctor) Within 1 to 2 days; Follow-up with orthopedics in 1 to 5 days for further evaluation and treatment of [REDACTED]. [MEDICATION NAME] as needed for pain . During a telephone interview with EI #14, the facility's Medical Director and RI #362's Primary Physician on 1/17/2020 at 1:30 PM, he acknowledged that he didn't recall being informed of the left wrist and shoulder x-ray results for RI #362. When asked should he have been informed of the results of the resident's x-ray, EI #14 answered yes. When asked how soon he would have liked to be informed, EI #14 replied, on a finding such as the results of the resident's x-ray results, at the time the facility becomes aware. EI #14 was asked, if a wrist fracture was an emergency situation. EI #14 replied, a wrist fracture was urgent but not an emergent situation. When asked would it have been necessary to send the resident to the hospital for further evaluation before discharging the resident, EI #14 answered, given the resident was being discharged , he would have asked the resident's family what they wanted the facility to do; being sent to the hospital would have been an option because it needed to be dealt with urgently, but the resident could have also been seen by an orthopedic doctor. In a follow-up interview with RI #362's family member on 1/29/2020 at 9:11 AM, she was asked had she been notified of that RI #362's x-ray results revealed the resident had sustained a distal radius fracture, what would have wanted the facility to do, RI #362's family member stated inform the family and send the resident to the hospital before letting RI #362 be discharged from the facility. ************************* On 2/1/2020 at 6:20 PM, the facility submitted an acceptable Removal Plan which documented: [STAFFING CO] Removal Plan for F [AGE]7 RI # 362 was discharged from the facility on 12/2/19. All labs/X-rays have been reviewed on 01/31/20 by the Director of Nursing to ensure physician has been notified in a timely manner of abnormal findings. Labs/X-rays reviewed with abnormal findings revealed the physician had been notified of the abnormal finding. Beginning 01/31/20 Licensed Nurses including agency nurses were inserviced on where to find diagnostic results in the Medical Record on PCC. Inservicing will continue until all licensed staff, including agency nurses have been inserviced. No nurse will be allowed to work until this inservice has been attended. All new hires, including agency staff will receive this inservice on hire. Unit Managers and DON will audit diagnostic reports in the a.m. 5 x a week and the House Supervisor will audit diagnostic reports in the a.m. on weekends to ensure all notifications have been made and appropriate actions taken per our policies and procedures. Any identified issues will be addressed immediately. Results of the audits will be brought to the weekly QAPI meeting for the next month to review for trends and any changes needed. Any identified trends or concerns will be addressed immediately. Alleging removal on 2/1/20. ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F [AGE]7 was lowered to a D level on 2/1/2020, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as the result of the investigation of complaint/report number AL 402.

Based on interview, review of Resident Identifier (RI) #1's medical record, the emergency room (ER) record and a complaint received by the Alabama State Survey Agency, the facility failed to provide pain management to a resident experiencing pain. From 8/14/2018 to 8/15/2018, RI #1 was assessed as having a pain level of 9 on a scale of 0 to 10 (0 = no pain and 10 = worst pain). The ordered pain medication, [MEDICATION NAME], was not available in the facility for administration. When the medication did not arrive on 8/15/2018, RI #1 requested to be sent to the ER for pain relief. At the ER, RI #1 was administered pain medication and sent back to the facility. This deficient practice affected RI #1, one of three sampled residents reviewed for pain management. Findings include: RI #1 was admitted to the facility on [DATE]. RI #1 has a medical history to include: [MEDICAL CONDITIONS], Pain in right knee and Chronic Pain. RI #1's physician's orders [REDACTED].#1 was ordered [MEDICATION NAME] Tablet 15 MG (milligram) Give 1 tablet by mouth every 6 hours related to [MEDICAL CONDITION] . Tylenol Extra Strength Tablet 500 MG Give 2 tablet by mouth every 4 hours as needed for Pain . Page 8 of Mosby's (YEAR) NURSING DRUG REFERENCE 30TH EDITION with a copyright date of (YEAR), indicated Tylenol is an nonopioid [MEDICATION NAME] used to treat mild to moderate pain or fever. Page 811, revealed [MEDICATION NAME] is an opioid [MEDICATION NAME] used to treat moderate to severe pain. RI #1's Medication Administration Record [REDACTED]. According to the MAR, RI #1 received two Tylenol Extra Strength tablets on 8/14/2018 at 12:48 AM for a complaint of pain. During an interview on 9/11/2018 at 2:23 PM, RI #1 stated he/she had run out of [MEDICATION NAME] on 8/14/2018. According to RI #1, the facility administered him/her Tylenol instead. RI #1 stated when the [MEDICATION NAME] wasn't available on 8/15/2018, he/she asked to be sent to the ER for some pain relief because the pain was so bad. RI #1's progress note dated 8/15/2018 1:36 AM, documented . Resident awake saying (he/she) is hurting all over and cannot take the pain anymore. Resident took Tylenol at midnight for pain. BP (blood pressure) 103/63 HR (heart rate) 76 R (respiration) 18. Resident states (he/she) wants to go to the ER . RI #1's progress note dated 8/15/2018 3:56 AM, documented . Resident went to the ER at (local hospital) via ambulance at approximately 2:15am . Returned at this time. Alert, stated (he/she) was feeling some better since receiving meds (medications) in the ER. BP 107/78 HR 76 R 16. States (he/she) will rest now . The local hospital's emergency room record for RI #1 indicated the resident arrived in theER on [DATE] at 2:25 AM, with a chief complaint of pain. The record documented . Pt (patient) presents to ER for pain. Pt arrives via (by way of) EMS from Chandler Health and Rehab (Ahava Healthcare of Alabaster) for pain that has been ongoing. (He/She) admits (he/she) is out of (his/her) prescribed [MEDICATION NAME] (2 days). (He/She) has generalized body pain and a headache . According to the record, RI #1 was administered one [MEDICATION NAME] 5 MG tablet and 100 MCG (microgram) of [MEDICATION NAME]. On 8/15/2018 at 3:32 AM, RI #1 was discharged back to the nursing facility. Page 496 and page 894 of Mosby's (YEAR) NURSING DRUG REFERENCE 30TH EDITION with a copyright date of (YEAR), indicated [MEDICATION NAME] and [MEDICATION NAME] are opioid [MEDICATION NAME] used to treat moderate to severe pain. This deficiency was cited as a result of the investigation of complaint/report number AL 840.

Based on a review of the facility's Behavior Management policy, Resident Identifier (RI) #1's medical record and staff interviews, the facility failed to ensure RI #1, a cognitively impaired resident identified as at risk for elopement, who repeatedly voiced a desire to leave the facility, was placed on a behavior management plan to address repeated wandering/exit-seeking behavior. Beginning in January 2017, RI #1, a resident diagnosed with [REDACTED]. In April 2017, RI #1 called a taxi to take him/her away from the facility. Then two days before RI #1 eloped from the facility, on 6/7/2017, the resident was observed cursing stating he/she had to leave this place and looking out the door. During the early morning hours on 6/9/2017, RI #1 eloped from the facility, without staff knowledge and was found a bystander one quarter to a half mile away from the facility. RI #1 had fallen on the ground and complained of pain. Emergency Medical Technicians (EMTs) responded and assessed RI #1 for injuries. Unbeknownst to the EMT personnel that RI #1 was a resident of the nearby nursing facility, RI #1 was transferred to the local hospital for further evaluation. After identification, it was discovered that RI #1 had eloped from(NAME)Health & Rehab Center. Staff interview revealed, RI #1's elopement could have potentially been avoided had the facility placed the resident on a behavior management plan in January 2017, when the RI #1 began to voice a desire to leave the facility. This deficient practice placed RI #1, one of four sampled residents in immediate jeopardy as it was likely to cause serious injury, harm or death. On 7/20/2017 at 5:34 PM, Employee Identifier (EI) #1, the Administrator; EI #2, the Director of Nursing (DON); and EI #18, the Regional Nurse Consultant, were notified of the findings of immediate jeopardy level in the area of Medically Related Social Services, F 250. Findings include: The facility's policy with a subject title Behavior Management with a revision date of 1/15/2015, documented POLICY: It is the policy of (corporation name) to identify monitor and manage resident behaviors through an interdisciplinary team approach with the goal of implementing interventions that are individualized and provide for a safe and secure for our residents . This program will provide the staff with tools to manage those residents with behavior issues . Categories of Behaviors 1. Physical 2. Verbal 3. Inappropriate 4. Wandering Types of Behavioral Problems . 9. Wandering . PROCEDURE: 1. The behavior management plan of care and documentation tool is to serve as the plan of care, as well as, a means of monitoring and documenting resident behaviors, and is to include the behavior problem, goal, and daily monitoring of the behaviors . The plan of care is initiated by the Social Service Staff and updated as necessary. 2. When a new behavior is observed, the nurse will document this behavior in the nurses notes and initiate a Behavior Flow Sheet . The licensed nurse will notify Social Services of receiving a report of the behavior. When Social Services is notified of this behavior, a behavior management care plan will then be developed and implemented based on this information by the Social Service Staff. This care plan will address each type of behavior, interventions to be used to decrease the behavior, behavior triggers, environmental factors and desired outcomes . 8. All staff should notify the assigned nurse of any resident behaviors. The nurse will document these in Nurses Notes if new and other behavior on the flow sheet if not. These behavior management flow sheets will be done on a daily basis if behaviors present and reviewed on a monthly basis by the Behavior Management team . RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's ELOPEMENT RISK assessment dated [DATE], revealed RI #1 was cognitively impaired with poor decision making skills and verbally expressed the desire to go home. RI #1's Departmental Notes dated 1/22/17 7:12 PM, completed by EI #15, a LPN, documented Resident agitated, stating that (he/she) wants to go home. I'm about to leave this facility . Resident called POA (power of attorney) to come and get (him/her) out of facility. During a telephone interview with EI #15, a Licensed Practical Nurse (LPN), on 7/20/2017 at 12:20 PM, he stated RI #1 talked about leaving the facility one to two times when he was assigned to care for the resident. RI #1's Departmental Notes dated 2/21/17 9:59 PM, completed by EI #19, a LPN, documented Has developed pattern of spending time and time @ desk on phone. Trying to reach someone to get (him/her) out of here . During an interview on 7/20/2017 at 3:30 PM, EI #19, a LPN acknowledged she wrote the note dated 2/21/17 at 9:59 AM. EI #19 stated RI #1 talked about leaving the facility two to three times per week. According to EI #19 when RI #1's behaviors occurred, she reported them to the Social Worker and the Unit Manager. RI #1's Departmental Notes dated 4/7/2017 3:18 PM, completed by EI #20, a LPN, documented Resident at desk, called taxi, spoke with the taxi company and explained to them that (he/she) was in a nursing home and has dementia . RI #1's care plan titled Resident yells out wanting to go home . with a problem onset date of 5/18/2017 had the following approaches *Document resident behavior *Do not argue with the resident *Administer resident's behavior medications as ordered by physician *Talk with resident in calm voice when behavior disruptive. During an interview with EI #14, the Care Plan (CP)/Minimum Data Set (MDS) Coordinator on 7/20/2017 8:55 AM, she reviewed RI #1's care plan titled Resident yells out wanting to go home . and stated there were no behavioral interventions put in place to prevent the resident from eloping from the facility. RI #1's Departmental Notes dated 6/7/2017 9:15 AM (two days before RI #1 eloped from the facility), completed by EI #20, a LPN, documented Resident up in w/c (wheelchair) cursing stating that (he/she) has to leave this place . Observed resident going down the hall, looking out the door . During an interview with EI #2, the DON, on 7/20/2017 at 9:10 AM, she stated RI#1 was never placed on any behavior monitoring tool. During an interview on 7/20/2017 at 3:00 PM, EI #8, the Social Worker was asked if RI #1 was on a behavior management plan. EI #8 replied no. When asked why not, EI #8 stated the only behaviors she was aware of for RI #1 was yelling and screaming. When asked about RI #1's repeated comments about going home, EI #8 acknowledged she was aware of the resident's desire to leave the facility and the resident had packed his/her belongings. After reviewing the facility's Behavior Management policy, EI #8 stated RI #1 should have been placed on daily behavior monitoring. When asked the importance of behavior management, EI #8 stated to prevent behaviors and implement interventions to redirect the resident. When asked when should this have occurred, EI #8 stated probably in January (2017) after the departmental note. EI #8 explained that RI #1's elopement could have possibly been avoided had the resident been placed on behavior management. ************************* On 7/21/2017 at 3:35 PM, the facility submitted an Acceptable Allegation of Compliance, which documented: . F250 Facility failed to insure RI#1 with the [DIAGNOSES REDACTED]. 1. Corrective action: RI#1 no longer resides in the facility. On 06/09/2017, resident eloped from facility and was transported by EMS to local hospital then placed at another facility that has a designated locked unit. II. Systemic changes to prevent reoccurrence: A. Social Services Director to educate Social Worker on elopement risk care plans with interventions and all behaviors including resident stating wanting to go home, packing their cloths, yelling and cursing starting 07/21/17 with the completion date 07/21/17. B. Tracking tool for behavior which includes type of behavior and interventions and outcomes provided to Social services on completion of training 07/21/17. C. Re-assessment of the 23 ambulatory residents identified with the [DIAGNOSES REDACTED]. For those identified at risk, interventions were implemented and care planned per the new Elopement Prevention Policy on 07/21/2017. The 23 ambulatory residents were reviewed for any elopement behaviors that would require implementation of a behavior management program. If warranted behavior management program and monitoring would be initiated 07/21/2017 . ************************* After reviewing the facility's information provided in their acceptable Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 250 was lowered to a D level on 7/21/2017 at 7:35 PM, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 187.

Based on a review of Resident Identifier (RI) #1's medical record, www.dictionary.com and staff interviews, the facility failed to ensure RI #1's ELOPEMENT RISK ASSESSMENT indicated whether the resident was at risk of elopement. Elopement is defined as an act or instance of leaving a safe area or safe premises, done by a person with a mental disorder or cognitive impairment. Further, the facility failed to reassess RI #1 for elopement risk when the resident voiced repeated statements about his/her desire to leave the facility. With an incomplete assessment and no behavioral interventions to redirect the resident's behavior, during the early morning hours on 6/9/2017, RI #1 eloped from the facility, without staff knowledge. RI #1 was found by a bystander one quarter to a half mile away from the facility. RI #1 had fallen on the ground and complained of pain. Emergency Medical Technicians (EMTs) responded and assessed RI #1 for injuries. Unbeknownst to the EMT personnel that RI #1 was a resident of the nearby nursing facility, RI #1 was transferred to the local hospital for further evaluation. After identification, it was discovered that RI #1 had eloped, without staff knowledge, from(NAME)Health & Rehab Center. Refer to F 323. These deficient practices placed RI #1, one of four sampled residents, in immediate jeopardy as it was likely to cause serious injury, harm or death. On 7/20/2017 at 5:34 PM, Employee Identifier (EI) #1, the Administrator; EI #2, the Director of Nursing (DON), and EI #18, the Regional Nurse Consultant were notified of findings of immediate jeopardy level in the area of Resident Assessments, F 272. Findings include: According to www.dictionary.com, elopement is defined as . an act or instance of leaving a safe area or safe premises, done by a person with a mental disorder or cognitive impairment . RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's ELOPEMENT RISK assessment dated [DATE], completed by EI #13, a Registered Nurse (RN) revealed RI #1 was cognitively impaired with poor decision making skills and verbally expressed the desire to go home. This assessment did not indicate whether or not RI #1 was at risk for elopement as the section labeled SUMMARY/CONCLUSIONS/RECOMMENDATIONS was blank. During an interview on 7/18/2017 at 6:30 PM, EI #13, a RN, acknowledged she completed RI #1's ELOPEMENT RISK assessment dated [DATE]. When asked was RI #1 at risk for elopement, EI #13 stated she didn't answer that portion of the assessment. EI #13 explained the assessment was left open for the Care Plan Coordinator and Interdisciplinary Team to complete. When asked what training the facility had provided her on how to complete the assessment, EI #13 stated she relied on her nursing experience. When asked what's the purpose of the ELOPEMENT RISK ASSESSMENT, EI #13 stated it gave the staff an idea as to whether or not the resident was at risk for elopement and how to care plan. During an interview with EI #2, the DON, on 7/19/2017 at 9:45 AM, she said the facility did not have a policy on completing the Elopement Risk Assessments. After reviewing RI #1's ELOPEMENT RISK assessment dated [DATE], EI #2 said staff should have documented under summary/conclusions/recommendations section if the resident was at risk for elopement. During an interview with EI #14, the Care Plan (CP)/Minimum Data Set (MDS) Coordinator on 7/20/2017 8:55 AM, was asked if RI #1 was at risk for elopement. EI #14 replied, based on the assessment information she would have to say yes. When asked what should have been done after RI #1 was identified at risk for elopement, EI #14 replied, Social Service should have reviewed the assessment and developed a care plan. EI #14 explained the resident could have been moved to the Wanderguard unit. When asked what training she had received on how to complete the ELOPEMENT RISK ASSESSMENT, EI #14 replied, she had not received any training. An interview with EI #18, the Regional Nurse Consultant, was conducted on 7/20/2017 at 10:00 AM. After EI #18 reviewed RI #1's ELOPEMENT RISK assessment dated [DATE], she confirmed the assessment did not indicate whether or not the resident was at risk for elopement. EI #18 explained the assessment should probably indicate the resident's risk so staff would know. According to EI #18 the assessment needed to be revamped. EI #18 acknowledged the facility did not have a policy on how to complete the ELOPEMENT RISK ASSESSMENT but there should be to avoid situations like this one. RI #1's Departmental Notes dated 1/22/17 7:12 PM, completed by EI #15, a Licensed Practical Nurse (LPN), documented Resident agitated, stating that (he/she) wants to go home. I'm about to leave this facility . Resident called POA (power of attorney) to come and get (him/her) out of facility. RI #1's Departmental Notes dated 2/21/17 9:59 PM, completed by EI #19, a LPN, documented Has developed pattern of spending time and time @ desk on phone. Trying to reach someone to get (him/her) out of here . RI #1's Departmental Notes dated 4/7/2017 3:18 PM, completed by EI #20, a LPN, documented Resident at desk, called taxi, spoke with the taxi company and explained to them that (he/she) was in a nursing home and has dementia . RI #1's Departmental Notes dated 6/7/2017 9:15 AM, completed by EI #20, a LPN, documented Resident up in w/c (wheelchair) cursing stating that (he/she) has to leave this place . Observed resident going down the hall, looking out the door . During an interview on 6/23/2017 at 1:15 PM, EI #8, the Social Worker was asked if staff should have reassessed RI #1 for elopement risk based on the behaviors documented in the Departmental Notes dated 1/22/2017, 2/21/2017, 4/7/2017 and 6/7/2017. EI #8 said yes. ************************ On 7/21/2017 at 3:35 PM, the facility submitted an Acceptable Allegation of Compliance, which documented: . F272 The facility failed to assess RI#1 on the admission Risk Elopement form, facility failed to re-assess RI#1 for elopement after statements, wanting to go home, packing clothes. Corrective Action I RI # 1 no longer resides at facility. On 06/09/2017, resident eloped from facility and was transported by EMS to local hospital then placed at another facility that has a designated locked unit. II Systematic changes to prevent reoccurrence: A new Elopement Prevention Plan policy and procedure and Elopement Risk Assessment Scoring form was developed by Corporate Nurse Consultant on 07/20/2017. Components of the new policy Elopement Assessment Scoring form to be completed on admission to include scoring to assist in recognizing elopement risk. This score if range is in the medium to high range to be reported to SW, DON, Administrator for review with the Interdisciplinary Team (IDT). Care plan for the risk of elopement to be developed with intervention by the SW, DON, Administrator, and other members of the IDT team if score indicated the potential, interventions to be developed. If the score is medium to high, nurse is to notify supervisor immediately and interventions put in place immediately until the IDT can meet the next day. The IDT team consists of Administrator, Director of Nursing, Social Services Director, Maintenance Director and the Unit Managers. Residents who exhibit elopement behaviors will be re-assessed by the SW and results to be reported to IDT team for update of care plan with interventions. If score is medium to high, social worker will notify nurse supervisor immediately and interventions put in place immediately until IDT can meet the next day. Residents will be re-assessed quarterly per Social Services. Social Services was educated on the new policy and form 07/20/17 by Corporate Nurse Consultant. All staff, Administration, Nursing, Dietary, Maintenance, Activities, Social Services, was in-serviced on behaviors that would indicate the potential to elope, in-serviced started 06/24/2017 and completed by 06/27/2017. In-service conducted by Staff Development Coordinator, Director of Nursing and Unit Managers. Staff that has not been in-serviced will not be allowed to work until they have been in-serviced. Corporate Nurse Consultant has provided training for the House Supervisor, Social Worker and Staff Educator who provided in-service and training on new policy and form for all nurses started on 7/21/2017 with the 11-7 shift and to continue through all shifts, completion date 07/21/2017, to explain how to use the form and the implementation of the form with interventions and monitoring all nurses and social worker to receive training. No employee will be allowed to work until they have received training relative to the Elopement Prevention Plan policy and procedure and the Elopement Risk Assessment Scoring form. 20 nurses and 2 social workers have been in-serviced. 19 weekend nurses remain to be in-serviced. Staff educator is calling the weekend nursing staff to come in for the 07/21/2017, 3 pm in-service. Those weekend nurses that do not receive training on 07/21/2017 will receive training before their weekend shift begins by Staff Educator. Those that do not receive training will not be allowed to work a scheduled shift until education is completed and signed off by the employee and trainer. Re-assessment of the 23 ambulatory residents identified with the [DIAGNOSES REDACTED]. For those identified at risk, interventions were implemented and care planned per the new Elopement Prevention Policy on 07/21/2017 . *************************** After reviewing the facility's information provided in their acceptable Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 272 was lowered to a D level on 7/21/2017 at 7:35 PM, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 187.

Based on review of Resident Identifier (RI) #1's medical record and staff interviews, the facility failed to ensure a comprehensive care plan was developed with interventions on how to provide RI #1 a safe, secure environment and appropriate supervision to reduce the risk of elopement. Through staff interviews it was determined that facility staff had not identified the resident as being high risk for elopement. This resulted in no specific interventions being implemented when the resident exhibited behaviors of wanting to leave the facility. On 6/9/2017 at 5:37 AM, RI #1 was found by a bystander, who found the resident on the side of the roadway; the resident had fallen. The local fire department was notified. RI #1 complained of right shoulder pain. The resident, who was not identified as being a resident of the nursing facility was transported to the local hospital. At the local hospital, the resident was able to tell the hospital staff (his/her) son's phone number. RI #1's son was called and he stated that (his/her) father was supposed to be at the nursing home and must have eloped. RI #1's son also stated the resident has dementia and had recently been trying to leave the facility. Refer to F 323. This deficient practice placed RI #1, one of four sampled residents, in immediate jeopardy as it was likely to cause serious injury, harm or death. On 7/20/2017 at 5:34 PM, Employee Identifier (EI) #1, the Administrator; EI #2, the Director of Nursing (DON), and EI #18, the Regional Nurse Consultant were notified of findings of immediate jeopardy level in the area of Comprehensive Care Plans, F 279. Findings include: RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's ELOPEMENT RISK assessment dated [DATE], completed by EI #13, a Registered Nurse (RN) revealed RI #1 was cognitively impaired with poor decision making skills and verbally expressed the desire to go home. This assessment did not indicate whether or not RI #1 was at risk for elopement as the section labeled SUMMARY/CONCLUSIONS/RECOMMENDATIONS was blank. RI #1's care plan titled Resident yells out wanting to go home . with a problem onset date of 5/18/2017 had the following approaches *Document resident behavior *Do not argue with the resident *Administer resident's behavior medications as ordered by physician *Talk with resident in calm voice when behavior disruptive. EI #13, the RN who completed RI #1's ''ELOPEMENT RISK ASSESSMENT was interviewed on 7/18/2017 at 6:30 PM. EI #13 was asked how RI #1's elopement risk was addressed in his/her care plans. EI #13 replied she did not know. According to EI #13, a care plan should have been developed after the assessment was completed. During an interview with EI #2, the DON, on 7/19/2017 at 9:45 AM, she was asked how RI #1's elopement risk was addressed in his/her care plan, EI #2 said it was not addressed. EI #2 said she did not know why RI #1's care plan was not initiated until 5/18/2017. According to EI #2, the Social Worker and the Minimum Data Set (MDS) Coordinator were responsible for initiating the care plan. After review of RI #1's Departmental Notes, EI #2 said the Social Worker should have been made aware so that a care plan could have been initiated. During an interview with EI #14, the Care Plan (CP)/MDS Coordinator on 7/20/2017 8:55 AM, she stated Social Service was responsible for developing care plan interventions for residents at risk for elopement. When asked what should have been done after RI #1 was identified as at risk for elopement, EI #14 stated Social Service should have reviewed the assessment, developed a care plan and could have moved the resident to the Wanderguard unit. According to EI #14, the facility only developed a care plan for residents at risk for elopement once they are moved to the South unit (the Wanderguard unit). When asked why, EI #14 replied she didn't know. EI #14 explained there was a chance a resident could elope from the facility if they were not identified at risk for elopement and care planned. EI #14 reviewed RI #1's care plan titled Resident yells out wanting to go home . and stated there were no behavioral interventions put in place to prevent the resident from eloping from the facility. During an interview with EI #8, the Social Worker, on 7/19/2017 at 3:05 PM, she stated if a resident was determined to be at risk for elopement, their care plan would call for placing the resident on a more secure unit, a Wanderguard bracelet, the resident's picture in the code alert book, and staff monitoring. When asked why RI #1 did not have a care plan addressing leaving the facility or packing clothes until 5/18/2017, EI #8 said because she did not consider RI #1 an elopement risk. EI #8 went on to explain that a lot of dementia residents pack their clothing, but she did not consider that an elopement red flag. EI #8 also stated she was only aware of one time RI #1 voiced the desire to leave the facility. When asked why this had not been addressed in a care plan if she was aware, EI #8 again stated a lot of residents want to go home, but she had never care planned for that. When asked why it was important to initiate care plans to address behaviors and potential elopement risk, EI #8 said so that staff can address the problem, know how to approach the resident, and redirect them. *************************** On 7/21/2017 at 3:35 PM, the facility submitted an Acceptable Allegation of Compliance, which documented: . F279 The facility failed to develop a care plan for the risk of elopement after RI#1 after stating he wanted to go home and packing his clothes. I. Corrective Action: RI#1 no longer residents in the facility. On 06/09/2017, resident eloped from facility and was transported by EMS to local hospital then placed at another facility that has a designated locked unit. II. Systemic changes to prevent the reoccurrence: A. All staff was in-serviced on behaviors that would indicate the potential to elope, in-serviced started 06/24/2017 and completed by 06/27/2017. In-service conducted by Staff Development Coordinator, Director of Nursing and Unit Managers. Staff that has not been in-serviced will not be allowed to work until they have been in-serviced. B. In-services presented by Social Services Director on development of elopement care plans and behavior monitoring to Social Worker on 07/20/17. C. Social Services to present in-services to all nurses on following elopement risk care plans and reporting behaviors to Social Services starting 07/21/2017 completing on 07/21/2017. All staff, Administration, Nursing, Dietary, Maintenance, Activities, Social Services, was in-serviced on behaviors that would indicate the potential to elope, in-serviced started 06/24/2017 and completed by 06/27/2017. In-service conducted by Staff Development Coordinator, Director of Nursing and Unit Managers. Staff that has not been in-serviced will not be allowed to work until they have been in-serviced. Corporate Nurse Consultant has provided training for the House Supervisor, Social Worker and Staff Educator who provided in-service and training on new policy and form for all nurses started on 7/21/2017 with the 11-7 shift and to continue through all shifts, completion date 07/21/2017, to explain how to use the form and the implementation of the form with interventions and monitoring all nurses and social worker to receive training. No employee will be allowed to work until they have received training relative to the Elopement Prevention Plan policy and procedure and the Elopement Risk Assessment Scoring form. 20 nurses and 2 social workers have been in-serviced. 19 weekend nurses remain to be in-serviced. Staff educator is calling the weekend nursing staff to come in for the 07/21/2017, 3 pm in-service. Those weekend nurses that do not receive training on 07/21/2017 will receive training before their weekend shift begins by Staff Educator. Those that do not receive training will not be allowed to work a scheduled shift until education is completed and signed off by the employee and trainer. D. Re-assessment of the 23 ambulatory residents identified with the [DIAGNOSES REDACTED]. For those identified at risk, interventions were implemented and care planned per the new Elopement Prevention Policy on 07/21/2017 . ************************* After reviewing the facility's information provided in their acceptable Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 279 was lowered to a D level on 7/21/2017 at 7:35 PM, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 187.

Based on observation, review of Resident Identifier (RI) #1's medical record, the facility's investigation file, the Online Incident Reporting System Report, the Emergency Medical Technician (EMT)-Paramedic report, RI #1's hospital record and facility staff and EMT personnel interviews, the facility failed to ensure staff identified RI #1, a cognitively impaired resident with [DIAGNOSES REDACTED].#1's safety. Further, once RI #1 began making repeated verbal statements and displaying exit seeking behaviors to include calling a taxi, no safety measures and/or interventions were implemented. Thus, RI #1 exited the facility without staff knowledge during the early morning hours on 6/9/2017. The facility further failed to ensure the main lobby door and North Hall unit door were secured in a manner to prevent RI #1 from leaving the facility's premises without staff's knowledge. These deficient practices placed RI #1, one of four sampled residents, in immediate jeopardy as it was likely to cause serious injury, harm or death. On 7/20/2017 at 5:34 PM, Employee Identifier (EI) #1, the Administrator; EI #2, the Director of Nursing (DON), and EI #18, the Regional Nurse Consultant were notified of findings of substandard quality of care at the immediate jeopardy level in the area of Quality of Care, F 323. Findings include: According to the Online Incident Reporting System Report, the facility submitted an initial report to the State Agency which documented RI #1 eloped from the facility on 6/9/2017 without staff knowledge. The report indicated RI #1 was found approximately a quarter to a half of a mile from the facility by the fire department and transported to the local hospital for evaluation. The facility began an investigation as to how RI #1 got out of the building. The Emergency Medical Technician (EMT)-Paramedic report revealed on 6/9/2017 at 5:38 AM, EMT personnel was dispatched to a nearby location for a fall victim. Once arrived to the nearby location, they found RI #1 with a chief complaint of a fall. The report indicated . Bystander found patient on side of roadway and called (local fire department) . Pt (patient) reports falling on the roadway . The report further indicated RI #1 complained of right shoulder pain. After assessment, RI #1 was transferred to the local hospital. In a telephone interview on 6/30/2017 at 12:55 PM, EMT personnel #1 was asked about the incident involving RI #1 that occurred on 6/9/2017. According to EMT personnel #1, the call came in from a female bystander. EMT personnel #1 stated RI #1 was complaining of pain in his/her leg and was sitting on the ground. EMT personnel #1 said the resident was not in any distress but from his/her conversation something appeared not right. The resident did not object to transport to the local hospital for further evaluation. During a telephone interview with EMT personnel #2 on 6/30/2017 at 1:15 PM, he was asked about the incident involving RI #1 that occurred on 6/9/2017. EMT personnel #2 acknowledged that the resident was found a few blocks away from the nursing home. The resident was sitting on the ground with a bystander. According to EMT personnel #2, the bystander said RI #1 had fallen and was complaining of leg pain. EMT personnel #2 said he was unaware that RI #1 was a resident of the nearby nursing facility. When asked how busy the roadway was during the time of morning RI #1 was found, EMT personnel #2 said it was a heavily traveled highway. The hospital record for RI #1 indicated on 6/9/2017 at 6:09 AM, RI #1 arrived in the Emergency Department (ED) with a chief complaint of Altered Mental Status. The ED notes dated 6/9/2017 6:17 AM documented . Son states he has power of attorney over (RI #1) and that (RI #1) is supposed to be a resident at Chandler and must have eloped from the facility. He informed me that (RI #1) has dementia and has recently been trying to leave the facility. The facility's completed investigation report was received by the State Agency on 6/16/2017. The report documented . Conclusion: (RI #1) wanted to go home and to the bank, (he/she) watched the staff and other resident during the day of 06/09/17, . (RI #1) was seen throughout the early morning hours walking in the hall, going to the snack machine and back to (his/her) room when the staff was busy and no one was in the hall (RI #1) walked up the hall and out the front door was (which) . It was day light and (RI #1) walked to the side walk and walked down it toward the fire dept. (RI #1) did have a fall with no injury and was seen by the fireman at the fire station whom called (EMS personnel) and (RI #1) was taken to the ER. The allegation of neglect could not be substantiated, (RI #1) watched for the staff to be busy and not watching (him/her) before (he/she) left building . On 6/20/2017 at 4:00 AM, a State surveyor arrived at the facility's lobby door entrance and pulled on the door handle. The front door was unlocked, which allowed the surveyor to enter the facility lobby unnoticed. During the initial tour of the facility, all exit doors were checked to determine whether or not the exit door was locked or unlocked. Three exit doors were found to be unlocked. Those doors were: the front lobby door; the back door from the North hall that led to the Laundry and Smoking area; and the door on the Medical Specialty Unit (MSU). On 7/19/2017 at 11:13 AM, EI #17, the Maintenance Supervisor, confirmed there were 24 exit doors in the facility, and the main lobby, the North hall and the MSU doors were not armed with alarms prior to RI #1's elopement on 6/9/2017. In an interview on 7/20/2017 at 9:10 AM, EI #2, the DON was asked should something have been in place to ensure the doors were secure. EI #2 replied, yes. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's ELOPEMENT RISK assessment dated [DATE], completed by EI #13, a Registered Nurse (RN) revealed RI #1 was cognitively impaired with poor decision making skills and verbally expressed the desire to go home. This assessment did not indicate whether or not RI #1 was at risk for elopement as the section labeled SUMMARY/CONCLUSIONS/RECOMMENDATIONS was blank. During an interview on 7/18/2017 at 6:30 PM, EI #13, a RN, acknowledged she completed RI #1's ELOPEMENT RISK assessment dated [DATE]. When asked was RI #1 at risk for elopement, EI #13 stated she didn't answer that portion of the assessment. EI #13 explained the assessment was left open for the Care Plan Coordinator and Interdisciplinary Team to complete. When asked what's the purpose of the ELOPEMENT RISK ASSESSMENT, EI #13 stated it gave the staff an idea as to whether or not the resident was at risk for elopement and how to care plan. RI #1's Departmental Notes dated 1/22/17 7:12 PM, completed by EI #15, a Licensed Practical Nurse (LPN), documented Resident agitated, stating that (he/she) wants to go home. I'm about to leave this facility . Resident called POA (power of attorney) to come and get (him/her) out of facility. During a telephone interview with EI #15, a LPN, on 7/20/2017 at 12:20 PM, he stated RI #1 talked about leaving the facility one to two times when he was assigned to care for the resident. According to EI #15, when the behavior occurred, he reported it to the House Supervisor. RI #1's Departmental Notes dated 2/21/17 9:59 PM, completed by EI #19, a LPN, documented Has developed pattern of spending time and time @ desk on phone. Trying to reach someone to get (him/her) out of here . During an interview on 7/20/2017 at 3:30 PM, EI #19, a LPN acknowledged she wrote the note dated 2/21/17 at 9:59 AM. EI #19 stated RI #1 talked about leaving the facility two to three times per week. According to EI #19 when RI #1's behaviors occurred, she reported them to the Social Worker and the Unit Manager. RI #1's Departmental Notes dated 4/7/2017 3:18 PM, completed by EI #20, a LPN, documented Resident at desk, called taxi, spoke with the taxi company and explained to them that (he/she) was in a nursing home and has dementia . During an interview on 7/19/2017 at 1:50 PM, EI #20, a LPN, stated she recalled RI #1 using the telephone to call a cab. According to EI #20, EI #3, the Unit Manager was aware and assisted in canceling the taxi. RI #1's Quarterly Minimum Data Set (MDS), with an assessment reference date of 4/21/2017, indicated RI #1 was moderately impaired in cognitive skills, with a Brief Interview for Mental Status (BIMS) score of 9. RI #1 was assessed as requiring limited assistance with walking in the corridor and locomotion off the unit. RI #1's care plan titled Resident yells out wanting to go home . with a problem onset date of 5/18/2017 had the following approaches *Document resident behavior *Do not argue with the resident *Administer resident's behavior medications as ordered by physician *Talk with resident in calm voice when behavior disruptive. RI #1's Departmental Notes dated 6/7/2017 9:15 AM (two days before RI #1 eloped from the facility), completed by EI #20, a LPN, documented Resident up in w/c (wheelchair) cursing stating that (he/she) has to leave this place . Observed resident going down the hall, looking out the door . During an interview on 7/19/2017 at 1:50 PM, EI #20, a LPN was asked what she did when RI #1 expressed a desire to leave the facility on 6/7/2017. EI #20 said she notified the Unit Manager and redirected the resident. On 7/19/2017 at 2:35 PM, EI #3, the LPN Unit Manager, was asked about RI #1's behavior of exit seeking. When asked about the departmental note dated 1/22/2017, EI #3 said she was not aware of this. Regarding the 2/21/2017 departmental note, EI #3 stated she was only aware of the resident's use of the telephone but not about RI #1 desire to leave the facility. When asked about the departmental note dated 4/7/2017, EI #3 denied any knowledge of the incident and said the LPN (EI #20) should have notified her. EI #3 was asked about the departmental note dated 6/7/2017 and she replied that she was not aware of this incident either but should have been notified. During an interview with EI #2, the DON, on 7/19/2017 at 9:45 AM, EI #2 said the facility did not have a policy on completing the Elopement Risk Assessments. After reviewing RI #1's ELOPEMENT RISK assessment dated [DATE], EI #2 said staff should have documented under summary/conclusions/recommendations section if the resident was at risk for elopement. EI #2 explained if staff determined a resident is at risk of elopement, they should notify the Social Worker so the resident could be reassessed, care planned, and placed on behavior monitoring. When asked how RI #1's elopement risk was addressed in his/her care plan, EI #2 said it was not addressed. EI #2 said she did not know why RI #1's care plan was not initiated until 5/18/2017. According to EI #2, the Social Worker and the MDS Coordinator are responsible for initiating the care plan. After review of RI #1's Departmental Notes, EI #2 said the Social Worker should have been made aware so that a care plan could have been initiated. EI #2 said RI #1 should have been moved to a more secure unit with a Wanderguard. During an interview with EI #14, the Care Plan (CP)/MDS Coordinator on 7/20/2017 8:55 AM, she stated Social Service was responsible for developing care plan interventions for residents at risk for elopement. EI #14 was asked if RI #1 was at risk for elopement. EI #14 replied, yes. When asked what should have been done after RI #1 was identified as at risk for elopement, EI #14 stated Social Service should have reviewed the assessment, developed a care plan and could have moved the resident to the Wanderguard unit. According to EI #14, the facility only developed a care plan for residents at risk for elopement once they are moved to the South unit (the Wanderguard unit). When asked why, EI #14 replied she didn't know. EI #14 explained there was a chance a resident could elope from the facility if they were not identified at risk for elopement and care planned. After EI #14 reviewed RI #1's ELOPEMENT RISK assessment dated [DATE], she stated RI #1 should have been care planned and moved to the South unit. EI #14 explained that even if RI #1 was not actively trying to leave the facility, the risk was still present. Furthermore, EI #14 reviewed RI #1's care plan titled Resident yells out wanting to go home . and stated there were no behavioral interventions put in place to prevent the resident from eloping from the facility. During an interview on 7/19/2017 at 3:05 PM, EI #8, the Social Worker was asked why RI #1 did not have any care plan interventions to address the resident's exit seeking behaviors. EI #8 replied, the DON (EI #2) decides. According to EI #8, the facility only care planned residents at risk for elopement once they were moved to the South unit. In a follow-up interview with EI #8, the Social Worker on 7/20/2017 at 3:00 PM, she was asked if RI #1 was at risk for elopement. EI #8 said yes. According to EI #8, when the staff noted RI #1 was wanting to leave the facility, behavioral interventions should have been implemented and the resident should have moved to the secure unit (South unit). When asked when should this have occurred, EI #8 stated probably in January (2017) after the departmental note. EI #8 explained that RI #1's elopement could have possibly been avoided had the resident been placed on behavior management. ************************ On 7/21/2017 at 3:35 PM, the facility submitted an Acceptable Allegation of Compliance, which documented: . F 323 Facility failed to insure staff identified RI#1 as an elopement risk on admission so interventions could be developed, facility also failed to re-assess RI#1 Once he stated stating (he/she) wanted to go home, yelling, cursing and packing (his/her) clothes, allowing RI#1 to exit the facility on 06/09/17. Facility failed to insure the front lobby door and the door at the end of North hall was secure allowing RI#1 to exit the facility on 06/09/17. I. Corrective action: RI# No longer resident at the facility. On 06/09/2017, resident eloped from facility and was transported by EMS to local hospital then placed at another facility that has a designated locked unit. II. Systemic changes to prevent the reoccurrence. A. New Elopement Prevention Plan policy and procedure and Elopement Risk Assessment Scoring form developed by Corporate Nurse Consultant to include elopement score with intervention to help identify residents with the potential for elopement completed 07/20/17, Social Services was educated on policy and form 07/20/17 by Corporate Nurse Consultant. B. New Elopement Risk Assessment Scoring form to be completed on admission and re-assessment when resident display behaviors including yelling, cursing, wanting to go home and packing their clothes, using the score with a range from low to medium to high range with interventions to match scoring. Scores to be reported for review by the Interdisciplinary Team. C. All entrance/exit doors have been equipped with audible alarms that sound when the door is opened. Completed 6/23/2016 (2017). D. All staff, Administration, Nursing, Dietary, Housekeeping, Laundry, Maintenance, Activities, Social Services and Rehab staff, has been in-serviced relative to securing the building. In-service related to securing the building and the use and implementation of the new risk assessment will be made part of new hire orientation and will be on-going will be done quarterly. Completed 06/23/2017. E. In-services on elopement risk and behaviors were started 06/24/2017 and will be completed by 06/27/2017. In-service was conducted by Staff Development Coordinator, Director of Nursing and Unit Managers. Staff that has not been in-serviced will not be allowed to work until they have been in-serviced. All residents will be in-serviced on the alarms on 6/26/2017. This in-service will be conducted by the Social Services at their Resident Council meeting. A letter will be mailed to all responsible parties explaining the changes. Maintenance Director and/or designee will monitor all alarms daily to ensure compliance. House supervisors will monitor all alarms between 8p and 8a to ensure compliance. New policy and form in-service and training started on 07/21/2017 with the 7-3 shift and to continue through all shifts and weekend shifts completion date 07/21/2017, to explain how to use the form and the implementation of the form with interventions and monitoring. All nurses will not be allowed to work until they have received in-service training. Audit tool for maintenance and the house supervisors will be used to document daily compliance and that all alarms are in proper working order started on 06/26/17. F. Re-assessment of the 23 ambulatory residents identified with the [DIAGNOSES REDACTED]. For those identified at risk, interventions were implemented and care planned per the new Elopement Prevention Policy on 07/21/2017 . ************************ After reviewing the facility's information provided in their acceptable Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 323 was lowered to a D level on 07/21/2017 at 7:35 PM, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 187.

Based on observation, review of the Administrator's, Director of Nursing's and Social Services' job descriptions, the Social Worker's training record and staff interviews, the facility's administrative staff failed to ensure the facility staff were trained on the completion and interpretation of the ELOPEMENT RISK ASSESSMENT. The administrative staff also failed to ensure Employee Identifier (EI) #8, the Social Worker, was trained on her responsibility in completing Elopement Risk Assessments, care plan development and the facility's behavior management program. Furthermore, the facility's administrative staff failed to ensure measures were in place to prevent a wandering resident from exiting the facility without staff knowledge. These deficient practices placed RI #1, one of four sampled residents, in immediate jeopardy as it was likely to cause serious injury, harm or death. On 7/20/2017 at 5:34 PM, EI #1, the Administrator; EI #2, the Director of Nursing (DON), and EI #18, the Regional Nurse Consultant were notified of findings of immediate jeopardy level in the area of Administration, F 490. Findings include: Refer to F 250, F 272, F 279 and F 323 1) The facility's undated ADMINISTRATOR JOB DESCRIPTION documented SUMMARY Lead and direct the overall operation of the facility in accordance with resident needs, governing regulations and Company policies so as to maintain care for the residents while achieving the facility's business objectives by performing the following duties personally or through subordinate supervisors . On 6/20/2017 at 4:00 AM, a State surveyor arrived at the facility's lobby door entrance and pulled on the door handle. The front door was unlocked, which allowed the surveyor to enter the facility lobby unnoticed. During the initial tour of the facility, all exit doors were checked to determine whether or not the exit door was locked or unlocked. Three exit doors were found to be unlocked. Those doors were: the front lobby door; the back door from the North hall that led to the Laundry and Smoking area; and the door on the Medical Specialty Unit (MSU). On 7/19/2017 at 11:13 AM, EI #17, the Maintenance Supervisor, confirmed there were 24 exit doors in the facility, and the main lobby, the North hall and the MSU doors were not armed with alarms prior to RI #1's elopement on 6/9/2017. In an interview on 7/20/2017 at 9:10 AM, EI #2, the DON was asked should something have been in place to ensure the doors were secure. EI #2 replied, yes. During an interview on 7/20/2017 at 9:30 AM, EI #1, the Administrator was asked who was ultimately responsible for ensuring the safety of the residents, EI #1 stated it was his and DON's responsibility. 2) The facility's undated DIRECTOR OF NURSING JOB DESCRIPTION documented GENERAL PURPOSE OF JOB POSITION The primary purpose of the job position is to plan, organize, develop and direct the overall operation of the Nursing Services Department in accordance with current Federal, State, and local standards, guidelines, and regulations that govern this facility . to ensure that the highest degree of quality of care is maintained at all times . ESSENTIAL JOB FUNCTIONS . * Assure residents of a comfortable, clean, orderly and safe environment . * Assist in development of Patient Care Plans . * Have the administrative authority, responsibility and accountability for all functions, activities, and training of the nursing services department . During an interview on 7/18/2017 at 6:30 PM, EI #13, a RN, acknowledged she completed RI #1's ELOPEMENT RISK assessment dated [DATE]. When asked what training the facility had provided her on how to complete the assessment, EI #13 stated she relied on her nursing experience. During an interview with EI #2, the DON, on 7/19/2017 at 9:45 AM, she said the facility did not have a policy on completing the Elopement Risk Assessments. In a follow-up interview with EI #2, the DON, on 7/19/2017 at 12:15 PM, she confirmed the facility did not have any training related to the Elopement Risk Assessments and how to interpret the answers. EI #2 further stated that she had not received any training on hoe to complete the ELOPEMENT RISK ASSESSMENT. When asked how staff would know the expectations without a policy or any training, EI #2 replied, . can't teach someone common sense and that training would not hurt. During an interview on 7/19/2017 at 12:49 PM, EI #16, the Staff Development Nurse acknowledged the facility had no documentation on how the staff was trained to complete the ELOPEMENT RISK ASSESSMENT. During an interview with EI #8, Social Worker, on 7/19/2017 beginning at 3:05 PM, she was asked what training she had received related to the facility's ELOPEMENT RISK ASSESSMENT. EI #8 said none. When asked how she would know whether a resident was at risk for elopement without training on interpreting the assessments, EI #8 said she would not know unless it was really obvious. During an interview with EI #14, the Care Plan (CP)/Minimum Data Set (MDS) Coordinator on 7/20/2017 8:55 AM, was asked what training she had received on how to complete the ELOPEMENT RISK ASSESSMENT, EI #14 replied, she had not received any training. An interview with EI #18, the Regional Nurse Consultant, was conducted on 7/20/2017 at 10:00 AM. EI #18 acknowledged the facility did not have a policy on how to complete the ELOPEMENT RISK ASSESSMENT but there should be to avoid situations like this one. 3) The undated SOCIAL SERVICES JOB DESCRIPTION documented GENERAL PURPOSE OF JOB POSITION The primary purpose of the job position is to assist the Director of Social Services to manage the medically-related Social Services Program of the facility in accordance with federal, state and local standards, guidelines and regulations, and Company policies and procedures to ensure the highest possible level of resident physical, mental and psychosocial well-being . During an interview with EI #8, the Social Worker, on 7/20/2017 at 3:00 PM, she stated she had never seen the facility's Behavior Management policy. EI #8 explained that if she would have known of the policy, RI #1 would have been placed on a behavior management plan. A review of EI #8's training record, revealed EI #8 had been employed in the facility since 2008 and there was no documentation to indicate how EI #8 was oriented and/or trained by the facility on behavior management and Elopement Risk Assessments. In an interview on 7/20/2017 at 3:45 PM, EI #16, the Staff Development Coordinator stated the Social Worker (EI #8) should have received orientation upon hire on her responsibilities as a Social Worker. At 4:00 PM, EI #16 returned and stated the facility had no documentation EI #8, the Social Worker, had Social Services orientation. ************************* On 7/21/2017 at 3:35 PM, the facility submitted an Acceptable Allegation of Compliance, which documented: . F490: Facility failed to train staff on the use of the Elopement form and how to interpret the form on completion. Facility failed to provide training on behavior monitoring to Social Services. Facility failed to have measures in place interventions to monitor for elopement risk and exiting the building without staff knowledge. I. Corrective action: RI#1 no longer resident in the facility. On 06/09/2017, resident eloped from facility and was transported by EMS to local hospital then placed at another facility that has a designated locked unit. II. Systemic changes to prevent reoccurrence: A. New Elopement Risk Assessment Scoring assessment form developed by Corporate Nurse Consultant to include elopement score with intervention to help identify residents with the potential for elopement completed 07/20/17, Social Services was educated on the form 07/20/17 by Corporate Nurse Consultant. B. New Elopement Prevention Plan policy and procedure and Elopement Risk Assessment Scoring form in-service and training started on 07/21/2017 with the 7-3 shift and to continue through all shifts and weekend shifts completion date 07/21/2017, to explain how to use the form and the implementation of the form with interventions and monitoring. All nurses will not be allowed to work until they have received in-service training. C. All nursing staff in-serviced on behaviors that would indicate the potential to elope, in-service started 06/24/2017 and completed by 06/27/2017. In-service conducted by Staff Development Coordinator, Director of Nursing and Unit Managers. Staff that has not been in-serviced will not be allowed to work until they have been in-serviced. D. Social Services to present in-services to all nursing staff on following elopement risk care plans and reporting behaviors to social services staffing 07/21/2017, completing on 07/21/2017 E. All entrance/exit doors have been equipped with audible alarms that sound when the door is opened. Completed 6/23/2017. F. Tracking tool for behavior which includes type of behavior and interventions and outcomes provided to Social services on completion of training 07/21/17. G. Social Services to maintain behavior monitoring on residents who exhibit behaviors that could be a potential elopement risk . ************************* After reviewing the facility's information provided in their acceptable Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 490 was lowered to an D level on 07/21/2017 at 7:35 PM, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 187.

Based on a review of the Regional Nurse Consultant JOB DESCRIPTION and staff interview, the governing body of the facility failed to ensure policies were developed and implemented regarding the use of the facility's ELOPEMENT RISK ASSESSMENT. With an incomplete assessment and no behavioral interventions to redirect the resident's behavior, during the early morning hours on 6/9/2017, Resident Identifier (RI) #1, a cognitively impaired resident, eloped from the facility, without staff knowledge. RI #1 was found by a bystander one quarter to a half mile away from the facility. RI #1 had fallen on the ground and complained of pain. Emergency Medical Technicians (EMTs) responded and assessed RI #1 for injuries. Unbeknownst to the EMT personnel that RI #1 was a resident of the nearby nursing facility, RI #1 was transferred to the local hospital for further evaluation. After identification, it was discovered that RI #1 had eloped, without staff knowledge, from(NAME)Health & Rehab Center. This deficient practice placed RI #1, one of four sampled residents, in immediate jeopardy as it was likely to cause serious injury, harm or death. On 7/20/2017 at 5:34 PM, Employee Identifier (EI) #1, the Administrator; EI #2, the Director of Nursing (DON), and EI #18, the Regional Nurse Consultant, were notified of the findings of immediate jeopardy level in the area of Governing Body, F 493. Findings include: Refer to F 272, F 279 and F 323 The Regional Nurse Consultant JOB DESCRIPTION signed by EI #18, the Regional Nurse Consultant on 4/9/2015, documented GENERAL PURPOSE OF JOB POSITION The primary purpose of the job position is to plan, organize, develop and direct the overall operation of the Nursing Services Department in accordance with current Federal, State, and local standards, guidelines, and regulations . to ensure that the highest degree of quality care is maintained at all times . ESSENTIAL JOB FUNCTIONS . * . Review, update and revise policies . * Develop and maintain . nursing policy and procedure manuals . During an interview with EI #2, the DON, on 7/19/2017 at 9:45 AM, she said the facility did not have a policy on completing the Elopement Risk Assessments. In an interview on 7/20/2017 at 10:00 AM, EI #18, the Regional Nurse Consultant, was asked about her role in the facility. EI #18 stated she discussed any problems, conducted audits and made sure everything was in order. When asked if she had seen the ELOPEMENT RISK ASSESSMENT used by the facility, EI #18 said they met about three years prior to computerize the assessment. When asked what the policy was on utilizing the ELOPEMENT RISK ASSESSMENT, EI #18 said staff just asked the questions and recorded the answers. EI #18 explained there was no criteria for whether a resident was deemed an elopement risk or not; the decision was based on how the questions were answered. After reviewing the ELOPEMENT RISK ASSESSMENT used by the facility, EI #18 said it would be better if it specified what should be done based on the number of yes answers to the questions. EI #18 said their form needed to be revamped. When asked who was responsible for implementing nursing policies, EI #18 said she was. EI #18 said she did not know why they did not have a policy addressing the ELOPEMENT RISK ASSESSMENT, but they probably should to avoid situations, such as RI #1's elopement. ************************* On 7/21/2017 at 3:35 PM, the facility submitted an Acceptable Allegation of Compliance, which documented: . F493 Facility failed to ensure policy development and implication regarding the use of the elopement form on admissions and re-assessments. Corrective Action: I. Corporate Nurse to develop new Elopement Risk Assessment form and Elopement Prevention Plan policy and procedure for the use of the form. Completed on 07/20/2017. II. Systemic changes to prevent reoccurrence: A. In-Service presented via phone with E-mail confirmation from Corporate Nurse to facility Corporate Nurse Consultant on the policy and procedure for the development and implementation of Elopement Risk Assessment done on 07/20/17. B. New Elopement Prevention Plan policy and procedure and Elopement Risk Assessment Scoring form in-service and training started on 07/21/2017 with the 7-3 shift and to continue through all shifts and weekend shifts completion date 07/21/2017, to explain how to use the form and the implementation of the form with interventions and monitoring. All nurses and social worker will not be allowed to work until they have received in-service training. House Supervisor, Social Worker and Staff Educator who provided in-service and training on new policy and form for all nurses started on 7/21/2017 with the 11-7 shift and to continue through all shifts, completion date 07/21/2017, to explain how to use the form and the implementation of the form with interventions and monitoring all nurses and social worker to receive training . ************************* After reviewing the facility's information provided in their acceptable Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 493 was lowered to a D level on 7/21/2017 at 7:35 PM, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 187.

Based on review of the facility's Quality Assessment and Assurance policy, the Quality Assurance and Performance Improvement Meeting minutes 06/29/17 . and staff interviews, the QAA committee failed to determine the root cause of Resident Identifier (RI) #1's 6/9/2017 elopement from the facility once the investigation was completed. The committee failed to develop an action plan to address the root cause of the incident and any contributing factors to prevent reoccurrence and ensure the safety of other residents remaining in the facility. This deficient practice placed RI #1, one of four sampled residents, in immediate jeopardy as it was likely to cause serious injury, harm or death. On 7/20/2017 at 5:34 PM, Employee Identifier (EI) #1, the Administrator; EI #2, the Director of Nursing (DON); and EI #18, the Regional Nurse Consultant, were notified of the findings of immediate jeopardy level in the area of Quality Assessment and Assurance, F 520. Findings include: Refer to F 250, F 272, F 279, F 323, F 490 and F 493 The facility's policy with a subject of Quality Assessment and Assurance , revised 1/15/2015, documented POLICY: The facility has an established and maintained quality assurance program. This program is governed by a committee that is responsible for identifying those issues, processes, events, risk areas and educational needs associated with quality assurance activities. This committee develops plans of action needed to correct identified areas that demonstrate needed improvement . In an interview on 7/20/2017 at 10:15 AM, EI #2, the DON stated RI #1's elopement from the facility on 6/9/2017 was discussed in a QAA on 6/29/2017. A typed document labeled Quality Assurance and Performance Improvement (QAPI) Meeting minutes 06/29/17 . documented . 2. Results of the last complaint survey conducted on 06/20-06/24/17 reviewing and reporting on the audit for the door alarms from the house supervisor and the maintenance, Social Services to report on the care plans, nurse's notes and interventions for the dementia resident who ambulate . During a follow-up interview on 7/20/2017 at 5:07 PM, EI #2, the DON stated she completed her investigation into RI #1's elopement by the 14th of June. When asked if she had identified the root cause, EI #2 said she was concentrated on the doors of the facility because they did not have alarms on them, but she had noted that RI #1 was not on behavior management and was only care planned for yelling. When asked if the QAA committee had developed an action plan to address the concerns identified, EI #2 said the facility had talked about it. When asked if there was an action plan developed to correct the identified areas of needed improvement, EI #2 replied no. ************************* On 7/21/2017 at 3:35 PM, the facility submitted an Acceptable Allegation of Compliance, which documented: . F520: Facility DON failed to discover the root cause of RI#1's elopement at the end of the investigation and to prevent the re-occurrence, and to implement a plan to correct the issue and contributing factors to prevent reoccurrence of other residents in the facility I. Corrective action: RI#1 no longer resides in the facility. On 06/09/2017, resident eloped from facility and was transported by EMS (Emergency Medical Service) to local hospital then placed at another facility that has a designated locked unit. II. Systemic changes to prevent the reoccurrence. A. Investigation was conducted 06/09/2017 to 06/14/2017 will be re-opened by Director of Nursing on 07/21/2017 using root cause analysis and new findings will be added on 07/21/2017. B. QAPI meeting will be scheduled to review findings of state reportable investigations documentation of the root cause, contributing factors and plan to correct the issue before submitting to ADPH (Alabama Department of Public Health). The next QAPI will be conducted on 07/21/2017. Items to be reviewed will be new elopement assessment policy and form, interventions, training for nurses and social worker, state reportable, behavior monitoring and findings from 06/09/2017 elopement incident. ************************* After reviewing the facility's information provided in their acceptable Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 520 was lowered to a D level on 7/21/2017 at 7:35 PM, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 187.

Based on observation, interview and record review the facility failed to provide supervision for a resident who had expressed [MEDICAL CONDITION] and had been placed on suicidal precautions since the time of admission. Resident Identifier (RI) #1's Hospice Admission information documented RI #1 had a history of [REDACTED]. The facility's policy and procedure for Suicide Prevention directed the facility to take all suicidal threats and actions seriously and immediately assign a staff member to the resident one-to-one. RI #1 exited the facility in a wheelchair, unsupervised, without the knowledge of the staff for approximately one hour. RI #1 was found outside in an overturned wheelchair on the asphalt/area by a passerby. RI #1 sustained a bloody laceration of the forehead and other upper body areas of injury. On [DATE] at 5:52 PM, the Administrator, Director of Nursing Services, Corporate Nurse, and Human Resource Director were notified of the findings of Immediate Jeopardy level of J in the area of Resident Behavior and Facility Practices, F224. This deficient practice affected, RI #1, one of one sampled resident, who was known to have [MEDICAL CONDITION]. The immediate jeopardy began on [DATE], until the facility implemented immediate corrective actions. The Immediate Jeopardy was relieved onsite on [DATE] at 5:10 PM. Findings include: On [DATE], the Department of Public Health received a complaint. The complainant alleged that on [DATE] around 4:15 p.m., a resident was found by a passerby outside of the facility on the cement asking for assistance. The resident was tilted over in a wheelchair with a big knot on the head that was steadily dripping blood. Review of the facility's policy titled, Abuse and Unusual Occurrence-Prevention, revised [DATE] documented, . This facility does not permit staff, other residents, visitors, friends, . or any other individuals to mistreat, neglect or abuse residents . No resident will experience neglect or lack of care or services that would cause physical harm, mental anguish or mental illness. RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Additionally, RI #1 was admitted to Hospice Service on [DATE]. The admission Minimal Data Set (MDS), with the assessment reference date of [DATE], revealed RI #1 scored a 14 out a possible score of 15, which indicates he/she was cognitively alert. RI #1 was dependent for transfers and did not ambulate since she had lower extremity deficits. A review of RI #1's Departmental Note dated [DATE], timed 3:13 p.m., documented, SW (Social Worker) was notified by DON (Director of Nursing) that resident has stated (he/she) wants to kill (his/herself). DON stated it was reported by activities department. SW spoke with activities department and found out that resident's mother died at this facility when (he/she) was 14 and (he/she) is blaming the facility for (his/her) mother's death. Resident does not want to be in this facility due to (his/her) mother dying [MEDICAL CONDITION] at age 54 and resident is 53. Resident previously requested to be transferred to (Name of another Nursing Home). Resident stated to writer (he/she) wanted to transfer to (Name of another Nursing Home) because it is closer to where (his/her) niece lives.SW notified DON and nursing staff of resident's responses. Social Service will continue to follow. Review of RI #1's medical record revealed a New Order Transmission Form (undated) with orders to, Admit to (Name of Hospice Agency) Hospice, DNR (Do Not Resuscitate) . On Suicide Precautions The Hospice Certification and Plan of care documented RI #1's Hospice care started [DATE], with the principal [DIAGNOSES REDACTED]. According to a local hospital discharge summary dated, [DATE], the goal of care was, - no further treatment options with [MEDICAL CONDITION] and recent perforation. The narrative portion of this form, RI #1 was with Stage 3 [MEDICAL CONDITION] diagnosed in [DATE] during the time of [DIAGNOSES REDACTED]. pt (patient) is very depressed due to (his/her) condition and fear of dying. (He/She) has less than 6 months to live if (his/her) condition advanced [MEDICAL CONDITION] follows its expected course. Note . HX (history) OF HOMICIDAL AND [MEDICAL CONDITION]. A review of the [DATE], Medication Administration Records (MAR) revealed Suicide Precautions were added to the plan of care on [DATE] that required documentation once a shift. There were no other instructions noted on the MAR. The Care Plan for RI #1 was also reviewed. On [DATE], an entry was made, .Short term: Suicidal ideation . Goal and Target Date *Resident will not inflict harm to self (with next review date of [DATE]) . Approaches . Monitor resident behavior and report any changes promptly. Review of the facility policy updated [DATE], titled, Suicide Prevention documented, POLICY: (Name of another nursing home) takes all suicide threats and actions seriously. If a resident makes a suicidal statement or action to staff members, other residents, or visitors, the following procedures will be followed: . 2. Immediately assign a staff member to the resident one-to-one until all interventions are in place. This policy was presented during the survey and identifed as the policy this facility followed, although the policy has the name of another nursing home listed on the document. Review of RI #1's Resident Incident Report dated and timed, [DATE], at 4:36 p.m. revealed, Incident Type: Unobserved fall . Type of Injury: Skin tear, Hematoma, Closed head injury, Contuse (Contusion) . Location: Facility grounds . Equipment: Wheelchair - non-motorized . Alert and oriented (RI #1) was sitting on the porch outside . (his/her) wheelchair, (she/he) got on the sidewalk and tumbled over in (her/his) wheelchair . on the very top of right shoulder ball of clavicle is a skin tear about the size of a tennis ball; apx (approximately) 2 (inch) skin tear on (his/her) right elbow, a ,[DATE] dollar size hematoma on (his/her) right temporal (temporal) area, all three were bleeding . On [DATE], at 4:28 pm, EI #4, the Certified Nursing Assistant (CNA) assigned to the resident for the evening shift, was asked about the events surrounding RI #1's incident on [DATE]. EI #4 stated she had gotten to the unit about 2:50 p.m., and he/she was in his/her room in the wheel chair, talking on a cell phone. EI #4 stated that was the only time she had seen him/her since EI #4 was preparing to pass ice when the receptionist called the nurse and said there was a man/woman on the ground. EI #4 stated, When we went out it was . (RI #1) in (his/her) wheelchair. EI #4 stated RI #1 stated the wheelchair had flipped over on the side and hit the ground. EI #1's assigned room is the second room from the nurse's station, which is approximately 40 feet from the nurse's desk to the exit where RI #1 left the building. The facility's Social Worker, EI#2 was interviewed [DATE], at 4:00 p.m. When asked about RI #1, EI #2 stated the resident had been at the facility about a month and RI #1's psychosocial indicates the resident was down and depressed. When asked how she knew RI #1 was suicidal, EI #1 stated RI #1's niece had informed her during a careplan meeting and the nurses had informed her also. When asked about RI #1's suicide precaution, EI #2 stated there was a careplan in place to be sure the resident did not hurt his/herself. When asked if the resident could go outside alone, EI #2 stated usually without any assistance. When asked how facility staff would know if RI #1 went outside, EI #2 stated the resident would usually tell someone he/she is going out. EI #2 was asked if she thought allowing RI #1 to go outside alone after having suicidal ideation was a potential problem. EI #2 responded yes. EI #2 admitted it was not a safe practice to allow someone who had expressed suicidal thoughts to go outside alone. On [DATE], at 4:50 p.m., an interview with EI #3 the Licensed Practical Nurse (LPN) who cared for RI #1 on the [DATE], the day of the fall. EI #3 was asked if RI #1 had expressed a desire to commit suicide. EI #3 stated the resident had told her in the past that he/she had thought about suicide. EI #3 knew RI #1 was on suicide precautions, but when asked if RI #1 was allowed to outside the building, EI #3 did not know if the resident was allowed to go outside alone or not. The Director of Nursing (DON), EI #1, was interviewed [DATE], at 5:15 p.m. EI #1 stated, the resident was admitted to hospice and had suicide precautions on admission. EI #1 explained the facility's responsibility was to monitor RI #1 every shift and all during the shift. But when asked about a specific monitoring schedule for RI #1, the DON admitted RI #1 had no clearly defined monitoring schedule and the resident was not placed on one to one supervision. EI #1 was asked if RI #1 should have been allowed to go outside alone while on suicide precautions. EI #1 answered no. This tag was cited as a result on the investigation of complaint number AL 682. ******************************************************** F224-Quality of Life Supervision for resident with suicide ideations The Facility must insure that RI #1 receives supervision for suicide ideation. I Corrective Action Resident RI #1 was placed under suicide prevention per policy on [DATE] with one-on-one supervision provided by facility CNAs and LPNs with every 15 minute documentation which includes date; time what the resident is doing, and staff invention and signature. This documentation is kept in resident's room at all times with CNA/LPN during observation. The outcome of the assessment performed by Social Services Consultant, David Gillock, MSW was patient scored 9 out of 35 which indicates a low risk. A low risk score requires routine safety monitoring unless the patient exhibits self-injurious behavior. Staff to search all belongings upon admission to any unit; remove patient's belongings from the room which are deemed hazardous to the patient. Search any bags brought in by visitors and remove any hazardous items, medications or weapons. Patient will be monitored by fifteen (15) minute safety rounds. II All alert residents that are capable of expressing [MEDICAL CONDITION] were assessed by use of the assessment tool provided by Social Service Consultant, David Gillock, MSW, for any signs of suicidal thoughts. Any resident that exhibits signs and symptoms of [MEDICAL CONDITION], a full assessment will be done. The criteria for the assessments are threatening to hurt or kill self, looking for ways to kill self, seeking access to pills, weapons or other means, talking or writing about death, dying or suicide, hopelessness, rage, anger, seeking revenge, acting reckless or engaging in risky activities, seemingly without thinking, feeling trapped, increasing alcohol or drug abuse, withdrawing from friends, family or society, anxiety, agitation, unable to sleep or sleeping all the time, dramatic changes in mood, no reason for living, no sense of purpose in life, history of suicide attempt, [MEDICAL CONDITION], medical history, family problems. These assessments were performed by facility RN's and facility nurse consultant. The in-services were conducted by Nurse Consultant and House Supervisor. III Systematic changes to prevent reoccurrence. A. The policy for suicide prevention was implemented [DATE] with interventions. B. House supervisors and Staff Development Coordinator provided in-service on Suicide Prevention policy to on duty staff on [DATE] repeating on [DATE] and [DATE] until all staff is in-serviced. No staff member will take an assignment until they have received in-service training. C. MD and family notified [DATE]. D. RI#1 received a comprehensive assessment by Social Services Consultant, David Gillock, MSW using suicide risk initial assessment tool with criteria threatening to hurt or kill self, looking for ways to kill self, seeking access to pills, weapons or other means, talking or writing about death, dying or suicide, hopelessness, rage, anger, seeking revenge, acting reckless or engaging in risky activities, seemingly without thinking, feeling trapped, increasing alcohol or drug abuse, withdrawing from friends, family or society, anxiety, agitation, unable to sleep or sleeping all the time, dramatic changes in mood, no reason for living, no sense of purpose in life, history of suicide attempt, [MEDICAL CONDITION], medical history, family problems. IV Nurse consultant and staff educator to monitor Suicide Prevention Policy remains in effect for RI #1 to include one-on-one supervision with documentation every 15 minutes. DON and/or designee to monitor all procedures and intervention have been implemented per Suicide Prevention Policy. In the absence of administration, house supervisor will monitor to ensure compliance. Will report results to the QA/QI meeting. ******************************************************** After review of RI #1's comprehensive assessment completed by the social worker consultant; observation that RI #1's suicide precautions were implemented, review of staff in-service material and interview with staff to validate their knowledge of the material concerning the facility's suicide policy, it was determined the facility had implemented their AOCC and demonstrated their knowledge of their Suicide Management policy and procedure, allowing the survey team to exit the facility at 5:10 p.m.

Based on interview and record review the facility failed to ensure a resident admitted with suicide precautions and who had a history of [REDACTED]. RI #1 was not referred for further treatment. According to the Medical Director the facility failed to notify him for need to evaluate so services could be provided. Resident Identifier (RI) #1's, Hospice Admission information documented RI #1 had a history of [REDACTED]. The facility's policy and procedure for Suicide Prevention directed the staff to take all suicidal threats and actions seriously and immediately assign a staff member to the resident one-to-one. The policy further directed the staff to contact social services to provide crisis intervention counseling for the resident such as psychological evaluation. Review of RI #1's medical record revealed, from the time the resident was placed on suicide precautions on [DATE], the social worker did not interact with RI #1 until [DATE], nine days after the order was written to place the resident on suicide precautions. The Social Worker failed to put interventions in place, and/or refer the resident to an outside agency for treatment. On [DATE] at 5:52 PM, the Administrator, Director of Nursing Services, Corporate Nurse, and Human Resource Director were notified of the findings of Immediate Jeopardy level of J in the area of Quality of Life, F250. This deficient practice affected, RI #1, one of one sampled resident, who was known to have suicidal ideations. The immediate jeopardy began on [DATE], until the facility implemented immediate corrective actions. The Immediate Jeopardy was relieved onsite on [DATE] at 5:10 PM. Findings include: The SOCIAL SERVICES Job Description documented . GENERAL PURPOSE OF JOB POSITION .The primary purpose of the job position is to manage the medically related Social Services Program of the facility in accordance with federal, state and local standards, guidelines and regulations and Company policies and procedures to ensure the highest possible level of resident physical, mental and psychosocial well-being . ESSENTIAL JOB FUNCTIONS . Investigates case situations and presents information to Psychiatrist and Clinical Psychologist . Serves as a link between patient, psychiatric agency . Works directly in treatment relationship with patients, individually or in groups, in consultation with Psychiatrist . Nursing Services Policies and Procedures Manual for Suicide Prevention with an update on [DATE], POLICY: (Name of another nursing hone)takes all suicide threats and actions seriously. If a resident makes a suicidal statement or action to staff members, other residents or visitors, the following procedures will be followed: PROCEDURE; .11. Social Services will be contacted to provide crisis intervention counseling for the resident such as a psychological evaluation. This policy was presented during the survey and identified as the policy this facility followed, although the policy had the name of another nursing home listed on the document. The facility policy Suicide Threats includes: Policy Statement Resident suicide threats shall be taken seriously and addressed appropriately. Policy Interpretation and Implementation .6. As indicated a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Additionally, RI #1 was admitted to Hospice Service on [DATE]. The admission Minimal Data Set (MDS), with the assessment reference date of [DATE], revealed RI #1 scored a 14 out a possible score of 15, which indicates he/she was cognitively alert. RI #1 was dependent for transfers and did not ambulate since he/she had lower extremity deficits. The [DATE], RI #1's Hospice admission orders [REDACTED]SW (social worker) was notified by DON (Director of Nursing) that resident has stated (he/she) wants to kill (his/herself). DON stated it was reported by activities department. SW spoke with activities department and found out that resident's mother died at this facility when (he/she) was 14 and (he/she) is blaming the facility for (his/her) mother's death. Resident does not want to be in this facility due to (his/her) brother dying of cancer at age 54 and resident us 53 SW spoke with resident. SW asked if (he/she) had any thoughts of suicide, Resident stated, 'No' SW asked resident, 'Do you have any plans to harm yourself?' Resident responded 'No, I am fine. Resident changed the subject . SW notified DON and nursing staff of resident's responses. SW will continue to follow . RI #1 continued on suicide precautions. An entry in the Care Plan, with a Problem Onset of [DATE], revealed: Short-Term: Suicidal Ideation: Resident reported to activities department that (he/she) hates it here because (his/her) mother passed away at this facility due to cancer @ (at) 54 y.o. (year old) and resident is [AGE] years old. The Goal with a target date of [DATE] stated Resident will not inflict harm to self. Approaches include .Contact Social Services for evaluation and 1:1 meeting with resident . On [DATE], at 12:10 p.m., the resident's sponsor was asked if the resident had been or was suicidal. The sponsor replied, not now that he/she was aware, but the resident had a history. On [DATE], at 12:18 p.m., RI #1 was asked by the surveyor if he/she had ever wanted to harm themselves. RI #1 replied that he/she did. On [DATE], at 12:30 p.m., the Activity Director, EI #16 stated RI #1 had informed her that he/she had wanted to kill herself while a family member was present in the area. EI #16 stated she told EI #1, Director of Nursing, and had followed up with EI #2, Social Worker. When asked if she knew RI #1 was on suicide precautions, EI #16 stated no, but knew to notify the Director Of Nursing and Social Worker. The Social Service Department Head, EI #13 was interviewed on [DATE] at 9:00 a.m. EI #13 was asked to clarify the policy for suicidal precautions. EI #13 stated the social worker or registered nurse goes to ask if the resident has a plan. If no plan for suicide, then a monitoring tool is put in place, checks ever one to two hours or how long the nurse writes and if they have plan, they are sent out to a psych unit. When asked how the social worker should monitor a resident on precautions, EI #13 stated the resident should been seen as often as the tool stated (every one to two hours or however long the nurse documented in the record). EI #13 stated social services should document for a resident on suicide precautions at least once a week in the notes and the note should include the resident's behaviors also. On [DATE] at 11:40 a.m., RI #1's physician, EI #11 was interviewed. EI #11 stated the facility had not made him unaware that RI #1 was on suicide precautions, but would expect the facility to follow their policy. This tag was cited as a result on the investigation of complaint number AL 682. ********************************************************** The facility must insure that RI # 1 receives Social Services assessment and follow-up related to Suicide Ideations. I Corrective Action A. Social Services Consultant, David Gillock, MSW, conducted an assessment on [DATE] for RI#1 using the Suicide Risk Initial Assessment tool with criteria threatening to hurt or kill self, looking for ways to kill self, seeking access to pills, weapons or other means, talking or writing about death, dying or suicide, hopelessness, rage, anger, seeking revenge, acting reckless or engaging in risky activities, seemingly without thinking, feeling trapped, increasing alcohol or drug abuse, withdrawing from friends, family or society, anxiety, agitation, unable to sleep or sleeping all the time, dramatic changes in mood, no reason for living, no sense of purpose in life, history of suicide attempt, psychosis, medical history, family problems. II All alert residents that are capable of expressing suicidal ideations were assessed by use of the assessment tool provided by Social Service Consultant, David Gillock, MSW, for any signs of suicidal thoughts. Any resident that exhibits signs and symptoms of suicidal ideations, a full assessment will be done using assessment tool provided by Social Services Consultant, David Gillock, MSW. These assessments were performed by facility RN ' s and facility nurse consultant. III Systematic changes to prevent reoccurrence: A. Social Services developed a care plan for Suicide Prevention which includes all interventions covered under Suicide Prevention Policy on [DATE]. B. All CNAs, LPNs and RNs were in-serviced using criteria for the assessments are threatening to hurt or kill self, looking for ways to kill self, seeking access to pills, weapons or other means, talking or writing about death, dying or suicide, hopelessness, rage, anger, seeking revenge, acting reckless or engaging in risky activities, seemingly without thinking, feeling trapped, increasing alcohol or drug abuse, withdrawing from friends, family or society, anxiety, agitation, unable to sleep or sleeping all the time, dramatic changes in mood, no reason for living, no sense of purpose in life, history of suicide attempt, psychosis, medical history, family problems. Suicidal Risk Initial Assessment tool was used. Facility House Supervisor conducted in-services on [DATE] and [DATE]. IV Nurse Consultant and Staff Educator to monitor suicide ideation assessment and follow up is completed appointments have been made as soon as possible ongoing to be reported in QA/QI with any changes or updates and kept in Social Services office for review. Facility nurse consultant will monitor Social Services assessments and follow up. ********************************************************** After review of RI #1's comprehensive assessment completed by the social worker consultant; review of the updated careplan for suicide prevention, review of the Suicidal Risk Initial Assessment tool, observations that RI #1's suicide precautions were implemented, review of staff in-service material and interview with staff to validate their knowledge of the material concerning the facility's suicide protocol, it was determined the facility had implemented their AOCC and demonstrated their knowledge of their Suicide Management policy and procedure, allowing the survey team to exit the facility at 5:10 p.m.

Based on record review and interview the facility failed to provide supervision for a resident on suicide precautions and who had a history of [REDACTED].#1 exited the building unattended 0n [DATE] and sustained an unwitnessed fall with injuries. According to Resident Identifier (RI) #1's, Hospice Admission information, RI #1 had a history of [REDACTED]. The facility's policy directed staff to take preventative actions to prevent the resident from endangering self and others and to take all suicidal threats and actions seriously and immediately assign a staff member to the resident one-to-one. The DON stated the facility did not conduct every 15 minute checks as outlined by policy. The facility staff members caring for Resident Identifier (RI) #1 confirmed they were unaware and did not provide the every 15 minute checks, resulting in RI #1 exiting the building unsupervised on [DATE] and sustaining an unwitnessed fall with injury that required medical attention beyond first aid. The fall resulted in injuries that included lacerations to the head, hematoma and edema to forehead, a large skin tear of the right shoulder that left the area denuded and skin tears of the right elbow and hand. In addition, the resident sustained [REDACTED]. On [DATE] at 5:52 PM, the Administrator, Director of Nursing Services, Corporate Nurse, and Human Resource Director were notified of the findings of Immediate Jeopardy level of J in the area of Quality of Care, F323 (Accidents). This deficient practice affected, RI #1, one of three sampled resident, who had sustained falls. The immediate jeopardy began on [DATE], until the facility implemented immediate corrective actions. The Immediate Jeopardy was relieved onsite on [DATE] at 5:10 PM. Findings include: On [DATE], the Department of Public Health received a complaint. The complainant alleged that on [DATE] around 4:15 p.m., a resident was found by a passerby outside of the facility on the cement asking for assistance. The resident was tilted over in a wheelchair with a big knot on the head that was steadily dripping blood. On [DATE], at 10:34 a.m., an interview was conducted with the passerby who found the resident outside on the cement on [DATE]. The passerby stated he and his daughter found the resident outside the facility, overturned in a wheelchair. The passerby stated the resident's head was injured and he noted a pool of blood as RI #1's head was on the asphalt and the rest of RI #1's body was out of the wheelchair. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Additionally, RI #1 was admitted to Hospice Service on [DATE]. The admission Minimum Data Set (MDS), with the assessment reference date of [DATE], revealed RI #1 scored a 14 out a possible score of 15, which indicates he/she was cognitively alert. RI #1 was dependent for transfers and did not ambulate since she had lower extremity deficits. According to the MDS, he resident had a fall prior to admission and sustained a fall with injuries while residing in the facility. RI #1's Care Plan dated [DATE], identified Problem/Need Potential to fall Terminal Cancer Impaired Mobility Generalized weakness Fall [DATE]. The new approach: Res (resident) may continue to go out on porches, but not propel self off the porches without assistance due to the fall on [DATE]. The Care Plan for RI #1 also included an entry on [DATE], .Short term: Suicidal ideation .Goal and Target Date *Resident will not inflict harm to self with next review date of [DATE].Approaches .Monitor resident behavior and report any changes promptly. During an interview on [DATE] at 11:15 a.m. EI #6 , an LPN working the night of the incident, stated made her rounds and last saw RI #1 at 3:30 p.m. During an interview on [DATE] at 9:28 a.m., EI #4 CNA, recalled seeing RI #1 sitting in a wheelchair talking on a cell phone in his/her room. A review of the incidents and accident reports date [DATE] at 4:30 p.m. revealed RI #1 had a history of [REDACTED]. At that time RI #1 was sent to the emergency room for evaluation. A second incident accident report dated [DATE] at 4:36 p.m., revealed RI #1 was found by a bystander lying in the asphalt driveway while overturned in the wheel chair with the wheels remaining on the sidewalk. At the time of this fall, RI #1 sustained injuries as described: on the very top of right shoulder ball of the clavicle is a skin tear about the size of a tennis ball; apx (approximately) 2 (inch) skin tear on (RI #1's) right elbow, a ,[DATE] dollar size hematoma on (RI #1's) right temporal area, all three were bleeding and care and tx (treatment) was rendered; cleaning application of abx (antibiotic) ointment and dressings, xrays of skull, elbow and shoulder were done as (RI #1) was complaining of pain in those areas .nursing assessment, cleaning and treatment of [REDACTED]. On [DATE] at 10:15 a.m., the surveyor walked the path from RI #1's point of exit around the sidewalk to the end point (where the resident was found). The circular sidewalk was adjacent to the driveway/parking lot on the outside with the exterior building surrounded by shrubs. The cemented side walk was inspected and found to have the following breaks: 1) superficial cracked area near the end of the sidewalk closest to the administrators office; 2) break/separation in the cement ,[DATE] inch deep as the sidewalk curves at the bushes: 3) two separate cracks at the juncture of two sections that came together to make a V-shape. At the deepest point of the V was a 1 ,[DATE] inch depression and 4) closest to the end of the circle, was a ,[DATE] inch separation in the cracked cement. On [DATE] at 9:55 a.m., EI #8, the day shift CNA, stated the shift had ended and she had left for the day. EI #8 had been informed by staff that RI #1 had gone outside and had flipped in the wheelchair. When asked if someone was with the resident, EI #8 said no, but thought someone should have been. On [DATE], at 4:28 p.m., EI #4, the evening shift CNA, stated she arrived on the unit on [DATE] at around 2:50 p.m. At that time, RI #1 was in the room, sitting in the wheelchair, talking on a cell phone. EI #4 did not observe RI #1 again until responding to the call concerning the fall. EI #4 went to assist with caring for RI #1 after the fall in the front of the building. EI #4 stated, When we went out, it was RI #1 in her wheelchair, RI #1 was on the sidewalk. Once you go around the bushes it narrows; RI #1 had flipped over the side and hit her head on the ground. When asked where the wheels were located, she replied they were cocked up on the side and as you went around at bushes the front wheel was at the cracked sidewalk and the chair was turned over. EI #4 further stated RI #1 was laying on the asphalt, bleeding from her forehead and the shoulder. When asked how much the resident was bleeding, EI #4 stated it was a lot, maybe a half cup already on the ground. Staff then took RI #1 to the room and cleaned the resident up. On [DATE] at 3:26 p.m., EI #5, the Registered Nurse Supervisor, was asked about the events surrounding RI #1 ' s [DATE] fall. EI #5 stated she went to the resident's room to assess the resident. EI #5 said he/she had been told RI #1 had fallen out of the wheelchair outside. EI #5 also stated there was no one with RI #1 at the time of the fall. RI #1 was cleaned up and the physician was notified of the fall. EI #5 stated the resident refused to go to the hospital so a mobile X-ray was completed at the facility. On [DATE], at 6:10 pm, RI #1 was asked if the facility explain why he/she needed to go to the hospital. RI #1 explained how he/she didn't want to go to (the local hospital) he/she wanted to go to (another local hospital). When asked why, RI #1 stated, just didn't want to go to the local hospital where my Mother and two brothers died . This tag was cited as a result on the investigation of complaint number AL 682. ************************************************************* The Facility must insure RI #1 remains safe and free of injury. I Corrective Action No resident will be allowed outside of the facility unless accompanied by facility staff or family member. The only allowable areas are southeast courtyard, front porch of facility, north wing back porch, front porch on MSU, front porch on Building Two and the garden area by the activity room/offices. Staff has been notified thru in-services, residents have been notified thru resident council meeting. Those residents that do not attend resident council will be notified by Activity and Social Service staff of the changes. Family will be notified by letter placed in month statements. A notice of these changes will be prominently placed at entrances to facility for visitors. II We have identified all residents as having the potential to be affected by this delinquent practice. Side walk was repaired on [DATE] at 10:30 am. III Systematic changes to prevent reoccurrence: A. Environment will be monitored by maintenance director and/or designee to identify hazards that could lead to accident or injury. Hazards identified will be corrected by maintenance or designee. Hazards identified during survey have been repaired on [DATE]. B. No resident will be allowed outside of the facility unless accompanied by facility staff or family member. IV Staff educator to maintain and report to QA/OI meeting bi-monthly. Reports maintained in staff educator ' s office for review. All alert residents that are capable of expressing suicidal ideations were assessed by use of the assessment tool provided by Social Service Consultant, David Gillock, MSW, for any signs of suicidal thoughts. Any resident that exhibits signs and symptoms of suicidal ideations, a full assessment will be done. The criteria is threatening to hurt or kill self, looking for ways to kill self, seeking access to pills, weapons or other means, talking or writing about death, dying or suicide, hopelessness, rage, anger, seeking revenge, acting reckless or engaging in risky activities, seemingly without thinking, feeling trapped, increasing alcohol or drug abuse, withdrawing from friends, family or society, anxiety, agitation, unable to sleep or sleeping all the time, dramatic changes in mood, no reason for living, no sense of purpose in life, history of suicide attempt, psychosis, medical history, family problems ************************************************************ After review of completed repairs, the facility's protocols for suicide precautions and posted notice of changes to outside access prominently placed at entrances to facility for visitors and review of facility's immediate plan for F 323, and interviews with staff, it was determined the facility had implemented their AOCC and demonstrated their knowledge of their Suicide Management policy and procedure, allowing the survey team to exit the facility at 5:10 p.m.

The Director of Nursing (DON) , whose main purpose is to plan, organize, develop and implement the overall operation of the Nursing Service Department, failed to direct the nursing staff on implementing the facility's suicidal precautions for a resident who had expressed [MEDICAL CONDITION]. According to Resident Identifier (RI) #1's, Hospice Admission information, RI #1 had a history of [REDACTED]. The facility's policy directed staff to take preventative actions to prevent the resident from endangering self and others and to take all suicidal threats and actions seriously and immediately assign a staff member to the resident one-to-one. The policy further directed the facility to contact social services to provide crisis intervention counseling for the resident such as psychological evaluation. Review of RI #1's medical record revealed from the time the resident was placed on suicide precautions on 08/13/2016, the social worker did not interact with the resident until 08/22/2016, nine days after the order was written to place the resident on suicide precautions. The Director of Nursing failed ensure interventions were in place, and/or refer the resident for treatment and follow up. The DON stated the facility did not conduct every 15 minute checks as outlined by policy. The facility staff members caring for Resident Identifier (RI) #1 confirmed they were unaware and did not provide the every 15 minute checks, resulting in RI #1 exiting the building unsupervised on 9/13/16 and sustained a fall with injury that required medical attention beyond first aid. On 09/24/2016 at 5:52 PM, the Administrator, Director of Nursing Services, Corporate Nurse, and Human Resource Director were notified of the findings of Immediate Jeopardy level of J in the area of Administration, F 490. This deficient practice affected, RI #1, one of three sampled resident, who had sustained falls. The immediate jeopardy began on 08/13/2016, until the facility implemented immediate corrective actions. The Immediate Jeopardy was relieved onsite on 09/26/2016 at 5:10 PM. Findings include: Cross reference F 224, F 250, and F 323. The DIRECTOR OF NURSING ' s Job Description documented: The Director of Nursing (DON), whose main purpose is to plan, organize, develop and implement the overall operation of the Nursing Service Department in accordance with current Federal, State, and local standards, guidelines, and regulations that govern this facility, and as may be directed by Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times. ESSENTIAL JOB FUNCTIONS include: .Develop and maintain nursing care objectives and standards of nursing care practices for this facility . Assist in development of Patient Care Plans for individual residents . Organize, develop, and direct the administration and resident care of the nursing service department. Comply with, support and enforce Company policies involving all safety . procedures . Review of the facility policy updated 6/10/2015 titled, Suicide Prevention documented, POLICY: (Name of another facility) takes all suicide threats and actions seriously. If a resident makes a suicidal statement or action to staff members, other residents or visitors, the following procedures will be followed: . 2. Immediately assign a staff member to the resident one-to-one until all interventions are in place. This policy was presented during the survey and identified as the policy this facility followed, although the policy had the name of another nursing home listed on the document. The facility policy Suicide Threats, revised 2007, includes: Policy Statement, Resident suicide threats shall be taken seriously and addressed appropriately. Policy Interpretation and Implementation 1. Staff shall report any resident threats of suicide immediately to the Nurse Supervisor/Charge Nurse. 2. The Nurse Supervisor/Charge Nurse shall immediately assess the situation and shall notify the Charge Nurse/Supervisor and/or Director of Nursing Services of such threats. 3. A staff member shall remain with the resident until the Nurse Supervisor/Charge nurse arrives to evaluate the resident. 4. After assessing the resident in more detail, the Nurse Supervisor/Charge Nurse shall notify the resident's Attending Physician and responsible party and shall seek further direction from the physician.6. As indicated a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. Resident Identifier (RI) #1 was admitted to Hospice Service on 8/13/16 with an order for [REDACTED].Short term: Suicidal ideation .Goal and Target Date *Resident will not inflict harm to self with next review date of 11/23/16.Approaches .Monitor resident behavior and report any changes promptly. A review of the Medication Administration Records (MAR) revealed Suicide Precautions were added to the plan of care on 8/17/16 that required documentation once a shift. There were no other instructions noted on the MAR indicated [REDACTED]. There was no further assessments for RI #1's psychosocial needs nor was the facility's suicide prevention or suicide threat policy implemented. Furthermore, the staff failed to investigate why RI #1 did not wish to be transported to a local hospital, put measures in place to prevent resident from exiting the building alone although suicide precautions were on the care plan. The staff was unaware the resident should not go out of the facility alone or be observed every 15 minutes. On 9/23/2016 at 5:15 p.m., the Director of Nursing (DON), Employee Identifier (EI) #1, was asked what her expectations for a resident on suicide precautions were. EI #1 responded, so residents will not harm themselves intentionally. EI #1 admitted she was aware that RI #1 was admitted to Hospice services on suicide precautions. When asked about the facility's responsibility to monitor the resident who was on suicide precautions, and about specific times to monitor the resident, EI #1 stated, No specific time with RI #1, the resident was not a one on one. When asked how does facility evaluate for suicide precautions and how was RI #1's mental status assessed, EI #1 stated that RI #1 was alert and oriented. EI #1 remarked that she was aware that RI #1 had a history of [REDACTED]. When asked if any in-services been completed on suicide precautions with the CNA and nursing staff, the DON state, No. In a follow up interview on 9/23/16 at 6:15 a.m., the Director of Nursing (DON), Employee Identifier (EI) #1 was asked to show evidence the plan of care for RI #1's suicide precautions had been followed. EI #1 stated the one on one had not been done. When asked if the policy was followed, EI #1 stated that nothing was set into action. This tag was cited as a result on the investigation of complaint number AL 682. *********************************************************** Facility must insure that RI #1 is placed on Suicide Prevention Policy and Procedure. I Corrective Action Resident RI #1 was placed under Suicide Prevention per policy on 9/24/16 at 6:00 pm with one-on-one supervision with documentation every 15 minutes which includes date; time what the resident is doing, and staff intervention and signature. CNAs, LPNs and RNs present were in-serviced on 9/25/16 by house supervisor on suicide prevention with criteria from Suicide Risk Initial Assessment tool. The criteria is threatening to hurt or kill self, looking for ways to kill self, seeking access to pills, weapons or other means, talking or writing about death, dying or suicide, hopelessness, rage, anger, seeking revenge, acting reckless or engaging in risky activities, seemingly without thinking, feeling trapped, increasing alcohol or drug abuse, withdrawing from friends, family or society, anxiety, agitation, unable to sleep or sleeping all the time, dramatic changes in mood, no reason for living, no sense of purpose in life, history of suicide attempt, [MEDICAL CONDITION], medical history, family problems. II All alert residents that are capable of expressing [MEDICAL CONDITION] were assessed by use of the assessment tool provided by Social Service Consultant, David Gillock, MSW, for any signs of suicidal thoughts. Any resident that exhibits signs and symptoms of [MEDICAL CONDITION], a full assessment will be done. The criteria is threatening to hurt or kill self, looking for ways to kill self, seeking access to pills, weapons or other means, talking or writing about death, dying or suicide, hopelessness, rage, anger, seeking revenge, acting reckless or engaging in risky activities, seemingly without thinking, feeling trapped, increasing alcohol or drug abuse, withdrawing from friends, family or society, anxiety, agitation, unable to sleep or sleeping all the time, dramatic changes in mood, no reason for living, no sense of purpose in life, history of suicide attempt, [MEDICAL CONDITION], medical history, family problems III Systematic changes to prevent reoccurrence: A. The policy for suicide prevention was implemented immediately with interventions. Nurse consultant and staff development coordinator provided in-service on Suicide Prevention policy to on duty staff on 9/24/16 repeating on 9/25/16 and 9/26/16 until all staff in-serviced. The criteria is threatening to hurt or kill self, looking for ways to kill self, seeking access to pills, weapons or other means, talking or writing about death, dying or suicide, hopelessness, rage, anger, seeking revenge, acting reckless or engaging in risky activities, seemingly without thinking, feeling trapped, increasing alcohol or drug abuse, withdrawing from friends, family or society, anxiety, agitation, unable to sleep or sleeping all the time, dramatic changes in mood, no reason for living, no sense of purpose in life, history of suicide attempt, [MEDICAL CONDITION], medical history, family problems. B. No staff member is to receive an assignment until they have been in-serviced on suicide prevention. C. MD and family notified 9/24/16. D. An assessment was completed on 9/26/16 by Social Services Consultant, David Gillock, MSW using Suicide Risk Initial Assessment tool. E. Social Services developed care plan on 9/24/16 for suicide prevention which include all interventions covered under Suicide Prevention Policy Problem. F. DON was in-serviced by Social Services Consultant, David Gillock, MSW, on suicide prevention, use of the suicide risk initial assessment, using criteria threatening to hurt or kill self, looking for ways to kill self, seeking access to pills, weapons or other means, talking or writing about death, dying or suicide, hopelessness, rage, anger, seeking revenge, acting reckless or engaging in risky activities, seemingly without thinking, feeling trapped, increasing alcohol or drug abuse, withdrawing from friends, family or society, anxiety, agitation, unable to sleep or sleeping all the time, dramatic changes in mood, no reason for living, no sense of purpose in life, history of suicide attempt, [MEDICAL CONDITION], medical history, family problems. This in-service was conducted on 9/26/16. IV Social Services Director and/or designee to maintain an active file of any resident on Suicide Prevention assessment and report to QA/QI meeting with records kept in the Social Services Director ' s office. ************************************************************* After review of RI #1's comprehensive assessment completed by the social worker consultant (MSW); observation that RI #1's suicide precautions were implemented, review of the Social Worker's in-service documentation with the Director of Nursing, review of staff in-service material and interviews with staff to validate their knowledge of the material concerning the facility's suicide policy, it was determined the facility had implemented their AOCC and demonstrated their knowledge of their Suicide Management policy and procedure, allowing the survey team to exit the facility at 5:10 p.m.

Based on record review and interview, the facility failed to ensure RI (Resident Identifier)#1 did not receive duplicate anticoagulant medications after [MEDICATION NAME] was discontinued by the physician on 1/25/2013. RI #1 received [MEDICATION NAME], without an indication for use from April 1 through April 23, in conjunction with Xarelto 20 milligrams another anticoagulant medication. This affected 1 of 2 sampled residents with orders for anticoagulant medications. Findings include: RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the Februrary and March 2013 Pharmacy printed copy of the monthly Physician order [REDACTED].#1: [MEDICATION NAME] 1 milligram tablet and a 6 milligram tablet everyday at bed, except for Wednesdays when [MEDICATION NAME], 4 milligram tablet , 2 tablets to equal 8 milligrams at bedtime. The February and March printed copy of the physician's orders [REDACTED]. The Pharmacy printed Physician order [REDACTED]. The MAR indicated [REDACTED]. These medications were given together for 23 days in April with no indication for the use of duplicate therapy. Review of the Nurses Notes dated 4/24/2013 on the 7-3 shift documented the resident was observed to have a nasal bleed. Review of the Nurses Notes dated 4/24/13 at 1:00 PM documented a order was written for a stat PT/INR and a local lab came out to collect. A call was placed to EI (Employee Identifier) #1, RI #1 physician, to inform of a medication error. It further documented RI #1 had received [MEDICATION NAME] and Xaralto for the month and the resident had a nose bleed. The note further documented the physician ordered Vitamin K and to hold Xarelto for one week. An interview was conducted with EI# 2, DON, Director of Nursing, on 7/9/13 at 10:24 AM. The surveyor asked EI #2 why was RI #1 sent to theER on [DATE]. EI #2 explained the resident had taken [MEDICATION NAME] and Xarelto and her blood was too thin from taking both of these medications. The surveyor asked what was the cause of her taking these two medications. EI #2 stated when the orders for April came out the [MEDICATION NAME] order was not discontinued. The surveyor asked when should the [MEDICATION NAME] order have been discontinued. EI #2 stated 1/25/2013. A phone interview was conducted with EI #7, Pharamacist, on 7/9/2013 at 11:20 AM. The surveyor asked if he reviewed the medications for RI #1 for the month of April. EI #7 explained he remembered she was the one that was taking Xarelto and [MEDICATION NAME] but that it was not brought to his attention until the day she went out and that he had not reviewed her chart for the month. EI #7 stated both the medications were anticoagulants and a potential for a over dose. A second interview was conducted with EI #2, DON, on 7/9/2013 at 4:18 PM. The surveyor asked how the [MEDICATION NAME] was refilled with no order. EI #2 stated the medication was reordered on [DATE] by fax and received on 4/4/13. The surveyor contacted the physician's, EI #1, office on 7/9/2013 at 4:40PM. EI #1 was in clinic and unable to come to the phone but did relay information via EI #1's Medical Assistant. The surveyor asked the Medical Assistant if EI #1 was aware RI #1 was administered Xarelto and [MEDICATION NAME] at the same time during the month of April. The Medical Assistant conveyed that EI #1 stated no. The surveyor then asked the Medical Assistant if EI #1 reordered [MEDICATION NAME] to be restarted in April the Medical Assistant explained that EI #1 said no. The Medical Assistant further explained that he (EI #1) was not aware of any administration of [MEDICATION NAME] and Xarelto given together until RI #1 was in the hospital.

Based on interview and record review, pharmacy services failed to identify and notify the facility of a duplicate therapy order for a medication. A physician order [REDACTED]. The pharamcy refilled the Coumadin medication on April 4, 2013 resulting in RI # 1 (Resident Identifier) receiving Xarelto and Coumadin, two anticoagulant medications at the same time. This affected 1of 2 sampled residents with an order for [REDACTED]. Findings include: RI #1was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Review of RI #1's physician's orders [REDACTED]. The April 2013 Pharmacy printed Physician orders [REDACTED]. The medication card for RI #1 for Coumadin 6 milligrams, Coumadin 1 milligram and Coumadin 4 milligrams indicated it was filled on April 4 , 2013 and sent to the facility. A review of RI # 1's April 2013 MAR indicated the resident received the Coumadin 1 milligram tablet to be given with a 6 milligram tablet every night at bedtime except on Wednesday (April 3, 10th adn 17th) and the Coumadin, 4 milligram tablet (two tablets = 8 milligram) every night on Wednesday (April 3, 10th and 17th). The MAR documentation also indicated that RI #1 received the Xarelto 20 milligrams everyday. The resident received these medications together for 23 days in April. A review of the Nurses Notes dated 4/24/2013 on the 7-3 shift documented the resident was observed to have a nasal bleed. Review of the Nurses Notes dated 4/24/13 at 1:00 PM documented a order was written for a stat PT/INR and a local lab came out to collect. A call was placed to EI (Employee Identifier) #1, RI #1 physician, to inform of a medication error. It further documented RI #1 had received Coumadin and Xaralto for the month and the resident had a nose bleed. The note further documented the physician ordered Vitamin K and to hold Xarelto for one week. A phone interview was conducted with EI # 7, Pharmacist for the facility on 7/9/2013 at 11:20 AM. The surveyor asked EI #7 how the Coumadin was placed back on the MAR and Phsicians order sheet for April 2013. EI #7 stated he assumed because it was refilled. He further stated he was unable to determine who ordered the medication and who refilled it as there were no initials on the forms. The surveyor asked EI #7 how could this happen. EI #7 stated he did not know and that the computer would have had a drug interaction warning but it was possible someone could have ignored it. He further stated the Coumadin medication should not have been reordered or refilled. The surveyor asked EI #7 what was the potential for harm if the two medications Xarelto and Coumadin given together. EI #7 replied it could be a potential for an overdose.

This deficiency was written as a result of complaint/report #AL 678. Based on record reviews and interviews, the facility failed to adequately supervise and assist Resident Identifier (RI) #26 to the toilet or bedside commode, in order to prevent falls. RI #26 was assessed to require one person physical assistance to transfer, to ambulate, and for toilet use. Although the resident was initially assessed as mostly incontinent, RI #26 improved and began having more continent episodes, but was not considered for a scheduled toileting plan. RI #26 experienced three falls while at the facility, one on 10/14/10, 12/19/10 and 12/25/10. At the time of these falls, RI #26, a confused resident with Alzheimer's Disease and Dementia, ambulated unassisted while attempting to use the toilet / bedside commode. After the fall on 12/19, RI #26 sustained a skin tear measuring 0.5 cm (centimeters) x (by) 1 cm to her mid back. After the fall on 12/25, the resident was transferred to the local emergency department and admitted to the hospital. As a result of the fall, RI #26 sustained an intertrochanteric fracture of the right femur, requiring surgery. This affected 1 of 4 sampled residents identified with falls. Findings include: The facility's guidelines and procedure, entitled FALLS-ASSESSMENT OF RISK, undated, documented: "GUIDELINE: Each resident receives an adequate supervision and assistive services to prevent accidents... PROCEDURE: 4. Use the assessment to assist in selecting appropriate approaches to prevent falls... 7. If this is the second time the Falls risk assessment is being filled out due to a fall then the resident will be placed on the Falling Star Program..." The facility's policy and procedure, entitled FALLING STAR PROGRAM, undated, documented: "GUIDELINES: It is the intent of this Nursing Home to strive to decrease the probability of accidents and to protect its residents from injury by following the 'Falling Stars' program. The purpose of the program is to identify a resident at risk for falls, to increase staff awareness of each resident's safety needs in order to protect the resident, to evaluate and determine reason(s) for falls and implement measures to prevent falls..." The facility's policy and procedure, entitled Urinary Incontinence - Clinical Protocol, revised April 2007, documented the following: "...Cause Identification ...3. The physician will help categorize incontinence as urge, stress, overflow, or functional. a. Identifying the correct category may help with appropriate treatment selection... Treatment/Management ...4. As appropriate, based on assessment of the category and causes of incontinence, the staff will provide scheduled, prompted voiding, or other interventions to try to improve the individual's continence status..." RI #26 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. and Systemic Sclerosis. RI #26's Admission Minimum Data Set (MDS), with an assessment reference date of 9/16/10, identified the resident as having short and long-term memory problems and as moderately impaired in cognitive skills for daily decision-making. RI #26 required limited assistance of one person(physical assistance) for bed mobility, transfers and walking. The resident was assessed to require extensive assistance to being totally dependent on one person for locomotion. RI #26 was identified as needing extensive assistance of one person for dressing, toilet use and personal hygiene. At the time of this assessment, RI #26 was assessed as incontinent of bowel and bladder. At the time of this assessment, the resident was not identified as having any falls within the last 6 month period. Other health conditions were shortness of breath and unsteady gait. RI #26's care plan, dated 9/21/10, for deficits in ADL (Activities of Daily Living), included the interventions/approaches: "...4 Assess resident's bowel and bladder habits to set up an elimination schedule. (Briefs, Pull Ups (12/21/10), Toilet, Incontinence Care and Assist were check marked under this approach)..." The resident's care plan, dated 9/21/10, for altered elimination, as evidenced by bowel and bladder incontinence, included the following interventions/approaches: "...Toileting / incontinent care PRN (as needed) before and after: bed, meals, (outings) activities... Assess elimination patterns and document to set-up & (and) maintain a toileting schedule... Educate Certified Nursing Assistances (CNAs) regarding the strict importance of reporting changes in elimination patterns..." The resident's care plan, dated 9/21/10, for impaired cognition included the approach: "... Anticipate resident needs qs (every shift) & provide care..." RI #26's fall care plan, dated 9/21/10, included the approaches: "...7 Assess Resident's ability to use call bell upon request and document findings: (Impaired was check marked under this approach), due to cognition... 10. Bed Alarm for safety (intervention not dated), 11. Educated on use of call light before attempting to ambulate during night hours (implemented after the fall on 10/14, stated in an interview with EI #2)... 13. Staff to toilet Resident q (every) 2 hrs (hours) to decrease chance of Resident getting out of bed by self. (suggested by Licensed Nurse, Employee Identifier (EI) #4 after the fall on 12/25, stated in an interview). The facility's Incident/Accident Report, dated 10/14/10, documented an incident occurred at 4:40 AM in the resident's room and was described as: "...Resident stated she was up to use the restroom. Urine found in the floor when nurse found resident. No injuries or signs of distress at this time..." The Nurse's Note, dated 10/14/10 at 4:40 AM by EI #2 (a Licensed Practical Nurse (LPN)), documented: "This nurse per bed alarm going off. Resident found in floor. Resident stated she needed to use the bathroom. Urine found on floor... Resident educated on use of call light before attempting ambulation..." The MDS, dated [DATE], for RI #26, identified the resident's cognitive pattern as being able to repeat three words, not oriented to year, month or date, and only able to recall one of three words. RI #26 was assessed as requiring limited assistance of one person with bed mobility, transfers, walking, and locomotion on the unit. At the time of this assessment, the resident required extensive assistance of one person with dressing, bathing, toilet use and personal hygiene. RI #26 was assessed as frequently incontinent of bowel and bladder. At the time of this assessment, there was no current toileting program (scheduled toileting, prompted voiding, or bladder training) or trial in place to manage the resident's urinary or bowel continence. RI #26's Fall Risk Assessments, dated 12/15, 12/19, and 12/25 documented the resident with total scores of 16, 16, and 18, respectively. A score of 10 or greater indicated the resident was a high risk for potential falls. An Incontinence Management Assessment, labeled with RI #26's name, with no date or assessor identification/signature, documented: the resident's mental status as confused, her mobility status as walks with assist; and resident was continent but occasionally incontinent and needs assist to the bathroom. In response to the question, "Is resident able to toilet independently?" the facility answered, no, needs assist with occasional incontinent episodes. RI #26's quarterly Incontinence Management Assessment, dated 12/15/10, documented the resident as disoriented, confused and compulsive. The resident's mobility status was documented as walker with assist. The facility staff answered no, needs assist to the question; "Is the resident able to toilet independently?" The facility's Incident/Accident Report, dated 12/19/10, by EI #3 (a LPN) documented an incident occurred in RI #26's room. The nurse described: "...Found in floor per CNA..." The fall investigation form documented the resident, who was confused, was walking at the time of the incident. This form indicated the resident was continent at times. The investigational statement, dated 12/19/10 and signed by EI #3, documented: "...1235 pm Informed per CNA, (name of EI #6) that (RI #26) was on floor in room from fall. Resident found on floor @ (at) end of bed near door lying on (R) (right) side... Small skin tear approx (approximately) 0.5 cm x 1 cm to mid back..." The investigational statement, dated 12/19/10 and signed by EI #6, documented: "...I (EI #6) was charting when (RI #29, roommate of RI #26) came + (and) told me that a lady was on the floor. Went to check it out + it was (RI #26)..." The facility's Incident/Accident Report, dated 12/25/10, signed by EI #4, documented an incident occurred at 3:50 AM in the resident's room and was described as: "...3:50 am Bed alarm went off. CNA went to Resident's room. resident found on floor (with) urine on floor and O2 (oxygen) cord @ feet, per resident she had to use bedside commode and started to urinate once trying to get out of bed and cord got tangled and she tripped... c/o (complained) of (R) hip pain X-ray ordered..." The Radiology Report (X-ray), by mobile equipment, for RI #26, dated 12/25/10, revealed: "...Exam (examination): HIP UNI-LAT... Results: The right hip joint is in alignment, but there is narrowing of the joint space due to modest degenerative changes. There is modest degenerative spurring involving the acetabular border and femoral head and neck junction. No fracture or dislocation is seen. Pubic rami are intact. Conclusion: Modest osteoarthritis of the right hip. The nurse's notes documented: "12/25/10 830 AM Resting quietly in bed... (zero) distress noted... 1215 pm Res (resident) resting in bed. Complains of pain (with) movement... 100 pm Res remains in bed. States her 'leg hurts' ROM (range of motion) to (R) leg. Resident yells out 'that hurts.' MD (Medical Doctor) paged for repeat X-ray... 150 pm MD ordered Res to be sent to (medical center) for repeat X-ray to (R) hip, (R) femur + (R) knee... 240 pm Transported via ambulance... 615 pm... Res to be admitted (with) fx (fracture) of (R) hip..." The radiology reports from the local hospital documented: "...Dec (December) 25 2010 4:19 PM... FEMUR 2 VIEWS - RIGHT... RESULT: Two views of the right femur show an intertrochanteric fracture of the right femur... IMPRESSION: Intertrochanteric fracture of the right femur..." The radiology reports from the local hospital documented: "...[DATE] 4:44 PM... Exam Reason: Trauma... CT (Computerized Axial Tomography) PELVIS w/o (without) contrast... RESULT: Multiple axial CT images of the pelvis were obtained with sagittal and coronal reformatted images. There is an intertrochanteric fracture of the right femur. The pelvic ring is otherwise intact without additional pelvic fracture identified. IMPRESSION: Somewhat impacted intertrochanteric fracture of the right femur..." An addendum, dated 1/3/2011, to the initial radiology report (by mobile X-ray) dated 12/25/10 documented: "...Addendum: There is a very subtle impacted right femoral intertrochanteric fracture. Osteoporosis..." This Discharge Summary from the medical center, dated 12/30/10, documented: "... 2. Right hip fracture, status [REDACTED]. X-rays at the nursing home, did not show fracture, but due to her inability to ambulate, she was transferred to the ED (Emergency Department). In the ED, CT scan showed intertrochanteric fracture of the right hip..." During an interview on 1/25/11 at 5:20 PM, EI #4 (a LPN) described RI #26 as pretty independent and continent. EI #4 stated the resident would get up and use the bedside commode. EI #4 stated RI #26 ambulated and would get up on her own. The surveyor and EI #4 reviewed the requirements for RI #26's transfers (limited assistance of one person). EI #4 responded she was not aware of the requirements, because the resident got up and down on her own. EI #4 stated after the fall on 12/25, she added the approach to toilet the resident to decrease chance of resident getting out of bed by self. EI #4 added that prior to RI #26's fall on 12/25, the care plan indicated to toilet but did not address how often. After being transferred to the hospital on 12/25, RI #26 did not return to the nursing facility. During an interview on 1/26/11 at 7:50 AM, EI #7 (a CNA) stated prior to finding RI #26 on the floor, the morning of 12/25, the resident was in bed sleeping around 2 o'clock AM. When asked when she had toileted RI #26, prior to finding her on the floor, EI #7 replied the resident had a bedside commode; and the only time she (EI #7) toileted the resident was when her alarm went off (sounded), which may have occurred around 12:30 AM. EI #7 stated she believed the resident was in a tight, described as not able to make it to the bedside commode or thinking she was on the bedside commode. The surveyor asked how often the resident required toileting. EI #7 replied the resident got herself up to the bedside commode and was not on a toileting plan to her knowledge. EI #7 stated RI #26 was more continent than incontinent. EI #7 stated RI #26 did not use the call-light, but would just get up and go. On 1/26/11 at 9:00 AM, the surveyor attempted to interview RI #29, the roommate of RI #26. RI #29 was unable to recall RI #26. At 9:38 AM on 1/26/11, the surveyor interviewed EI #3 (LPN). EI #3 stated RI #26 was very confused, anxious (the nurse related this do the resident's hypoxia) and was often getting up. EI #3 stated RI #26 needed assistance to the bathroom and to transfer. EI #3 described RI #26 as being very unsteady, not cognitive enough to understand she needed to stay seated, and unaware of her safety. EI #3 further stated the resident never really used her call-light and did have a concept of how to use the call-light. EI #3 stated if the resident used the call-light, it was a random act. EI #3 stated RI #26 was frequently incontinent. EI #3 further stated she did not know if the CNAs asked the resident if she needed to be toileted, when performing rounds. EI #3 stated after the fall on 12/19, she did not implement a care plan approach and was reprimanded for not doing so. During an interview on 1/26/11 at 10:25 AM, EI #2 (LPN) stated RI #26 was disoriented and ambulatory. The surveyor asked how the resident toileted. EI #2 stated after the fall on 10/14, she initiated a bedside commode and non-skid strips for the resident. EI #2 later stated she was unsure when the bedside commode was initiated. EI #2 further stated she updated the resident's care plan, after the fall on 10/14, to re-educate resident on the use of the call-light. EI #2 stated on the day of the re-education, RI #26 was able to do a return demonstration on the use of the call-light; however she did not remember RI #26 ever using the call-light again. EI #2 further explained the resident could not remember. EI #2 stated on 10/14, the resident was attempting to go to the bathroom. EI #2 stated RI #26 was continent of bowel and bladder, although she had some leakage from time to time. During an interview on 1/26/11 at 12:30 PM, EI #6 (a CNA) stated the resident preferred someone with her when she toileted. EI #6 described RI #26 as active, lonely, able to walk, although not safe, due to shortness of breath. EI #6 stated the resident could transfer on her own; and as far as she knew the resident's care plan indicated she could transfer on her own. EI #6 stated there was no toileting schedule for RI #26. The resident would use the call-light for assistance, sometimes make mistakes (periods of incontinency), or come out into the hallway to make staff aware she needed to use the bathroom. The surveyor asked EI #6 to describe the circumstances of the incident on 12/19. EI #6 stated RI #26's roommate came to the desk and told staff there was a lady on the floor. EI #6 went to the room to find RI #26 on the floor. EI #6 stated there was no alarm sounding, because the resident had been in her wheelchair, which did not have an alarm. EI #6 further stated that when RI #26 was in the chair, staff were supposed to have her up front by the nurses' station. However on this day, the resident was not by the nurses' station, because she wanted to go to her room and went on her own. EI #6 stated she was not aware RI #26 was in her room in the chair until after the fall. EI #6 stated it was lunch time and residents had to be taken into the dining room. EI #6 stated RI #26 was the kind of resident one had to keep an eye on; and she (EI #6, the assigned CNA) could not keep an eye on RI #26 right then. EI #6 stated that unit, where RI #26 resided, had a lot of wanderers, who be moving. EI #6 stated the resident was on a every two hour toileting plan, but would call her (EI #6) more often. On 1/26/11 at 3:30 PM, EI #5 (a LPN/Unit Manager) stated when RI #26 was first admitted , she was sort of bedridden and gradually improved to being in her wheelchair and even walking. EI #5 stated although the resident would get up unassisted, she needed assistance with ambulation, because she was unsteady. EI #5 stated the resident was assessed as incontinent on admission, but improved and even had a bedside commode. EI #5 stated RI #26 was alert enough to know she needed to go to the restroom, but not alert enough to know to call for assistance. EI #5 stated the resident would not have been reassessed, unless she was totally continent or had a large improvement; and the resident's improvement was gradual. EI #5 stated the resident was checked every two hours and as needed, with the use of the call-light. The surveyor asked what was RI #26's toileting plan, EI #5 responded that all incontinent residents were offered a change. EI #5 added there was no written program. EI #5 and the surveyor reviewed the Kardex (care plan used by CNAs) for RI #26 and the ADL sheets for November and December 2010. EI #5 stated on the Kardex, they have her (the resident) marked continent; and on the ADL sheets, it has her marked continent in several places, and even by self. The surveyor asked why RI #26 was not on a toileting plan. EI #5 replied if RI #26 was that continent (as reflected on the ADL sheets and Kardex), she (EI #5) did not know why she was not on a toileting plan. EI #5 stated a three day voiding pattern was usually done on admission and whenever deemed necessary. However, a three day voiding pattern was not done on RI #26, because she was admitted with incontinence. EI #5 explained the resident initially was admitted for respite care and then became long-term. EI #5 stated when the resident became long-term, a three day voiding pattern should have been done by the nurses and CNAs. EI #5 further stated the residents were educated on the use of the call-lights; but this approach was not appropriate for RI #26, because she did not have a long enough attention span to use a call-light. During an interview on 1/27/11 at 11:08 AM, EI #1 (the Director of Nursing (DON)) stated the determined causative factors for RI #26's falls were her advanced Dementia and her need to go to the bathroom. EI #1 further stated the resident did not know how to use the call-light to call for assistance. The surveyor asked what was done by staff to assist the resident to the toilet or bedside commode. EI #1 replied the residents were on two hour checks, during rounds; and CNAs should assist if they hear the alarm or the resident puts on her call-light. EI #1 stated RI #26 was not on a formal toileting plan, she would be checked on every two hours. Again, EI #1 stated the resident was not on a structured program (for toileting). EI #1 explained that RI #26 came into the facility wearing pull-ups and diapers. EI #1 stated, the resident was continent at times and incontinent at times. The surveyor asked why the resident was not on a scheduled toileting plan. EI #1 replied the resident was admitted with a history of incontinence, wore diapers, and never asked to go to the bathroom. EI #1 stated the facility did not have a bowel and bladder program; and a program would be set-up in the future by the consultant nurse.

Based on interviews with the facility staff, and medical record review, the facility failed to revised and implement preventive measures to prevent falls for Resident Identifier (RI) #4. RI #4 experienced a fall in the facility with injuries, one of which resulted in a laceration to the forehead and a laceration to right thumb. This deficient practice affected RI #4, one (1) of three (3) sampled residents for falls/fractures. Findings Include: RI #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of RI #4's medical record revealed the Resident Assessment Protocol Summary (RAPS) for Falls, dated 9/10/10. The "RAPS" documented the following: "RAP triggered falls due to the following MDS (Minimum Data Set) responses: J4a - fell in the past 30 days, J4b - fell in the past 31 - 180 days, O4c - antidepressant 7 (days). Staff Notes: Resident will have a c/p (care plan) written d/t (due to) his multiple falls prior to this admission bruising his Rt (right ) hip which he already had THA (Total Hip Adjustment) in the same hip. He is now touch down weight bearing as tolerated. He does received therapy for gait, strengthening and transfers." A form entitled "Fall Risk Assessment" (no date), documented that a total score of 10 or above represents HIGH RISK. RI #4's score was "12" on this assessment, indicating he was a high risk for falls. A "Fall" care plan dated 9/10/10, documented "Fall Potential R/T (related to) AEB (As Evidence By) H/O (history of) chronic falls with injuries prior to admission. 9/17/10 found on floor by bed. 11/1/10 found on floor." The "Goals" included "Res (Resident) will have no fall related to injuries thru next review. Risk reduced evidence by implementation of approaches written thru next review w/n (within) 90 days." The "Intervention / Approaches" included "1. Call bell in use with return demonstration of use, 2. Redirect any unsafe behavior observed such as attempting to get up without assistance, 3. Keep environment clean and clean of clutter, 4. Keep bed lowest to floor, 5. Fall assessment risk qtrly (quarterly) or more often, 6. Assist of 2 staff members for transfer, 7. Staff to use any transfer devices and equipment ordered, 8. Consult with OT (occupational Therapy) PT (Physical Therapy) when changes occur such as a fall, ... 10. Bed alarm - 9/17/10 added chair alarm, ... 12. Chair alarm for safety, maintain function and placement 9/12/10." The 30 day MDS (Minimum Data Set) assessment dated [DATE], identified RI #4 to have short and long term memory problems and Moderately Impaired decisions poor cues / supervision required. Also, RI #4 had no behaviors, RI #4 was identified to extensive assistance with bed mobility, transfers, locomotion on the unit, toilet use and personal hygiene. Under Section G5b, wheeled self, G6b, Modes of Transfer, RI #4 was identified used bed rails for bed mobility or transfer. Under Section J4., Accidents, RI #4 was identified J4a. fell in past 30 days, J4b. fell past 31 - 180 days, J4c. hip fracture in last 180 days. RI #4 was frequently incontinent of bowel and totally incontinent of bladder. Review of the nurses notes (NN) dated 11/1/10 at 9:15 p.m., documented "CNA ) Certified Nursing Assistant) called undersigned to room 260, found res laying on his left side with wheelchair and him still in sitting position with chair alarm sounding. Noted to have hematoma to forehead - skin tear to left lower arm - right inner thumb has deep cut - assisted up to bed MAEW (move all extremities well) - equal strength to all ext (extremities). Notified daughter... Received order to send to ___ (name of hospital) ER (emergency room ) ... " There were no new approaches added to RI #4's care plan after this fall on 11/1/10 at 9:15 a.m. The Licensed Nurse who worked with RI #4 when this fall occurred failed to develop an immediate plan of action to prevent further occurrences and document the plan of action on the resident care plan. On 11/17/10 at 3:47 p.m., the surveyor conducted an interview with Employee Identifier (EI) #2, the licensed staff member who worked 11/1/10, on the 7a - 3p shift with RI #4. Also included in the interview were EI # 4, the Director Of Nursing (DON), and EI #1, the MDS Coordinator. The surveyor asked the staff members after RI #4's fall on 11/1/10, who would have been responsible for updating his care plan? The MDS Coordinator stated, "Who ever was there at the moment with (RI #4) and wrote a treatment to take care of his needs." The surveyor asked the staff members was RI #4's care plan discussed and updated by the facility staff? The staff members said, "we don't see anything on the care plan." There were no additional preventive measures implemented or approaches added to RI #4's care plan after this fall on 11/1/10. This deficiency was cited as a result of the investigation of complaint / report number (#) AL 432.