Every finding on record at The Oaks Rehabilitation and Healthcare Center

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure bed rails were assessed for clinical indication, safety, and resident need and failed to obtain informed consent for bed rail use for one (1) of four (4) sampled residents. Resident #1Findings Include:A review of the facility's policy Proper Use of Bed Rails, dated 11/7/25, revealed, .It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails.Resident Assessment.2. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. 3. The resident assessment must also assess the resident's risk from using bed rails.On 5/6/26 at 11:49 AM, in an observation, Resident #1 was sitting in a wheelchair in her room. She had quarter-length bedrails on both sides of the bed that were raised.Record review of Resident #1's clinical record revealed there were no bed rail assessments and no informed consent records for bed rail use. On 5/7/26 at 2:20 PM, in an interview with the Director of Nursing (DON), she confirmed there was no bedrail assessment or informed consent records related to bedrail use. She stated the facility had recent system updates with the electronic health records and the informed consent may have been misplaced in medical records. A record review of the admission Record for Resident #1 revealed the facility admitted Resident #1 on 3/8/25 and she had current diagnoses including of Metabolic Encephalopathy.A record review of the 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/5/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated her cognition was severely impaired.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the environment remained as free of accident hazards as possible as evidenced by failure to investigate an initial fall, implement interventions to prevent recurrence, and ensure the resident's bed was maintained in a low position for one (1) of four (4) residents reviewed for accidents. Resident #1 Findings include:A review of the facility's policy, Fall Prevention Program, dated 11/7/25, revealed .Each resident will.receive care services in accordance with their individual level of risk to minimize the likelihood of falls.Policy Explanation and Compliance Guidelines.9. When any resident experiences a fall, the facility will.d. Complete an incident report.A record review of the Nursing Progress Note, dated 3/27/26 at 7:22 AM, for Resident #1 revealed, .Nurse called to room at 0710 (7:10 AM). Found resident on floor.Called (proper name of ambulance service).Will notify AM (morning) nurse.A record review of the ED (Emergency Department) information for Resident #1 from a local acute care hospital, dated 3/27/26 at 8:06 AM, revealed, .Chief Complaint Patient presents with Fall.NH (Nursing Home) staff reports that she was found on the floor this morning.A review of the clinical record for Resident #1 revealed there was no facility fall investigation completed for the fall that occurred on 3/27/26 at 7:10 AM.A record review of the Nursing Progress Note, dated 3/27/26 at 2:59 PM, for Resident #1 revealed, .Called to resident's room. Resident was noted lying on floor on right side.Resident remained on floor until (Proper Name of Ambulance Service) arrived.RP (Responsible Party) called and made aware. Requested to send to (Proper Name of Another Local Acute Care Hospital).A record review of the Emergency Department information for Resident #1 from another local acute care hospital, revealed, .arrival 3/27/26 14:36 (2:36 PM).Chief complaint Fall.EMS (emergency medical services) reports that patient was picked up from (first local acute care hospital ED) and taken back to nursing home. EMS reports shortly after, nursing home called with a reports that patient was found on the floor.A record review of the facility's Fall investigation for Resident #1, dated 3/27/26 at 1:45 PM, revealed .Incident Description.Nursing Description: Resident noted on the floor face down, in between bed and end table. The report was prepared by Registered Nurse (RN) #1.On 5/6/26 at 9:45 AM, during an interview with Emergency Medical Technician (EMT) Student #1, he stated he and the EMT transported Resident #1 on 3/27/26 after a fall at the facility. He reported the resident had also been transported to a hospital earlier the same day and was returned to the facility. He reported Emergency Medical Services (EMS) had left the facility and were called back within minutes due to Resident #1 having another fall. He stated he did not believe the resident could have flipped over the bedrails. He reported Resident #1 was placed in bed with the bedrails raised and the head of the bed elevated prior to EMS departure on 3/27/26.On 5/6/26 at 11:49 AM, during an observation of Resident #1, she was in her room, which was across from the nurses' station. Quarter length bedrails were present on the bed on each side and the bed was in the lowest position. Resident #1 was unable to recall the fall event.On 5/6/26 at 12:23 PM, in an interview with Certified Nurse Aide (CNA) #2, she stated that when she had just arrived to work on the morning of 3/27/26 around 7:00 AM, Resident #1 was sent to the emergency room (ER). She stated when the resident returned from the hospital that afternoon, she had another fall within minutes. She stated the EMS personnel commonly leave resident beds elevated in a high position after returning residents to the facility.On 5/6/26 at 12:48 PM, during an interview with Registered Nurse (RN) #1, she explained Resident #1 had already been sent to the hospital for the first fall that occurred on 3/27/26 when she came on duty that morning. When Resident #1 returned to the facility by ambulance that afternoon, she entered the room with the EMT staff to assess the resident. She stated she left the room briefly to obtain vital sign equipment, and when she returned, Resident #1 was on the floor. She confirmed the bed was elevated. She stated Resident #1 had a raised area on her right forehead. RN #1 explained interventions put in place following the fall included keeping the bed in a low position and therapy services. She stated she did not complete a fall investigation report for the first fall for Resident #1 that occurred on 3/27/26 prior to her arrival to work.On 5/7/26 at 2:50 PM, in an interview with the Director of Nursing (DON), she stated the facility will implement a fall risk prevention program per facility policy and will implement fall interventions for the safety of the residents.A record review of the admission Record for Resident #1 revealed the facility admitted Resident #1 on 3/8/25 and she had current diagnoses including of Metabolic Encephalopathy.A record review of the 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/5/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated her cognition was severely impaired.

Based on staff interview, record review, and facility policy review, the facility failed to revise the comprehensive care plan to reflect actual falls with interventions for one (1) of four (4) sampled residents. Resident #1.Findings include:A review of the facility's policy, Comprehensive Care Plans, dated 11/14/25, revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident.to meet a resident's medical, nursing.needs.A record review of the Care Plan Report revealed Resident #1 had a Focus including at risk for falls r/t (related to) confusion. The care plan was not revised to include the two (2) actual falls, along with interventions, that occurred on 3/27/26. The care plan also had an intervention dated 4/1/24 for Bed in low position.A record review of the Nursing Progress Note, dated 3/27/26 at 7:22 AM, for Resident #1 revealed, .Nurse called to room at 0710 (7:10 AM). Found resident on floor.Called (proper name of ambulance service).Will notify AM (morning) nurse.A record review of the ED (Emergency Department) information for Resident #1 from a local acute care hospital, dated 3/27/26 at 8:06 AM, revealed, .Chief Complaint Patient presents with Fall.NH (Nursing Home) staff reports that she was found on the floor this morning.A review of the clinical record for Resident #1 revealed there was no facility fall investigation completed for the fall that occurred on 3/27/26 at 7:10 AM.A record review of the Nursing Progress Note, dated 3/27/26 at 2:59 PM, for Resident #1 revealed, .Called to resident's room. Resident was noted lying on floor on right side.Resident remained on floor until (Proper Name of Ambulance Service) arrived.RP (Responsible Party) called and made aware. Requested to send to (Proper Name of Another Local Acute Care Hospital).A record review of the Emergency Department information for Resident #1 from another local acute care hospital, revealed, .arrival 3/27/26 14:36 (2:36 PM).Chief complaint Fall.EMS (emergency medical services) reports that patient was picked up from (first local acute care hospital ED) and taken back to nursing home. EMS reports shortly after, nursing home called with a reports that patient was found on the floor.A record review of the facility's Fall investigation for Resident #1, dated 3/27/26 at 1:45 PM, revealed .Incident Description.Nursing Description: Resident noted on the floor face down, in between bed and end table. The report was prepared by Registered Nurse (RN) #1.During an interview on 5/6/26 at 12:23 PM, Certified Nurse Aide (CNA) #2 she stated that when she had just arrived to work on the morning of 3/27/26 around 7:00 AM, Resident #1 was sent to the emergency room (ER). She stated when the resident returned from the hospital that afternoon, she had another fall within minutes. During an interview on 5/6/26 at 12:48 PM, Registered Nurse (RN) #1 explained Resident #1 had already been sent to the hospital for the first fall that occurred on 3/27/26 when she came on duty that morning. When Resident #1 returned to the facility by ambulance that afternoon, she entered the room with the EMT staff to assess the resident. She stated she left the room briefly to obtain vital sign equipment, and when she returned, Resident #1 was on the floor. RN #1 explained interventions put in place following the fall included keeping the bed in a low position and therapy services, although the intervention of Bed in low position was previously recorded on the care plan on 4/1/24 and was not a new intervention and therapy services was not listed as an intervention.During an interview on 5/7/26 at 1:02 PM, RN #2 stated she was the Minimum Data Set (MDS)/Care Plan nurse for the facility. She stated the purpose of the care plan is to inform staff on how to care for residents by reviewing the care plan and ensuring the resident needs are met. During an interview, on 5/7/26 at 2:50 PM, the Director of Nursing (DON), stated the facility will educate staff regarding care plans and Kardex usage and will review care plan interventions for the safety of the residents. A record review of the admission Record for Resident #1 revealed the facility admitted Resident #1 on 3/8/25 and she had current diagnoses including of Metabolic Encephalopathy.A record review of the 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/5/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated her cognition was severely impaired.

Based on staff interview, record review, facility investigation and facility policy review, the facility failed to implement its abuse prevention policy when Licensed Practical Nurse (LPN) #2 did not immediately notify the Administrator or designee of an abuse allegation for one (1) of 3 sampled residents, Resident #1.Findings Include: A review of the facility's policy, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation dated 10/14/2025, revealed, .It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment.are reported immediately to the Administrator of the facility.Compliance Guidelines.8Procedure for Response and Reporting Allegations of Abuse/Neglect/Exploitation.When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated 1. The Licensed Nurse will.c. Notify the Administrator or designee. A record review of the facility's Verification of Investigation revealed the DateTime of Occurance was 08/06/2025 at 12:20 PM and was completed by the facility's Administrator for Resident #1. Review of the .initial and final report revealed on 8/6/25 at 12:20 PM, Resident #1 reported to Licensed Practical Nurse (LPN) #1 that a girl last night told me not to touch my call bell again or she was going to put something on me. LPN #1 then reported this immediately to the Director of Nursing (DON) in which he repeated the allegation. Resident #1 stated it was a CNA, but was unable to recall the CNA's name. The resident's roommate identified the CNA as CNA #1. The DON contacted LPN #2 who had worked on 8/5/25 and she reported that while she was passing medicines, she overhead Resident #1 cursing in his room. Resident #1 told LPN #2 that the CNA had told him not to touch his call bell or she was going to spank him. LPN #2 then called CNA #1 into the room and the CNA explained she was joking and apologized to the resident and he responded It's fine, I'm done with it. Corrective actions included a full body audit was completed on Resident #1, interviews were conducted with all alert and oriented residents to identify any complaints regarding abuse/neglect. Body audits were completed on residents that were unable to be interviewed. All employees were educated on abuse/neglect, reporting requirements, and professional conduct/communication. On 11/19/25 at 9:56 AM, during an interview with CNA #1, she stated that on 8/5/25, she had food trays in her hand when she saw Resident #1's call light on. CNA #1 entered the room and asked the resident if he needed anything. She stated she asked Resident #1 to turn off the call light, and he told her he did not turn it on. CNA #1 reported she said, I know baby, I know you didn't, I asked if you can turn it off. I'm going to spank you, I asked if you can turn it off for me. CNA #1 stated the resident laughed and turned off the light. Later, she was informed that her comment offended the resident. CNA #1 stated she apologized to Resident #1, was suspended pending investigation, and received in-service training on professional communication. On 11/19/25 at 10:49 AM, during an interview with LPN #1, she stated that on 8/6/25, Resident #1 reported that during the previous night's shift on 8/5/25, CNA #1 had told him that if he used his call light, she would put something on him. LPN #1 reported the allegation immediately to the DON, who then initiated the facility's investigation. LPN #1 confirmed that CNA #1 was suspended and that all staff were in-serviced on reporting abuse and professional communication.On 11/19/25 at 11:23 AM, during an interview with LPN #2, she stated that on 8/5/25, she heard Resident #1 cursing in his room. LPN #2 stated she entered to check on the resident, who told her that a CNA had said if he touched his call light again, she would get him. LPN #2 called CNA #1 into the room to discuss the incident. CNA #1 admitted to saying it jokingly and apologized. LPN #2 stated she did not report the allegation because the resident said he was fine. LPN #2 confirmed she did not notify the Administrator or DON and was later suspended during the investigation. LPN #2 acknowledged she knew she should have safeguarded the resident and immediately notified the Administrator or DON.On 11/19/25 at 11:50 AM, during an interview with the DON, she stated she was not informed of the incident until 8/6/25. The DON reported that LPN #2 did not report it immediately because she thought the resident knew the CNA was joking. The DON confirmed that LPN #2 was suspended and received one-on-one in-service training on reporting and professional communication. The DON stated it was her expectation that staff contact her day or night if they hear or suspect any form of abuse. On 11/19/25 at 2:06 PM, during an interview with the Regional Director of Clinical Services (RDCS), she stated that she was notified of the incident by the DON on 8/6/25. The RDCS confirmed that the failure to report the allegation timely was identified, and corrective action was taken through suspension and re-education. The RDCS stated her expectation was that all staff report even the suspicion of abuse immediately to the DON or Administrator. A record review of the admission Record revealed the facility admitted Resident #1 on 9/25/19 with current diagnoses including Abnormalities of Gait and Mobility.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/27/2025 revealed Resident #1had a Brief Interview for Mental Status (BIMS) score of 13 indicating he was cognitively intact.Based on the facility's implementation of corrective Actions on 8/7/25, the SA determined the deficiency to be Past Non-Compliance (PNC) and corrected as of 8/7/25, prior to the SA's entrance 11/19/25.Validation:The SA validated on 11/19/25 through interview and record review, that all corrective actions had been implemented as of 8/7/25 and the facility was in compliance, prior to the SA's entrance on 11/19/25.

Based on observations, staff and resident interviews, plan of correction review, and facility policy review, the facility failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) plan as evidenced by one (1) re-cited deficiency originally cited in January 2024 on an annual recertification survey. This is for (1) of seven (7) cited deficiencies on the current annual recertification survey. Findings include: A review of the facility's policy, Policies and Procedures .Quality Assurance Performance Improvement, with a revision date of 11/30/2014, revealed, .Performance Indicators: 10. The center will establish performance indicators for data collected .Systematic Analysis and Action: The center will ensure systems and actions are in place to improve performance . A review of the Centers for Medicare & Medicaid Services (CMS) 2567 statement of deficiencies on the recertification survey from January 2024 revealed the facility was cited F677 for failing to ensure a resident's nails were clipped for one (1) of eighteen (18) sampled residents. On 6/23/2025, at 12:31 PM, Resident #57 was observed sitting on the side of her bed. The State Agency (SA) observed Resident #57's toenails appeared noticeably long and jagged. Resident #57 expressed that she would like assistance trimming them, noting that no one has come to help. A review of the current recertification survey from June 2025 revealed the facility was again cited F677 for failing to ensure a resident's nails were clipped for one (1) of nineteen (19) sampled residents. On 06/26/2025 at 11:52 AM, in an interview the Administrator, pointed out that while he cannot specifically identify the reason behind why the previous plan of correction (POC) for Activities of Daily Living (ADL) care is not currently being adhered to, he does say that he expects the designated staff to adhere to all grooming requirements set by the facility. During an interview conducted at 12:09 PM on 6/26/2025, the Director of Nursing (DON) suggested that the staff may be overlooking this aspect of grooming when providing care to residents, which could explain the lack of adherence to the original POC for ADLs.

Based on observation, interview, record review and facility policy review, the facility failed to ensure a Resident who is unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene for one (1) nineteen (19) sampled residents. Resident #57. Findings include: A record review of the facility policy Activities of Daily Living dated 2/1/22, revealed, Policy: To encourage resident choice and participation in activities of daily living (ADL) and provide .assistance as necessary. ADLs include bathing, dressing, grooming . On June 23, 2025, at 12:31 PM, Resident #57 was observed sitting on the side of her bed, having just awakened from a nap as the State Agency (SA) entered the room. The SA noticed a visible amount of long, white chin hair, approximately half an inch thick as well as black and gray facial hair on her upper lip. When gently asked about it, Resident #57 quietly shared that she wishes the staff would help her remove the hair, but they haven't done so. The SA also observed that her toenails appeared noticeably long and jagged. Resident #57 expressed that she would like assistance trimming them, noting that no one has come to help. At 12:42 PM on June 23, 2025, during an interview with the Director of Nursing (DON), she stated that it is the responsibility of the Licensed Practical Nurses (LPNs) to trim residents' toenails. She also clarified that Certified Nursing Assistants (CNAs) are expected to perform grooming tasks for female residents during their daily ADL care, such as hair removal, and that this should be done consistently whenever needed. On June 23, 2025 at 3:03 PM, in an interview, CNA #2 stated that although she does not frequently provide care for Resident #57, she is not aware of the resident ever refusing care. On June 24, 2025 at 7:39 AM, in a follow-up interview, Resident #57 expressed that the facial hair she has is very unsightly. She further stated that if she had access to the proper tools, she would remove it herself; however, due to her health challenges, she has been unable to do so. On June 24, 2025 at 7:41 AM, during an interview conducted outside the resident's room, CNA #1 stated that ADL care for the resident include trimming facial hair, provided the resident does not refuse the service. On June 24, 2025 at 7:52 AM, while in Resident #57's room with LPN #1, she confirmed Resident #57 had long facial hair on her chin that did not appear to have been recently trimmed. LPN #1 confirmed that grooming, including facial hair trimming, typically falls under the responsibilities of the CNA during daily ADL care. She also confirmed that the resident's toenails were very long and stated they are overdue for trimming. A record review of the admission Record revealed the facility admitted the resident on 3/18/25 with diagnoses including Muscle Weakness and Hypertensive Heart Disease with Heart Failure. A record review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/25/25 reveals a Brief Interview Mental Score of five (5) indicating Resident #57 had severe cognitive impairment.

Based on observations, interviews, record reviews, and facility policy reviews, the facility failed to ensure ongoing assessment and documentation of skin integrity for one (1) of two (2) residents reviewed for wound care. Specifically, Resident #35, who was at high risk for skin breakdown, did not receive Weekly Skin Integrity Reviews as required by facility policy and clinical standards of practice. Findings Include: A record review of the facility's policy Skin Evaluation with a revision date of 4/1/2017 revealed a license nurse will complete a total body evaluation on each resident weekly and document the observation on the Skin Evaluation form. Record review of the Weekly Skin Integrity Review documentation for Resident #35 revealed that it was completed only on 6/4/25, with no further documentation of weekly assessments as required, including after the initiation of a Quality Assurance and Performance Improvement (QAPI) intervention on 6/5/25. Interview with the Director of Nursing (DON) on 6/25/25 at 9:30 AM, confirmed that the facility became aware of the missed reviews on 6/4/25, but the QAPI plan had not been implemented effectively, and weekly skin checks remained undocumented for Resident #35. She revealed that inconsistently performing and documenting weekly skin integrity evaluations for a high-risk resident compromised early detection and treatment of skin breakdown. The Nursing Home Administrator (NHA) acknowledged in an interview on 6/26/25 at 10:25 AM that failure to follow through with the QAPI plan for skin assessments indicated noncompliance with established internal corrective strategies. A record review of Resident #35's Order Listing Report revealed a physician order dated 4/18/25, Clean re-open stage 3 pressure ulcer to left ischial with normal saline (NS), pat dry. Apply collagen powder to site. Cover with bordered foam dressing. A record review of Resident #35's admission Record revealed an admission date of 10/03/2019, with diagnoses including Contracture of Muscle, Multiple Sites. A record review of Resident #35's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/08/2025 revealed a Brief Interview for Mental Status (BIMS) score of four (4), indicating severely impaired cognition.

Based on observation, interviews, record reviews, and facility policy review the facility failed to provide perineal (peri) care in accordance with professional standards of care for one (1) of two (2) peri care observations (Resident #35). Findings include: A review of the facility's policy, Perineal Care, with a revision date of 9/5/2017, revealed, .Perform hand hygiene . On female residents, wash from front to back to avoid urethral or vaginal contamination . On 06/25/2025 at 10:23 AM, during an observation of wound care for Resident #35 provided by Registered Nurse (RN) 1, who is the Wound Care Nurse, and assisted by Certified Nursing Assistant (CNA) #5 revealed RN #1 stated to CNA #5 that the resident had a bowel movement. CNA #5 removed gloves and gown, sanitized hands, and exited the room. CNA #5 returned with a brief in hand and gown on. CNA #5 did not sanitize hands upon re-entry and applied clean gloves. He pulled out three peri wipes and wiped the anus three times front to back. CNA #5 asked RN #1 to assist in turning the resident over and applied a clean brief. CNA #5 did not perform peri care in the front vaginal area. On 06/25/2025 at 10:50 AM, during an interview, CNA #5 confirmed he did not wash the vaginal area. He stated the resident is contracted and hard to clean in the vaginal area. He acknowledged he did not fully complete peri care and was supposed to provide care to the vaginal area. On 06/25/2025 at 2:04 PM, during an interview, RN #1 confirmed that CNA #5 did not perform peri care in the vaginal area. She stated he was supposed to clean the vaginal area. She stated Resident #35 could develop a urinary tract infection (UTI) or skin breakdown from the care CNA #5 provided. On 06/26/2025 at 10:06 AM, during an interview, the Director of Nursing (DON) stated CNA #5 should have started peri care at the front and moved to the back. She stated Resident #35 was placed at risk for a UTI. A record review of Resident #35's Order Listing Report revealed a physician order dated 4/18/25, Clean re-open stage 3 pressure ulcer to left ischial with normal saline (NS), pat dry. Apply collagen powder to site. Cover with bordered foam dressing. A record review of Resident #35's admission Record revealed an admission date of 10/03/2019 with diagnoses including Contracture of Muscle, Multiple Sites. A record review of Resident #35's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 4/8/2025 revealed a Brief Interview for Mental Status (BIMS) score of four (4), indicating severely impaired cognition.

Based on observation, interview, record review, and facility policy review, the facility failed to provide perineal (peri) and wound care in a manner to prevent the possibility of spreading infection for two (2) of five (5) observations of care (Resident #35). Findings included: A review of the facility's policy, Hand Hygiene, with a revision date of 02/05/2021, revealed, Hand hygiene should be performed before initiating procedure, before and after care. A review of the facility's policy, Dressing Change, with a revision date of 12/06/2017, revealed, .Cleanse wound as ordered .dispose of gauze, remove gloves .perform hand hygiene . Apply treatment as ordered and clean dressing . On 06/25/2025 at 10:23 AM, during an observation of wound care for Resident #35 provided by Registered Nurse (RN)# 1, who is the Wound Care Nurse, and assisted by Certified Nursing Assistant (CNA)# 5 revealed RN #1 did not perform hand hygiene after initiating wound care. She stated to CNA #5 that the resident had a bowel movement. CNA #5 removed his gloves and gown, sanitized his hands, and exited the room. CNA #5 returned to the room with a brief and a gown on. He did not sanitize his hands before applying clean gloves. On 06/25/2025 at 10:50 AM, during an interview with CNA #5, he stated that he forgot to wash his hands when entering the room. He acknowledged that the resident could get an infection as a result. On 06/25/2025 at 2:04 PM, during an interview with RN #1, she confirmed CNA #5 did not perform hand hygiene before starting peri-care. She stated Resident #35 could get a urinary tract infection and skin breakdown due to the care CNA #5 provided. She confirmed that she failed to perform hand hygiene at each step of the wound care process. She stated she should have removed gloves and sanitized hands after each phase: cleansing, drying, applying collagen, and applying the dressing. She acknowledged that improper technique could result in a wound infection. On 06/26/2025 at 9:30 AM, during an interview, Licensed Practical Nurse (LPN) #3, who is the Infection Preventionist, stated she had recently completed in-service training on handwashing. She explained that RN #1 should have changed gloves and performed hand hygiene throughout the wound care process, and CNA #5 should have done the same before peri-care. She stated both staff placed the resident at risk for wound and urinary tract infections, including the possibility of introducing bacteria into the wound. On 06/26/2025 at 10:00 AM, during an interview with the Director of Nursing (DON), she stated RN #1 should have changed gloves and performed hand hygiene throughout the wound care process. She confirmed that Resident #35 was at risk of wound infection. She stated CNA #5 should have performed hand hygiene before putting on gloves to complete peri-care. She stated Resident #35 was placed at risk for urinary tract infection (UTI). A record review of Resident #35's admission Record revealed an admission date of 10/03/2019, with diagnoses including Contracture of Muscle, Multiple Sites, and Essential Hypertension. A record review of Resident #35's Order Listing Report revealed a physician order dated 4/18/25, Clean re-open stage 3 pressure ulcer to left ischial with normal saline (NS), pat dry. Apply collagen powder to site. Cover with bordered foam dressing. A record review of Resident #35's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/08/2025 revealed a Brief Interview for Mental Status (BIMS) score of four (4), indicating severely impaired cognition.

Based on observation, interview, record review, and facility policy review, the facility failed to provide reasonable accommodation of needs by not individualizing a blind resident's call system for one (1) of nineteen (19) sampled residents (Resident #17). Findings included: A record review of the facility's policy, Policies and Procedures .Resident Rights, with a revision date of 11/30/2014, revealed, Policy: The facility will ensure that the resident is not deprived of his/her rights . On 06/23/2025 at 11:30 AM, during an interview with Resident #17, who is in a private room, she explained that she is blind and unable to see or reach the current call light system. She reported that even when the call light is within reach, she has no way of knowing whether it is functioning correctly. The resident expressed uncertainty and vulnerability when needing assistance and stated she often yells out for help. On 06/23/2025 at 11:41 AM, during an interview Certified Nursing Assistant (CNA) #3, explained that she occasionally provides care for Resident #17 and confirmed that the call light was attached to the wall rather than the resident's chair. She acknowledged the resident could not access the call light based on current setup. On 06/24/2025 at 7:42 AM, during an observation, Resident #17 was sitting up in bed. The call light was attached to the wall at the foot of the bed, out of the resident's reach. Resident #17 stated that no staff placed the call light within reach during the night and that staff never do so. When asked how she calls for assistance, she stated she has to yell out. On 06/26/2025 at 7:10 AM, during an interview with Licensed Practical Nurse (LPN) #2, who works the 11:00 PM to 7:00 AM shift, she accompanied the State Agency to the resident's room and confirmed that the call light was out of reach on the wall. She explained that the call light should not be placed at the foot of the bed, especially since the resident is blind and unable to see or reach it. On 06/26/2025 at 7:25 AM, during an interview with the Director of Nursing (DON) in Resident #17's room, she stated it would be beneficial to obtain a more accessible device for residents needing assistance, especially for those with vision impairments. A record review of Resident #17's admission Record revealed an admission date of 08/09/2024, with diagnoses including Legal Blindness and Anxiety Disorder. A record review of Resident #17's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/19/2025 revealed a Brief Interview for Mental Status (BIMS) score of thirteen (13), indicating Resident #17 was cognitively intact.

Based on observations, interviews, and facility policy review, the facility failed to properly dispose of food and to seal open foods in bags to prevent the possibility of a foodborne illness for one (1) of two (2) kitchen tours. Findings include: A review of the facility's policy, Food Preparation, with a revision date of 2/2023, revealed, .Dining services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological and chemical contamination. On 06/23/2025 at 10:45 AM, during an initial kitchen tour with the Dietary Manager (DM), there was a ten (10) pound box of Sunkist oranges under the prep table, dated 6/10/2025. The box was three-fourths full, and three oranges had black and white mold. Gnats were observed flying out of the box when opened. Additionally, there was an unsealed bag of food thickener with a hole in it, exposed to the air. On 06/23/2025 at 11:14 AM, during an interview, the DM stated it was the cook's responsibility to dispose of the oranges. She confirmed the oranges were received on 6/10/2025 and acknowledged that both the oranges and thickener could cause foodborne illness. She stated it was her responsibility to check behind the cook and that all staff should date items when opened. On 06/23/2025 at 11:23 AM, during an interview, the cook stated she should have closed the thickener after use. She stated she checks behind the three dietary staff but was not paying attention in this case. She acknowledged the residents could get sick from improper food storage. On 06/25/2025 at 1:20 PM, during an interview, the Director of Food Services stated the Sunkist oranges should have been discarded. He stated the DM performs sanitation rounds five days a week and the thickener should have been sealed and dated. He acknowledged that the oranges could cause foodborne illness or a stomach virus, and the unsealed thickener posed a cross-contamination risk. He expects dietary staff to always serve safe food and provide high-quality service. On 06/26/2025 at 1:05 PM, during an interview, the Nursing Home Administrator (NHA) stated he expects staff to always maintain date compliance and store food appropriately.

Based on interviews, record review, the facility's investigation, and facility policy review, the facility failed to ensure residents' right to be free from physical and verbal abuse when Certified Nurse Aide (CNA) 1 was reported by two staff members (CNA #2 and CNA #3) to have physically abused Resident #1 on 3/7/25 at 6:45 AM and verbally abused Resident #2 date/time unknown, both vulnerable residents, and the facility did not take immediate protective action for two (2) of four (4) sampled residents. Additionally, the Administrator was not informed of the allegation until 3/17/25, at which time CNA #1 was suspended. This left residents vulnerable for ten (10) days after the abuse was initially witnessed by staff. The facility's failure to provide immediate protective action placed these residents and other vulnerable residents at risk for serious harm, injury, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 3/7/25 when CNA #1 was witnessed physically abusing Resident #1. The facility Administrator was notified of the IJ and SQC and was presented with an IJ Template on 4/3/25 at 5:00 PM. The facility provided an acceptable Removal Plan on 4/3/25, in which they alleged all corrective action to remove the IJ was completed on 4/3/25 and the IJ was removed on 4/4/25. The State Agency (SA) validated the Removal Plan on 4/4/25 and determined the IJ was removed on 4/4/25, prior to exit. Therefore, the scope and severity for CFR 483.12(a)(1)(5) Freedom from Abuse, Neglect, and Exploitation (F600) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: A review of the facility's policy, Abuse, Neglect, Exploitation & (and) Misappropriation revised 11/16/2022, revealed .It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights., including the right to be free from abuse, neglect, mistreatment, exploitation and or misappropriation of property .Employees of the center are charged with the continuing obligation to treat residents so they are free from abuse . No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment and or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal, provided herein. Definitions .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Physical abuse includes but is not limited to . corporal punishment, which is physical punishment, is used as a means to correct or control behavior. Corporal punishment includes, but is not limited to; spanking, slapping of hands, flicking or hitting with an object. 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 . A review of the facility's investigation, dated 3/17/25, revealed that on Monday, 3/17/25, at 10:44 AM, the facility's Administrator found two (2) different anonymous pieces of paper on his desk that stated CNA #1 had been abusing residents. Interviews were conducted with all residents able to effectively communicate and there were no complaints on staff received from the residents interviewed. There were no obvious signs of abuse on any of the residents who were unable to communicate. Interviews with staff members that work around or directly with CNA #1 were conducted. Upon those interviews, a witness stated she was changing a resident and heard CNA #1 tell Resident #2 that if she (expletive) out the bed like she did yesterday, she was going to beat her (expletive). Another witness stated she was assisting CNA #1 with providing care to a combative resident, when she grabbed the residents nose, causing it to leak blood and told the combative resident, It how you deal with crazy (expletive) like you. Resident #1 A record review of the Admission Record revealed the facility admitted Resident #1 on 3/08/2013 with current diagnoses including Parkinson's Disease and Dementia. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated her cognition was moderately impaired. Resident #2 A record review of the Admission Record revealed the facility admitted Resident #2 on 10/3/2019 with current diagnoses including Hypertension and Major Depressive Disorder. A record review of the Quarterly MDS with an ARD of 3/12/25 revealed Resident #2 had a BIMS score of 3 which indicated her cognition was severely impaired. Section GG revealed Resident #2 is dependent on staff for toileting hygiene. Record review of the facility's Assignment sheets, dated 3/6/25, revealed CNA #1 and CNA #3 were scheduled on the same hall on 3/7/25 at 6:20 AM. Record review of the facility's time sheets, dated 3/6/25 through 3/7/25, revealed CNA #1 and CNA #3 worked the 11-7 shift and were present at the facility at 6:20 AM. On 04/02/25 at 11:00 AM, during an interview with CNA #3, she stated that on 03/07/25 at approximately 6:20 AM, she was working the overnight shift (11:00 PM - 7:00 AM), although her normal schedule was the 7:00 AM - 3:00 PM shift. CNA #3 explained that Licensed Practical Nurse (LPN) #1 asked her to assist CNA #1 with providing care to Resident #1, as the resident was reportedly combative. As care began, Resident #1 swung at both CNAs. CNA #3 reported that she held the resident's hands gently and reassured her, telling her everything was okay. The resident then pulled away from her grasp and grabbed CNA #1 by the hair. CNA #3 reported that in response, CNA #1 grabbed the resident's nose and twisted it upwards, which caused the resident's nose to bleed. According to CNA #3, CNA #1 then stated, This is how you deal with crazy (expletive) like you. CNA #3 recalled telling CNA #1, You can't treat and talk to her like that, and stated she attempted to leave the room to locate the nurse but did not see her nearby. Not wanting to leave the resident alone with CNA #1, CNA #3 returned to the room and offered to finish providing care. She stated that CNA #1 appeared to ignore her and refused to leave the room. CNA #1 continued providing care, cleaned the blood from the resident's face using the resident's gown, finished dressing her, and transferred her to the chair before exiting the room. CNA #3 stated that she did not report the incident to the nurse, Director of Nursing (DON), or Administrator until 03/17/25 because she feared retaliation from other staff. She confirmed she had previously received training and in-services regarding abuse, neglect, and the requirement to report such incidents. On 04/02/25 at 11:15 AM, during an interview with CNA #2, she stated she was in Resident #2's room providing care to the roommate when she overheard CNA #1 say to Resident #2, If you (expletive) in the bed like you did yesterday, I'm going to beat your (expletive). CNA #2 stated she immediately told CNA #1 that she could not speak to a resident in that manner, to which CNA #1 replied, I bet it works. CNA #2 explained she did not report the incident at the time because she was afraid of retaliation from staff, stating that people had recently been losing their jobs and there were concerns about false allegations being made through the compliance hotline. CNA #2 confirmed she had received prior training and in-service education on abuse, neglect, and reporting requirements. On 04/02/25 at 11:30 AM, during an interview with CNA #4, she stated that she occasionally worked on the same hall as CNA #1 and observed CNA #1 speaking to residents in an aggressive and assertive manner. CNA #4 expressed concern about the tone and way CNA #1 communicated with residents but stated she was told by other staff members that that's just her personality and not to take it seriously. CNA #4 explained that, based on those comments, she did not report the behavior to the Director of Nursing (DON), believing it was not considered a serious issue by other staff. On 04/02/25 at 11:45 AM, during an interview with CNA #5, he stated that he worked alongside CNA #1 on the same hall and often heard her speak to residents in an angry tone of voice. CNA #5 stated he initially believed it was just part of her personality and admitted he did not pay much attention to her behavior at the time. On 04/02/25 at 12:01 PM, during an interview with CNA #1, she denied physically abusing Resident #1 and verbally abusing Resident #2. CNA #1 stated she believed the accusations were fabricated by another CNA because she was not part of the clique among staff at the facility. She further stated she had never worked with CNA #3 on the hall and that CNA #3's primary responsibility was providing showers. CNA #1 confirmed she had received training and in-service education on abuse, neglect, and reporting requirements. On 04/02/25 at 12:05 PM, during an interview with LPN #1, she stated she was the nurse assigned to the hall on 03/07/25. LPN #1 explained that CNA #1 approached her that morning and reported that Resident #1 was combative and refusing care. In response, LPN #1 asked CNA #3 to assist CNA #1 with providing care to the resident. LPN #1 stated she was not made aware of any physical abuse involving the resident and that neither CNA reported any concerns to her. She recalled observing Resident #1 later that shift, seated in a wheelchair, fully dressed, and noted that the resident appeared confused. On 04/02/25 at 1:00 PM, during an interview with the Social Worker, she stated she was not made aware of the allegations of physical and verbal abuse until she was informed by the Administrator on 3/17/25. She reported that after learning of the incident, she checked on the involved residents to assess for any concerns and confirmed that no psychosocial issues were identified at that time. On 04/02/25 at 1:30 PM, during an interview with the Assistant Director of Nursing (ADON) explained that she had been informed by the DON and the Administrator that two (2) anonymous letters were found on the Administrator's desk alleging that CNA #1 had physically abused Resident #1 and verbally abused Resident #2. The ADON reported that she assisted the DON and the Administrator in conducting full body audits on the residents and participating in the investigation of the abuse allegations. She confirmed that no bruises or physical injuries were observed on either resident. On 04/02/25 at 1:45 PM, during an interview with the Administrator, he stated that on 03/17/25, he found two anonymous letters on his desk alleging abuse by CNA #1. The first letter described an incident in which CNA #1 physically abused Resident #1 during incontinent care by grabbing the resident's nose-causing it to bleed-and saying, It's how you deal with crazy (expletive) like you. The second letter alleged that CNA #1 verbally abused Resident #2 by stating, If you (expletive) out the bed like you did yesterday, I'm going to beat your (expletive), while CNA #1 was providing care. The Administrator stated CNA #1 was immediately suspended pending an investigation and was terminated on 03/18/25. As part of the investigation, full body audits were conducted for all residents on the 200 hall where CNA #1 had worked, and cognitive residents were interviewed regarding potential abuse. The Administrator reported that an in-service on abuse and neglect was provided to staff, and a Quality Assurance (QA) meeting was held on 03/26/25. He confirmed the abuse allegations were substantiated based on the statements from two CNAs: CNA #3, who witnessed physical abuse of Resident #1, and CNA #2, who witnessed verbal abuse directed at Resident #2. On 04/03/25 at 12:10 PM, during an interview with LPN #2, she described CNA #1 as having good days and bad days, noting that if CNA #1 arrived smiling, it was typically a good day, but if she arrived and did not speak to others, it was a bad day. LPN #2 also stated CNA #1 did not follow instructions well and often argued when asked to perform tasks. She acknowledged she had not documented or reported these concerns to the Director of Nursing (DON) but stated the tasks generally got done. LPN #2 reported she was unaware of any allegations of physical or verbal abuse involving CNA #1. On 04/03/25 at 12:45 PM, during an interview with Registered Nurse (RN) #1, she stated she was the Unit Manager and had observed that CNA #1 often demonstrated a negative attitude. She further stated CNA #1 had shown increased frustration, particularly when the staff schedule was modified or when she was asked to complete specific tasks. On 04/03/25 at 1:00 PM, during an interview with the Director of Nursing (DON), she stated she was informed about the anonymous letters that had been placed on the Administrator's desk. She reported that CNA #1 was immediately suspended following the allegations. The DON stated that body audits were conducted on all cognitively impaired residents on Station 2, and interviews were completed with cognitively intact residents to assess for any physical or verbal abuse. Staff members working on Station 2 were also interviewed. The DON confirmed that the CNAs failed to report the allegations of abuse until 03/17/25, despite having received in-service training on abuse and neglect at the time of hire. The Facility presented the following Removal Plan on 4/4/25: On 4/2/25 Quality Assurance (QAPI) Committee met at 5:45 pm to review, develop, and implement the facility policy on abuse and neglect with an emphasis on reporting abuse and neglect and to determine the root cause. The root cause was determined to be that employees were afraid of retaliation from other employees. Attendees were the Executive Director, (ED), Minimum Data Service (MDS) nurse, Medical Records (MRC), Regional Director of Clinical Services, (RDCS), Assistant Director of Nursing (ADON), Medical Director, Social Services (SSD) Staff Development/ Infection Preventionist nurse, Activities Director (AD), Human Resources (HR) Housekeeping, Dietary Manager, Therapy director, Unit Managers and the Admission Coordinator. There were no changes made to the policy and procedure. The areas that were discussed were the re-education of staff members on the abuse and neglect policy with an emphasis on reporting requirements and that failure to do so is a crime. On 3/17/25 body audits were completed on Resident # 1 and Resident #2 by the Staff Development nurse and a licensed nurse. No signs of physical abuse was identified. On 3/17/25 interviews were conducted by SSD with alert and oriented residents on side 2. No residents voiced complaints of abuse. On 3/17/25 the physician and the Resident Representatives of Resident # 1 and Resident 2 were notified. On 3/17/25 education was started by the Staff Development Nurse. On 3/26/25 the Quality Assurance Performance Improvement Committee met to review the physical and verbal abuse. On 4/2/25 Social Services completed a psychosocial follow up with Resident # 1 and Resident #2. On 4/2/25 100% body audits were performed on all facility residents by the unit manager RN and the Minimum Data Set nurses to ensure that residents did not have physical signs of abuse. No residents were identified. On 4/2/25 the ED was educated on the abuse policy by the RDCS and timely reporting of abuse within 2 hours to the state agency, attorney general and the abuse and neglect policy. On 4/2/25 the SSD and the Admissions Coordinator interviewed all alert and oriented residents (census) using the Risk Management Quality Improvement Questionnaire to determine if any residents had been abused or witnessed abuse. There were no residents that voiced any complaints of abuse. The Staff Development nurse started education with licensed nurses, CNA's and non-direct care staff on the abuse and neglect policy and procedure with an emphasis on reporting requirements on 4/2/25 and 100 % has been completed on 4/3/25. All facility staff members were interviewed by the ED, HR, and ADON by phone on 4/2/25 to ask if they ever witnessed any employee abuse a resident and explained the process of what to do if they ever witness abuse or neglect, with an emphasis on reporting requirements and that failure to do so is a crime. CNA # 2 received one on one education on the abuse policy and the reporting requirements with an emphasis placed on the fact of not reporting being a crime. New hires will be educated during orientation. Corrective Actions were completed on 4/3/25, and the Immediate Jeopardy was removed. Validation: The SA validated on 4/4/25, through interview and record review, that all corrective actions had been completed as of 4/3/25, and the IJ removed on 4/4/25.

Based on interviews, record review, and facility policy review, the facility failed to implement its abuse policy, allowing an abusive act to occur without staff intervening or prompt reporting for two (2) of four (4) sampled residents. Resident #1 was physically abused on 3/7/25 by Certified Nurse Aide (CNA) #1 which was witnessed by CNA #3 and Resident #2 was verbally abused by CNA #1 and was witnessed by CNA #2. CNA #1 and CNA #2 did not intervene to prevent the violation of the residents' rights to be free from abuse. The facility's failure to intervene and immediately report to the Administrator placed Resident #1, Resident #2 and other residents at risk for similar abuse including the risk for serious harm, injury, impairment, or death. The situation was determined to Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 3/7/25 when CNA #1 was witnessed physically abusing Resident #1. The State Agency (SA) notified the facility's Administrator of the IJ and SQC on 4/3/25 at 5:00 PM and the facility provided an acceptable Removal Plan on 4/3/25 and the IJ was removed on 4/4/25. The SA validated the Removal Plan on 4/4/25 and determined the IJ was removed on 4/4/25, prior to exit. Therefore, the scope and severity for 42 CFR(s): 483.12(b)(1) Implement Written Policies (F607) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: A review of the facility's, Abuse, Neglect, Exploitation & (and) Misappropriation revised 11/16/22, revealed, .Procedure .2. Training .Employee obligation All employees have a duty to respect the rights of all residents .and to prevent others from violating their rights. Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, .to a resident, is obligated to report such information, but no later than 2 hours after the allegation is made .to the Administrator and to other officials in accordance with State Law. An employee shall be deemed to have violated his obligations .if he does any of the following .Fails to report an incident of abuse witnessed by or known to him/her . Resident #1 A record review of the Admission Record revealed the facility admitted Resident #1 on 3/08/2013 with current diagnoses including Parkinson's Disease and Dementia. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated her cognition was moderately impaired. Resident #2 A record review of the Admission Record revealed the facility admitted Resident #2 on 10/3/2019 with current diagnoses including Hypertension and Major Depressive Disorder. A record review of the Quarterly MDS with an ARD of 3/12/25 revealed Resident #2 had a BIMS score of 3 which indicated her cognition was severely impaired. Section GG revealed Resident #2 is dependent on staff for toileting hygiene. In an interview on 4//2/25 at 11:00 AM with CNA # 3, she stated that on 3/07/25 at approximately 6:20 AM, she was working the overnight shift (11:00 PM - 7:00 AM) and Licensed Practical Nurse (LPN) #1 asked her to assist CNA #1 with providing care to Resident #1 because she was reportedly combative. As care began, Resident #1 swung at both CNAs. The resident grabbed CNA #1 by the hair and in response, CNA #1 grabbed the resident's nose and twisted it upwards, which caused the resident's nose to bleed. According to CNA #3, CNA #1 then stated, This is how you deal with crazy (expletive) like you. CNA #3 recalled telling CNA #1, You can't treat and talk to her like that, and stated she attempted to leave the room to locate the nurse but did not see her nearby. Not wanting to leave the resident alone with CNA #1, CNA #3 returned to the room and offered to finish providing care. She stated that CNA #1 appeared to ignore her and refused to leave the room. CNA #1 continued providing care, cleaned the blood from the resident's face using the resident's gown, finished dressing her, and transferred her to the chair before exiting the room. CNA #3 admitted that she did not report the incident to the nurse, Director of Nursing (DON), or Administrator until 03/17/25, leaving all residents at risk for potential abuse from CNA #1. CNA #3 revealed she was aware that she should have intervened and reported the abuse immediately because she had been trained on the facility's abuse policy, but she feared retaliation from other staff. In an interview with CNA #2 on 4/02/25 at 11:15 AM, she stated she was in Resident #2's room providing care to the roommate when she overheard CNA #1 say to Resident #2, If you (expletive) in the bed like you did yesterday, I'm going to beat your (expletive). CNA #2 stated she immediately told CNA #1 that she could not speak to a resident in that manner, to which CNA #1 replied, I bet it works. CNA #2 explained she did not report the incident at the time because she was afraid of retaliation from staff, stating that people had recently been losing their jobs and there were concerns about false allegations being made through the compliance hotline. CNA #2 also revealed that she had been trained on the facility's abuse policy which instructed staff to report abuse to protect the residents. During an interview with CNA #1 on 4/02/25 at 12:01 PM, she denied physically abusing Resident #1 and verbally abusing Resident #2. CNA #1 stated she believed the accusations were fabricated by another CNA because she was not part of the clique among staff at the facility. She further stated she had never worked with CNA #3 on the hall and that CNA #3's primary responsibility was providing showers. During an interview with the Administrator on 4/02/25 at 1:45 PM, he stated that on 3/17/25, he found two anonymous letters on his desk alleging abuse by CNA #1. The first letter described an incident in which CNA #1 physically abused Resident #1 during incontinent care by grabbing the resident's nose, causing it to bleed, and saying, It's how you deal with crazy (expletive) like you. The second letter alleged that CNA #1 verbally abused Resident #2 by stating, If you (expletive) out the bed like you did yesterday, I'm going to beat your (expletive), while CNA #1 was providing care. The Administrator stated CNA #1 was immediately suspended pending an investigation and was terminated on 03/18/25. The Administrator also confirmed that CNAs #2 and #3 did not receive disciplinary action regarding their inaction of immediately protecting the residents and reporting, however, they were inserviced on the abuse policy. The Facility presented the following Removal Plan on 4/4/25: On 4/2/25 Quality Assurance (QAPI) Committee met at 5:45 pm to review, develop, and implement the facility policy on abuse and neglect with an emphasis on reporting abuse and neglect and to determine the root cause. The root cause was determined to be that employees were afraid of retaliation from other employees. Attendees were the Executive Director, (ED), Minimum Data Service (MDS) nurse, Medical Records (MRC), Regional Director of Clinical Services, (RDCS), Assistant Director of Nursing (ADON), Medical Director, Social Services (SSD) Staff Development/ Infection Preventionist nurse, Activities Director (AD), Human Resources (HR) Housekeeping, Dietary Manager, Therapy director, Unit Managers and the Admission Coordinator. There were no changes made to the policy and procedure. The areas that were discussed were the re-education of staff members on the abuse and neglect policy with an emphasis on reporting requirements and that failure to do so is a crime. On 3/17/25 body audits were completed on Resident # 1 and Resident #2 by the Staff Development nurse and a licensed nurse. No signs of physical abuse was identified. On 3/17/25 interviews were conducted by SSD with alert and oriented residents on side 2. No residents voiced complaints of abuse. On 3/17/25 the physician and the Resident Representatives of Resident # 1 and Resident 2 were notified. On 3/17/25 education was started by the Staff Development Nurse. On 3/26/25 the Quality Assurance Performance Improvement Committee met to review the physical and verbal abuse. On 4/2/25 Social Services completed a psychosocial follow up with Resident # 1 and Resident #2. On 4/2/25 100% body audits were performed on all facility residents by the unit manager RN and the Minimum Data Set nurses to ensure that residents did not have physical signs of abuse. No residents were identified. On 4/2/25 the ED was educated on the abuse policy by the RDCS and timely reporting of abuse within 2 hours to the state agency, attorney general and the abuse and neglect policy. On 4/2/25 the SSD and the Admissions Coordinator interviewed all alert and oriented residents (census) using the Risk Management Quality Improvement Questionnaire to determine if any residents had been abused or witnessed abuse. There were no residents that voiced any complaints of abuse. The Staff Development nurse started education with licensed nurses, CNA's and non-direct care staff on the abuse and neglect policy and procedure with an emphasis on reporting requirements on 4/2/25 and 100 % has been completed on 4/3/25. All facility staff members were interviewed by the ED, HR, and ADON by phone on 4/2/25 to ask if they ever witnessed any employee abuse a resident and explained the process of what to do if they ever witness abuse or neglect, with an emphasis on reporting requirements and that failure to do so is a crime. CNA # 2 received one on one education on the abuse policy and the reporting requirements with an emphasis placed on the fact of not reporting being a crime. New hires will be educated during orientation. Corrective Actions were completed on 4/3/25, and the Immediate Jeopardy was removed. Validation: The SA validated on 4/4/25, through interview and record review, that all corrective actions had been completed as of 4/3/25, and the IJ removed on 4/4/25.

Based on interviews, record review, the facility's investigation and facility policy review, the facility failed to report abuse within the required two (2) hour timeframe (Resident #1 and #2) and failed to submit a completed investigation for an allegation of abuse (Resident #3) to the State Agency (SA) within five (5) working days for (3) of four (4) sampled residents. Resident #1 was physically abused on 3/7/25 by Certified Nurse Aide (CNA) 1 which was witnessed by CNA #3 and Resident #2 was verbally abused by CNA #1 and was witnessed by CNA #2. CNA #1 and CNA #2 did not immediately report the abuse, until 3/17/25, which was ten (10) days after the first instance of abuse was witnessed. The facility's failure to immediately report the abuse placed Resident #1 and Resident #2 and other residents at risk for continued abuse by the abuser including the risk for serious harm, injury, impairment, or death. The situation was determined to Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 3/7/25 when CNA #1 was witnessed physically abusing Resident #1. The State Agency (SA) notified the facility's Administrator of the IJ and SQC on 4/3/25 at 5:00 PM. The facility provided an acceptable Removal Plan on 4/3/25 and the IJ was removed on 4/4/25. The SA validated the Removal Plan on 4/4/25 and determined the IJ was removed on 4/4/25, prior to exit. Therefore, the scope and severity for 42 CFR(s): 483.12(c)(1) Reporting of Alleged Violations (F609) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: A review of the facility's policy, Abuse, Neglect, Exploitation & (and) Misappropriation revised 11/16/22, revealed, .Procedure .2. Training .Employee obligation .Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment .to a resident, is obligated to report such information, but no later than 2 hours after the allegation is made .to the Administrator and to other officials in accordance with State Law 5. Investigation The Abuse Coordinator or his/her designee shall investigate all reports or allegations of abuse, neglect, misappropriation and exploitation .Review of Report: Report the results of all investigation to the Executive Director or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident . Resident #1 A record review of the Admission Record revealed the facility admitted Resident #1 on 3/08/2013 with current diagnoses including Parkinson's Disease and Dementia. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated her cognition was moderately impaired. Resident #2 A record review of the Admission Record revealed the facility admitted Resident #2 on 10/3/2019 with current diagnoses including Hypertension and Major Depressive Disorder. A record review of the Quarterly MDS with an ARD of 3/12/25 revealed Resident #2 had a BIMS score of 3 which indicated her cognition was severely impaired. Section GG revealed Resident #2 is dependent on staff for toileting hygiene. During an interview on 4//2/25 at 11:00 AM with CNA #3, she stated that on 03/07/25 at approximately 6:20 AM, she was working the overnight shift (11:00 PM - 7:00 AM) and Licensed Practical Nurse (LPN) #1 asked her to assist CNA #1 with providing care to Resident #1 because she was reportedly combative. As care began, Resident #1 swung at both CNAs. The resident grabbed CNA #1 by the hair and in response, CNA #1 grabbed the resident's nose and twisted it upwards, which caused the resident's nose to bleed. According to CNA #3, CNA #1 then stated, This is how you deal with crazy (expletive) like you. CNA #3 recalled telling CNA #1, You can't treat and talk to her like that, and stated she attempted to leave the room to locate the nurse but did not see her nearby. Not wanting to leave the resident alone with CNA #1, CNA #3 returned to the room and offered to finish providing care. She stated that CNA #1 appeared to ignore her and refused to leave the room. CNA #1 continued providing care, cleaned the blood from the resident's face using the resident's gown, finished dressing her, and transferred her to the chair before exiting the room. CNA #3 confirmed that she did not report the incident to the nurse, Director of Nursing (DON), or Administrator until 03/17/25, leaving all residents at risk for potential abuse. She stated she feared retaliation from other staff. During an interview with CNA #2 on 04/02/25 at 11:15 AM, she stated she was in Resident #2's room providing care to the roommate when she overheard CNA #1 say to Resident #2, If you (expletive) in the bed like you did yesterday, I'm going to beat your (expletive). CNA #2 stated she immediately told CNA #1 that she could not speak to a resident in that manner, to which CNA #1 replied, I bet it works. CNA #2 explained she did not report the incident at the time because she was afraid of retaliation from staff, stating that people had recently been losing their jobs and there were concerns about false allegations being made through the compliance hotline. In an interview with CNA #1 on 04/02/25 at 12:01 PM, she denied physically abusing Resident #1 and verbally abusing Resident #2. CNA #1 stated she believed the accusations were fabricated by another CNA because she was not part of the clique among staff at the facility. She further stated she had never worked with CNA #3 on the hall and that CNA #3's primary responsibility was providing showers. In an interview with the Administrator on 04/02/25 at 1:45 PM, he stated that on 03/17/25, he found two anonymous letters on his desk alleging abuse by CNA #1. The first letter described an incident in which CNA #1 physically abused Resident #1 during incontinent care by grabbing the resident's nose, causing it to bleed, and saying, It's how you deal with crazy (expletive) like you. The second letter alleged that CNA #1 verbally abused Resident #2 by stating, If you (expletive) out the bed like you did yesterday, I'm going to beat your (expletive), while CNA #1 was providing care. The Administrator stated CNA #1 was immediately suspended pending an investigation and was terminated on 03/18/25. Resident #3 The State Agency (SA) received a facility reported incident (CI: 28355) on 3/20/25 at 1:00 PM reporting an allegation of verbal abuse; it was reported that CNA #2 spoke very harshly to Resident #3. The Administrator called in the allegation of verbal abuse on the complaint hot line stating an anonymous call was made on the facility's compliance hot line. CNA #2 was suspended pending an investigation. As of 3/28/25 at 1:25 PM the Administrator has not submitted the final report. The SA attempted to converse with the Administrator on 3/27/25 several times and was not able to make contact. A record review of Resident #3's Admission Record revealed the facility admitted the resident on 11/10/23 with the diagnoses of Parkinsons, Hypertension, and Alcohol Abuse. A record review of Resident #3's Quarterly MDS with an ARD of 3/4/25 revealed BIMS score of 15 which indicated the resident was cognitively intact. During an interview on 4/2/25 at 4:00 PM the Administrator stated he received a complaint from an anonymous person on the compliance hot line stating that CNA #2 was verbally abusing Resident #3. The Administrator said he started the investigation. The Administrator also confirmed he failed to send in the final investigation within five (5) days to the State Agency (SA). The Administrator explained the DON was supposed to send in the final investigation. The Administrator said the DON had been sick and was not in the building. He failed to send the final report into the State Agency. During an interview on 4/2/25 at 4:30 PM with the DON confirmed the facility received a complaint from the compliance hot line stating CNA #2 verbally abused Resident #3. This was from an anonymous person. The DON said they started investigating the complaint. The DON confirmed she was responsible for sending in the final report and got sick. She confirmed she forgot to remind the Administrator to send it in. The Facility presented the following Removal Plan on 4/4/25: On 4/2/25 Quality Assurance (QAPI) Committee met at 5:45 pm to review, develop, and implement the facility policy on abuse and neglect with an emphasis on reporting abuse and neglect and to determine the root cause. The root cause was determined to be that employees were afraid of retaliation from other employees. Attendees were the Executive Director, (ED), Minimum Data Service (MDS) nurse, Medical Records (MRC), Regional Director of Clinical Services, (RDCS), Assistant Director of Nursing (ADON), Medical Director, Social Services (SSD) Staff Development/ Infection Preventionist nurse, Activities Director (AD), Human Resources (HR) Housekeeping, Dietary Manager, Therapy director, Unit Managers and the Admission Coordinator. There were no changes made to the policy and procedure. The areas that were discussed were the re-education of staff members on the abuse and neglect policy with an emphasis on reporting requirements and that failure to do so is a crime. On 3/17/25 body audits were completed on Resident # 1 and Resident #2 by the Staff Development nurse and a licensed nurse. No signs of physical abuse was identified. On 3/17/25 interviews were conducted by SSD with alert and oriented residents on side 2. No residents voiced complaints of abuse. On 3/17/25 the physician and the Resident Representatives of Resident # 1 and Resident 2 were notified. On 3/17/25 education was started by the Staff Development Nurse. On 3/26/25 the Quality Assurance Performance Improvement Committee met to review the physical and verbal abuse. On 4/2/25 Social Services completed a psychosocial follow up with Resident # 1 and Resident #2. On 4/2/25 100% body audits were performed on all facility residents by the unit manager RN and the Minimum Data Set nurses to ensure that residents did not have physical signs of abuse. No residents were identified. On 4/2/25 the ED was educated on the abuse policy by the RDCS and timely reporting of abuse within 2 hours to the state agency, attorney general and the abuse and neglect policy. On 4/2/25 the SSD and the Admissions Coordinator interviewed all alert and oriented residents (census) using the Risk Management Quality Improvement Questionnaire to determine if any residents had been abused or witnessed abuse. There were no residents that voiced any complaints of abuse. The Staff Development nurse started education with licensed nurses, CNA's and non-direct care staff on the abuse and neglect policy and procedure with an emphasis on reporting requirements on 4/2/25 and 100 % has been completed on 4/3/25. All facility staff members were interviewed by the ED, HR, and ADON by phone on 4/2/25 to ask if they ever witnessed any employee abuse a resident and explained the process of what to do if they ever witness abuse or neglect, with an emphasis on reporting requirements and that failure to do so is a crime. CNA # 2 received one on one education on the abuse policy and the reporting requirements with an emphasis placed on the fact of not reporting being a crime. New hires will be educated during orientation. Corrective Actions were completed on 4/3/25, and the Immediate Jeopardy was removed. Validation: The SA validated on 4/4/25, through interview and record review, that all corrective actions had been completed as of 4/3/25, and the IJ removed on 4/4/25.

Based on interview, record review, and facility policy review, the facility failed to implement comprehensive care plan interventions for one (1) of four (4) care plans reviewed, Resident #1. Findings included: A review of the facility's policy, Plans of Care, dated revised 9/25/2017, revealed, .implement an individualized Person-Centered comprehensive plan of care .as determined by the resident's needs or as requested by the resident, and, to the extent practicable . A record review of the Admission Record revealed the facility admitted Resident #1 on 3/08/2013 with current diagnoses including Parkinson's Disease and Dementia. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated her cognition was moderately impaired. A record review of the comprehensive care plan revealed a Focus of (Proper Name of Resident #1) has behaviors of occasionally being physically aggressive (hitting at staff) and verbally aggressive (yelling and cursing at staff and calling staff names) r/t (related to) dementia, psychosis, anxiety disorder, major depressive disorder, and lack of coordination. Interventions revised on 6/26/23 for When resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later . An interview on 04/02/25 at 11:00 AM with Certified Nursing Assistant (CNA) #3, she stated that on 03/07/25 at approximately 6:20 AM, she explained she was assisting CNA #1 with incontinence care and Resident #1 swung at both CNAs. CNA #3 reported that she held the resident's hands gently and reassured her, telling her everything was okay. The resident then pulled away from her grasp and grabbed CNA #1 by the hair. CNA #3 reported that in response, CNA #1 grabbed the resident's nose and twisted it upwards, which caused the resident's nose to bleed. According to CNA #3, CNA #1 then stated, This is how you deal with crazy (expletive) like you. CNA #3 acknowledged that the resident's care plan was not followed. An interview on 4/2/25 at 12:45 PM with Registered Nurse (RN) #2, she confirmed the staff failed to follow the care plan on 3/7/25 when the CNAs failed to give Resident #1 time to calm down before attempting care again. RN #2 stated the care plan was designed to guide care for the resident and the expectation was for staff to follow those guidelines. On 4/2/25 at 1:45 PM, during an interview with the Administrator, he confirmed staff failed to follow the comprehensive care plan by not stepping away and returning after the resident had calmed down. He stated it was his expectation that staff follow the residents' care plans. On 4/3/25 at 1:00 PM, during an interview with the Director of Nursing (DON), she confirmed staff failed to follow the care plan related to the resident's behaviors. She stated staff should have stopped the care and returned later, as instructed in the plan of care.

Based on interview, record review, and facility statement review the facility failed to ensure sufficient nursing staff was available to meet the needs of residents resulting in a resident being left soiled all night for one (1) of five (5) sampled residents. Resident #2 Findings include: Record review of a statement on facility letterhead, submitted by the Director of Nursing (DON), undated and unsigned revealed Facility staffs according to facility acuity. On February 25, 2025, at 2:06 PM, during a telephone interview, Licensed Practical Nurse (LPN) #1 revealed that on the night of February 23, 2025, during the 11:00 PM to 7:00 AM shift, the facility was staffed with three LPNs and one Certified Nurse Aide (CNA). LPN #1 stated that three CNAs had failed to call in absent for the shift. LPN #1 further revealed that the DON was contacted but did not respond. The staffing LPN was then called and provided a list of phone numbers to contact potential replacements. However, none of the staff contacted were available, and no further direction or assistance was provided by the DON or the Scheduler. During a telephone interview on February 25, 2025, at 2:26 PM, CNA # 1 revealed that she was the only CNA in the facility from 11 PM to 7AM and stated she did what she could do with assistance of the three (3) LPNs in the facility. CNA #1 stated that there were two no call/no shows of the two CNAs that the facility knew were already leaving on travel assignments. On February 26 2025 at 2:06 PM, an interview with Resident #2 revealed that on Sunday evening (2/23/2025), the facility had only one CNA on duty for the 11:00 PM to 7:00 AM shift. The resident stated that due to the lack of staff, she was forced to remain in urine the entire night, and I have an overactive bladder, so I go pretty often. She further stated that it was uncomfortable and that she believed the facility should have called in additional staff to address the shortage. Record review of the Admission Record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included Overactive bladder, which was present upon admission. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/9/2024, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Section H indicated the resident was always incontinent of urine. Record review of the Staffing Grid revealed that for the overnight shift on 2/23/2025 (11:00 PM to 7:00 AM), only one CNA was scheduled and present in the facility.

Based on staff and resident interviews and review of the Facility Assessment, the facility failed to ensure all required elements were included in the Facility Assessment, including specific staffing needs by shift, a plan for recruitment and retention of staff, and contingency planning that does not require activation of the facility's emergency plan for three (3) of three (3) days of a complaint survey. Findings Include: A review of the document titled Facility Assessment Tool revealed that 8-10 Licensed Practical Nurses (LPNs), 16-18 Nurse Aides, 5 non-nursing administrative employees, 2 Social Services workers, 1 contracted Dietitians, and 10 contracted dietary workers with zero respiratory workers were identified as sufficient to meet the facility's staffing needs in a 24-hour period. However, the assessment failed to specify staffing requirements for each eight-hour shift or account for changes in the resident population. Further review revealed the Facility Assessment did not include information regarding staff recruitment and retention plans or contingency planning for situations that do not require activation of the facility's emergency operations plan. On February 26, 2025, at 1:05 PM, an interview with the Administrator revealed that he was unaware that federal regulations required the facility's assessment plan to address staffing by shift based on changes in resident population. Upon review of the facility's document, he acknowledged that the plan addressed staffing over a 24-hour period but did not specify staffing needs by shift. On February 26, 2025, at 2:06 PM, a resident interview with Resident# 2 revealed that on the evening of February 23, 2025, the facility had only one Certified Nurse Aide (CNA) on duty. The resident stated, I was forced to sit in urine the entire night, and I have an overactive bladder, so I go pretty often. The resident expressed discomfort and stated that the facility should have had contingency plans in place for staffing shortages. A record review of the Admission Record revealed Resident #2 was admitted on [DATE], with a diagnoses that included Overactive bladder. Record review of the Order Listing Report revealed the resident had an active physician ' s order, dated February 22, 2025, for Detrol LA 2 mg (Tolterodine Tartrate) to be administered once daily for overactive bladder. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/9/2024, revealed a Brief Interview for Mental Status (BIMS) score of 15, demonstrating no cognitive impairment. Section H indicated the resident was always incontinent of urine. Record review of the Staffing Grid revealed that for the overnight shift on 2/23/2025 (11:00 PM to 7:00 AM), only one CNA was scheduled and present in the facility.

Based on observation, staff interviews, and record review, the facility failed to ensure daily nurse staffing information was posted in a visible and accessible location for two (2) of three (3) survey days. This failure limited residents, family members, and the public from accessing required staffing information and impeded transparency regarding facility staffing levels. On February 24, 2025 at 2025 at 2:00 PM, in an interview Licensed Practical Nurse (LPN)# 2, revealed that staffing is normal posted near the copier room in a glass case. LPN # 2 revealed after observation that there was no staffing posted. On February 25, 2025 at 2025 at 10:00 AM, in an interview LPN#3, revealed that staffing is normal posted near the copier room in a glass case. LPN# 3 confirmed after observation there was no staffing posted. On February 25, 2025, at 11:10 AM, an observation of the facility's designated staffing information posting area revealed that required daily nurse staffing information was not posted. No alternative posting location was identified. On February 26, 2025, at 9:30 AM, a follow-up observation confirmed there were no staffing postings available for February 24 or 25, 2025. Further observation at 11:00 AM revealed the required staffing information had not been posted. On February 26, 2025, at 11:15 AM, in an interview the Administrator stated that staffing postings were typically placed on the wall near the nurse's station but acknowledged that no postings were present for the previous two days. The Administrator further stated, We may have forgotten to put them up, but we do track our staffing internally. On February 26, 2025, at 2:00 PM, in an interview, the DON revealed that staffing is normal posted near the copier room in a glass case. The DON stated that staffing not getting posted was in error and confirmed that this failure limited residents, family members, and the public from accessing required staffing information and impeded transparency regarding facility staffing levels. A record review of the facility staffing postings revealed staffing information was not posted for February 24 or 25, 2025.

Based on interviews, record review, and facility policy review, the facility failed to honor a resident's right to refuse treatment when Resident #1, who was a hospice patient and had a signed Do Not Resuscitate (DNR) Physician's Order, received cardiopulmonary resuscitation (CPR) by facility staff for one (1) of four (4) residents reviewed. Resident #1 Resident #1's medical record had conflicting information regarding the code status of the resident and caused Resident #1 to receive CPR by facility staff for 25 minutes, which was against his wishes and the Physician's Order. The situation was determined to be an Immediate Jeopardy (IJ) which began on [DATE] when the facility received a signed DNR Physician's Order. This situation placed Resident #1 and other residents with DNR orders at risk for the likelihood of serious injury, serious harm, serious impairment or death. The State Agency (SA) notified the facility's Administrator of the IJ on [DATE] at 1:40 PM and provided the Administrator with the IJ templates. Based on the facility's implementation of corrective actions on [DATE], the SA determined the IJ to be Past Non-Compliance (PNC) and the IJ was removed on [DATE], prior to the SA's entrance on [DATE]. Findings include: A review of the facility's policy, Advanced Directives, revised [DATE], revealed POLICY: .The center will honor all properly executed advance directives that have been provided by the resident and/or resident representatives. Process .5. Advanced Directives will be reviewed .Hospice Admission . A record review of the facility's investigation Code Status Incident, revealed on [DATE], Resident #1 was found to be unresponsive. License Practical Nurse (LPN) #2 and LPN #3 verified in his hard chart (non-electronic medical chart) that Resident #1 was a Full Code (all resuscitation procedures would be provided) and his Advanced Directive sheet also indicated he was Full Code. At 5:45 AM, CPR was initiated. CPR was terminated at 6:10 AM when the Hospice nurse arrived at the facility and verified Resident #1 had a DNR status. On [DATE] at 6:30 AM, during an interview with LPN #3, she stated on [DATE] around 5:45 AM, Resident #1 was unresponsive, so she and LPN #2 reviewed the resident's chart. The hard chart did not indicate that he was DNR, but the electronic health record did. The Advanced Directive and the Physician's Order in the hard chart indicated he was Full Code. LPN #3 stated there was a discrepancy and since there was confusion, the nurses initiated CPR. The hospice nurse entered the facility after 6:00 AM and provided proof of the resident being DNR because there was a signed Advanced Directive in the hospice chart at the nurse's station. She reported that CPR was stopped at that time. On [DATE] at 9:28 AM, during an interview with LPN #1, she stated Resident #1 returned to the facility from the hospital on [DATE]. He had hospital discharge orders for DNR and Hospice services. She confirmed that she entered the DNR and Hospice orders into the electronic medical record but did not make any changes in the hard chart. She stated that since all orders are reviewed in the clinical meeting the next day, the necessary paperwork would have been reviewed by the Director of Nurses (DON) and the Social Worker at that time and they would make sure all the required documentation was on the resident's hard chart. On [DATE] at 9:42 AM, during an interview with the Social Services Director, she confirmed that she was unaware Resident #1's code status had changed on [DATE] when he returned from the hospital. She stated she was aware that he was on hospice services, but not all residents with hospice services have DNR orders. The Social Services Director stated she did not review the resident's new orders during the clinical meeting on [DATE], which was the day following the resident's return to the facility. On [DATE] at 10:05 AM, during an interview with the DON, she confirmed during the clinical meeting held on [DATE], the staff did not discuss new Physician's Orders for Resident #1, including the change to DNR status and the hospice admission. She stated the DNR order was correctly entered into the electronic health record, but a copy was not placed in the resident's hard chart. The DON stated she had made the mistake of not researching Resident #1's new Physician's Orders received upon the hospital discharge on [DATE] and following up with the Hospice provider. On [DATE] at 12:00 PM, during an interview with the hospice provider nurses, Registered Nurse (RN) #2 and RN #3, they confirmed that on [DATE] at approximately 7:00 PM, RN #3 entered the facility and gave LPN #1 the new orders from the hospice provider which indicated Resident #1 was DNR and the Advanced Directive signed by the family. She placed the documents in the resident's hospice binder at the nurse's station. On [DATE], RN #3 returned to the facility with the Advanced Directive signed by the Physician and placed it in the hospice binder. She stated this was the normal procedure for a resident when they are admitted to hospice services. A record review of the Admission Record revealed the facility admitted Resident #1 on [DATE] and he had diagnoses including Dementia and Osteomyelitis. A record review of the Discharge Summary revealed Resident #1 was admitted to a local acute care hospital on [DATE] and was discharged from the hospital on [DATE]. Review of the Hospital Course revealed ,d+[DATE](2024) Discussed with family, POA (Power of Attorney). Patient is DNR, code status changed XXX,d+[DATE] (2024) .discussed with family and they wish hospice/comfort care . ,d+[DATE] (2024) .Plan to discharge to hospice today . The Goals of Care Treatment Preferences revealed, Code Status: DNR). A record review of the facility's Order Summary Report revealed Resident #1 had physician's orders, dated [DATE], for Do NOT Resuscitate and Hospice: Admit to (Proper Name of Hospice Service). A record review of the Mississippi Physician Orders for Sustaining Treatment (POST), revealed on [DATE], Resident #1's family member signed the form, indicating the facility should not attempt resuscitation (DNR) and medical interventions was Comfort Measures Only. The primary physician signed the form on [DATE]. Based on the facility's implementation of corrective actions on [DATE], the SA determined the IJ to be Past Non-Compliance (PNC), and the IJ was removed on [DATE], prior to the SA's entrance on [DATE]. Corrective Actions: Brief Summary of Events: 1. On [DATE] at 5:26 PM the Executive Director reported incident to State Agency via e mail. 2. On Friday [DATE] 100 % audit of Code Status was conducted by the Social Services Director (SSD) to ensure hard chart code status order, Advanced Directive sheet and code status order in PCC match. There were no other discrepancies noted. 3. On Friday, [DATE], the Social Services Director and Regional Director of Clinical Services initiated and completed on [DATE] notification of all Residents and /or Resident Representatives (RR) to verify and review wishes for an Advanced Directive to include Code Status. 4. On Friday, [DATE], the Director of Nursing (DON) verified the code status for 2 Residents currently on Hospice and reviewed the Hospice charts for any code status discrepancies. There were no discrepancies noted. The Director of Nursing (DON) combined Hospice charts with the facility hard chart. 5. On Friday [DATE] a 100% audit of all Residents physician orders was initiated and completed on [DATE] by the Regional Director of Clinical Services (RDCS), Director of Nursing (DON) and the Social Services Director (SSD). 6. On Saturday [DATE] review of Care Plans was initiated and completed on [DATE]. Care Plans were reviewed by the Director of Nursing (DON), Social Services Director (SSD) and Regional Director of Clinical Services (RDCS) to ensure Residents code status is appropriately care planned, code status in PCC and Resident paper chart reconcile and no discrepancies found between Hospice Chart and facility hard chart. No discrepancies were found. 7. On Friday [DATE] Quality Assurance Performance Improvement (QAPI) Committee met to review policies on Advance Directives SS 124, Abuse and Neglect N 1265, N 140 Physician Orders, SS 260 Resident Rights, CPR N 302 and process for verifying code status on admit and readmit, determine Root Cause Analysis and begin immediate actions plan. There were no changes made to policies. There was a process implemented for verifying code status on admit and readmit to prevent future occurrences. The new process will include Physician orders from last 24 hours will be printed by Unit Manager (UM) every morning Monday - Friday and brought to the morning clinical meeting for review. When there is a change in Code Status Social Worker will address and verify Code Status with Resident and /or RP and update Advanced Directive Sheet. When a Resident is admitted or readmitted the admitting nurse will notify the physician, Resident and Representative if appropriate to verify code status and update Advanced Directive. This will allow for Residents wishes for Advanced Directives and Code Status to be honored in the event there is a change in Code Status between Clinical Meetings. Attendees was Director of Nursing (DON), Executive Director (ED), Regional Director of Clinical Services (RDCS) , Social Services Director (SSD) , Minimum Data Set (MDS) Nurse , Business Office Manager (BOM) , Human Resources Director (HRD) ,Infection Control Preventionist Licensed Practical Nurse (ICP-LPN), Activities Director (AD) , Therapy Manager and Unit Manager - Registered Nurse (UM-RN). The Medical Director attended via telephone. Monitoring will include #8 and #9. 8. Quality Monitoring of code status and Advanced Directives began by the Social Services Director and continues weekly for 4 weeks then monthly for 2 months. Monitoring includes ensuring DNR order noted on hard chart and signed by physician, Comprehensive Care Plan reflects current code status, Code status on demographic sheet in Electronic Health Record (EHR) reconciles with code status noted on the Residents paper chart, Care Plan and Advanced Directive Form. 9. Regional Director of Clinical Services began monitoring morning clinical meeting twice weekly for 2 weeks, then weekly for 2 weeks then monthly for 2 months to ensure physician orders were being reviewed in clinical meeting to include code status physician orders. 10. On Friday [DATE] Regional Director of Clinical Services (RDCS) conducted education with the Director Nursing (DON), Executive Director (ED) and the Social Services Director (SSD) on Advance Directives SS 124, Care Plans N 1015, Abuse and Neglect N 1265, N 140 Physician Orders, SS 260 Resident Rights, CPR N 302 and Process for verifying code status on admit and readmit. Physician orders from last 24 hours will be printed by Unit Manager (UM) every morning Monday - Friday and brought to the morning clinical meeting for review. When there is a change in Code Status Social Worker will address and verify Code Status with Resident and /or RP and update Advanced Directive Sheet. When a Resident is admitted or readmitted the admitting nurse will notify the physician, Resident and Representative if appropriate to verify code status and update Advanced Directive. This will allow for Residents wishes for Advanced Directives and Code Status to be honored in the event there is a change in Code Status between Clinical Meetings. 11. On Friday, [DATE], the Regional Director of Clinical Services (RDCS) conducted education with the Executive Director (ED), Director of Nursing (DON), and Social Services Director (SSD) on Comprehensive Care Plans and ensuring Care plans are comprehensive to include code status. The Comprehensive Care Plan will be implemented within 7 days after completing the comprehensive assessment. 12. On Friday [DATE] DON initiated education to all Licensed Nurses on Advance Directives SS 124, Abuse and Neglect N 1265, Care Plans 1015, N 140 Physician Orders, SS 260 Resident Rights, CPR N 302 and process for verifying code status on admit and readmit. Physician orders from last 24 hours will be printed by Unit Manager (UM) every morning Monday - Friday and brought to the morning clinical meeting for review. When there is a change in Code Status Social Worker will address and verify Code Status with Resident and /or RP and update Advanced Directive Sheet. When a Resident is admitted or readmitted the admitting nurse will notify the physician, Resident and Representative if appropriate to verify code status and update Advanced Directive. This will allow for Residents wishes for Advanced Directives and Code Status to be honored in the event there is a change in Code Status between Clinical Meetings. Education was completed on [DATE]. Education with new hires will be done in orientation. All corrective actions were completed as of [DATE] and the facility alleges the IJ removed on [DATE]. Validation: On [DATE], the SA validated through record review and interview the facility reported the incident to the SA via email on [DATE]. On [DATE], the SA validated through record review and interview that 100 % audit of Code Status was conducted by the Social Services Director (SSD) to ensure the hard chart code status order, Advanced Directive sheet, and code status order in PCC match. No other discrepancies were noted through record reviews and interviews. On [DATE], the SA validated through record reviews and interviews the Social Services Director and Regional Director of Clinical Services initiated and completed on [DATE] notification of all Residents and /or Resident Representatives (RR) to verify and review wishes for an Advanced Directive to include Code Status. On [DATE], the SA validated through record review and interviews the DON verified the code status for 2 Residents currently on Hospice and reviewed the Hospice charts for any code status discrepancies. There were no discrepancies noted. The Director of Nursing (DON) combined Hospice charts with the facility hard chart. On [DATE], the SA validated through record review and interviews 100% audit of all Residents physician orders was initiated and completed on [DATE] by the Regional Director of Clinical Services (RDCS), Director of Nursing (DON) and the Social Services Director (SSD). On [DATE], the SA validated through record review and interviews Care Plans was initiated and completed on [DATE]. Care Plans were reviewed by the Director of Nursing (DON), Social Services Director (SSD) and Regional Director of Clinical Services (RDCS) to ensure Residents code status is appropriately care planned, code status in PCC and Resident paper chart reconcile and no discrepancies found between Hospice Chart and facility hard chart. No discrepancies were found. On [DATE], the SA validated through record review and interviews Quality Assurance Performance Improvement (QAPI) Committee met to review policies on Advance Directives SS 124, Abuse and Neglect N 1265, N 140 Physician Orders, SS 260 Resident Rights, CPR N 302 and process for verifying code status on admit and readmit, determine Root Cause Analysis and begin immediate actions plan. There were no changes made to policies. There was a process implemented for verifying code status on admit and readmit to prevent future occurrences. The new process will include Physician orders from last 24 hours will be printed by Unit Manager (UM) every morning Monday - Friday and brought to the morning clinical meeting for review. When there is a change in Code Status Social Worker will address and verify Code Status with Resident and /or RP and update Advanced Directive Sheet. When a Resident is admitted or readmitted the admitting nurse will notify the physician, Resident and Representative if appropriate to verify code status and update Advanced Directive. This will allow for Residents wishes for Advanced Directives and Code Status to be honored in the event there is a change in Code Status between Clinical Meetings. Attendees was Director of Nursing (DON), Executive Director (ED), Regional Director of Clinical Services (RDCS) , Social Services Director (SSD) , Minimum Data Set (MDS) Nurse , Business Office Manager (BOM) , Human Resources Director (HRD) ,Infection Control Preventionist Licensed Practical Nurse (ICP-LPN), Activities Director (AD) , Therapy Manager and Unit Manager - Registered Nurse (UM-RN). The Medical Director attended via telephone. Monitoring will include #8 and #9. On [DATE], the SA validated through record review and interviews Quality Monitoring of code status and Advanced Directives began by the Social Services Director and continues weekly for 4 weeks then monthly for 2 months. Monitoring includes ensuring DNR order noted on hard chart and signed by physician, Comprehensive Care Plan reflects current code status, Code status on demographic sheet in Electronic Health Record (EHR) reconciles with code status noted on the Residents paper chart, Care Plan and Advanced Directive Form. On [DATE], the SA validated through record review and interviews the Regional Director of Clinical Services began monitoring morning clinical meeting twice weekly for 2 weeks, then weekly for 2 weeks then monthly for 2 months to ensure physician orders were being reviewed in clinical meeting to include code status physician orders. On [DATE], the SA validated through record review and interviews the Regional Director of Clinical Services (RDCS) conducted education with the Director Nursing (DON), Executive Director (ED) and the Social Services Director (SSD) on Advance Directives SS 124, Care Plans N 1015, Abuse and Neglect N 1265, N 140 Physician Orders, SS 260 Resident Rights, CPR N 302 and Process for verifying code status on admit and readmit. Physician orders from last 24 hours will be printed by Unit Manager (UM) every morning Monday - Friday and brought to the morning clinical meeting for review. When there is a change in Code Status Social Worker will address and verify Code Status with Resident and /or RP and update Advanced Directive Sheet. When a Resident is admitted or readmitted the admitting nurse will notify the physician, Resident and Representative if appropriate to verify code status and update Advanced Directive. This will allow for Residents wishes for Advanced Directives and Code Status to be honored in the event there is a change in Code Status between Clinical Meetings. On [DATE], the SA validated through record review and interviews the Regional Director of Clinical Services (RDCS) conducted education with the Executive Director (ED), Director of Nursing (DON), and Social Services Director (SSD) on Comprehensive Care Plans and ensuring Care plans are comprehensive to include code status. The Comprehensive Care Plan will be implemented within 7 days after completing the comprehensive assessment. On [DATE], the SA validated through record review and interviews DON initiated education to all Licensed Nurses on Advance Directives SS 124, Abuse and Neglect N 1265, Care Plans 1015, N 140 Physician Orders, SS 260 Resident Rights, CPR N 302 and process for verifying code status on admit and readmit. Physician orders from last 24 hours will be printed by Unit Manager (UM) every morning Monday - Friday and brought to the morning clinical meeting for review. When there is a change in Code Status Social Worker will address and verify Code Status with Resident and /or RP and update Advanced Directive Sheet. When a Resident is admitted or readmitted the admitting nurse will notify the physician, Resident and Representative if appropriate to verify code status and update Advanced Directive. This will allow for Residents wishes for Advanced Directives and Code Status to be honored in the event there is a change in Code Status between Clinical Meetings. Education was completed on [DATE]. Education with new hires will be done in orientation.

Based on interviews, record review, and facility policy review, the facility failed to develop comprehensive care plan interventions regarding Advanced Directives for one (1) of four (4) residents reviewed. Resident #1 The facility's failure to develop comprehensive care plan interventions caused Resident #1 to receive cardiopulmonary resuscitation (CPR) by facility staff which was against his wishes and the Physician's Order. Resident #1 received CPR for 25 minutes. The situation was determined to be an Immediate Jeopardy (IJ) which began on [DATE]. The State Agency (SA) notified the facility's Administrator of the IJ on [DATE] at 1:40 PM and provided the Administrator with the IJ templates. This situation placed Resident #1 and other residents with DNR orders at risk for the likelihood of serious injury, serious harm, serious impairment or death. Based on the facility's implementation of corrective actions on [DATE], the SA determined the IJ to be Past Non-Compliance (PNC) and the IJ was removed on [DATE], prior to the SA's entrance on [DATE]. Findings include: A review of the facility policy Plans of Care, revised on [DATE], revealed, An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements .Procedure .Develop a comprehensive plan of care for each resident .to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment .Develop and implement an individualized Person-Centered comprehensive plan of care .within seven (7) days after completion of the comprehensive assessment (MDS). A review of Resident #1's comprehensive care plan revealed Focus: [DATE] (Proper Name of Resident #1) has advanced directives r/t (related to) DNR. The date initiated was [DATE] which was the day after Resident #1 received CPR. Review of the medical record revealed there was no comprehensive care plan developed on [DATE] when the signed Advanced Directive was received from the hospice provider. A record review of the Baseline Care Plan and Summary revealed a baseline care plan for Advanced Directives which indicated Resident #1 as Full Code and had a handwritten date of [DATE]. A record review of the facility's investigation Code Status Incident, revealed on [DATE], Resident #1 was found to be unresponsive. License Practical Nurse (LPN) #2 and LPN #3 verified in his hard chart (non-electronic medical chart) that Resident #1 was a Full Code (all resuscitation procedures would be provided) and his Advanced Directive sheet also indicated he was Full Code. At 5:45 AM, CPR was initiated. CPR was terminated at 6:10 AM when the Hospice nurse arrived at the facility and verified Resident #1 had a DNR status. A record review of the Discharge Summary revealed Resident #1 was admitted to a local acute care hospital on [DATE] and was discharged from the hospital on [DATE]. Review of the Hospital Course revealed ,d+[DATE](2024) Discussed with family, POA (Power of Attorney). Patient is DNR, code status changed XXX,d+[DATE] (2024) .discussed with family and they wish hospice/comfort care . ,d+[DATE] (2024) .Plan to discharge to hospice today . The Goals of Care Treatment Preferences revealed, Code Status: DNR). A record review of the facility's Order Summary Report revealed Resident #1 had a Physician's Order, dated [DATE], for Do NOT Resuscitate. A record review of the Mississippi Physician Orders for Sustaining Treatment (POST), with an effective date of [DATE], revealed Resident #1's family member signed the form, indicating the facility should not attempt resuscitation (DNR) and medical interventions was Comfort Measures Only. The primary physician signed the form on [DATE]. During an interview on [DATE] at 9:42 AM, during an interview with the Director of Nurses (DON), she confirmed that on [DATE] during the clinical meeting, Resident #1's new orders were not reviewed and the change in his code status was addressed. The DON explained that a comprehensive care plan should have been developed within 14 days after [DATE] when Resident #1 was admitted to the facility. She stated the facility should have accurately completed a comprehensive care plan by [DATE]. The DON stated it was her expectation that the nursing staff develop the comprehensive care plan within the correct timeframe. She expressed that since the comprehensive care plan was not developed for Resident #1, he underwent CPR which was not his wishes. On [DATE] at 11:00 AM, during an interview with LPN #4/MDS (Minimum Data Set) Nurse, she confirmed that a comprehensive care plan for Resident #1 was not developed and explained that it should have been developed by [DATE], which was 14 days after the facility admitted him. On [DATE] at 11:20 AM, in an interview with Registered Nurse (RN) #1/MDS, she confirmed the facility did not develop a comprehensive care plan for Resident #1 and it should have been developed after the completion of the comprehensive MDS. Based on the facility's implementation of corrective actions on [DATE], the SA determined the IJ to be Past Non-Compliance (PNC), and the IJ was removed on [DATE], prior to the SA's entrance on [DATE]. Corrective Action Plan Brief Summary of Events: Facility failed to honor Residents wishes and implement an Advanced Directive for Resident to be a Do Not Resuscitate (DNR) which resulted in the Resident receiving Cardiopulmonary Resuscitation for 25 minutes. Facility Failed to develop comprehensive, care plan interventions regarding Advanced Directives for Resident #1, who had a signed Do Not resuscitate (DNR) Physicians Order. On [DATE] state agency representative notified Executive Director and the Director of Nursing of Immediate Jeopardy for F 578 and F 656 and presented template for Immediate Jeopardies. [DATE] Resident was transferred to hospital and was a Full Code at the time of Transfer with an Advanced Directive Consent Form in hard chart. While at the hospital was diagnosed with Respiratory failure secondary. On Thursday [DATE] Resident returns. Return orders included DNR orders. License Practical Nurse (LPN) did enter Do Not Resuscitate (DNR) in Electronic Health Record but did not communicate change in status to Social Services, change advanced directive on the hard chart or provide copy of DNR order in hard chart. Physician order reconciliation was not performed on [DATE] during the clinical nursing review and a signed DNR was in the hospice chart at the facility. On [DATE] the Hospice Nurse placed the Advance Directives with a signature on the Hospice Chart. The Mississippi Physician Order for Sustaining Treatment (POST) was not finalized with signature until [DATE]. Hospice nurse placed Mississippi POST to Hospice chart but did not communicate to anyone in facility the Mississippi POST for DNR had been placed on hospice chart. On Friday [DATE] Resident was unresponsive, and License Practical Nurse (LPN) #2 and LPN #3 verified code status in hard chart which was Full code and Advanced Directive Sheet indicating Full Code. Code Blue called at 0544 am. CPR was initiated at 0545 am. EMS and Hospice nurse arrived and according to nurses' notes took over and verified DNR Status. Cardiopulmonary Resuscitation (CPR) was terminated at 0610 am after Hospice Nurse arrived at facility and informed staff, she had placed a Mississippi POST for DNR on Residents Hospice Chart on [DATE], Family notified at 0620 am. Resident pronounced expired at 0625 am. Nurse Practitioner notified at 0750 am. On Friday [DATE] after incident DON found Mississippi Code Status POST in Hospice Binder that was signed and dated by family on [DATE]. Corrective Actions: 1. On [DATE] at 5:26 PM the Executive Director reported incident to State Agency via e mail. 2. On Friday [DATE] 100 % audit of Code Status was conducted by the Social Services Director (SSD) to ensure hard chart code status order, Advanced Directive sheet and code status order in PCC match. There were no other discrepancies noted. 3. On Friday, [DATE], the Social Services Director and Regional Director of Clinical Services initiated and completed on [DATE] notification of all Residents and /or Resident Representatives (RR) to verify and review wishes for an Advanced Directive to include Code Status. 4. On Friday, [DATE], the Director of Nursing (DON) verified the code status for 2 Residents currently on Hospice and reviewed the Hospice charts for any code status discrepancies. There were no discrepancies noted. The Director of Nursing (DON) combined Hospice charts with the facility hard chart. 5. On Friday [DATE] a 100% audit of all Residents physician orders was initiated and completed on [DATE] by the Regional Director of Clinical Services (RDCS), Director of Nursing (DON) and the Social Services Director (SSD). 6. On Saturday [DATE] review of Care Plans was initiated and completed on [DATE]. Care Plans were reviewed by the Director of Nursing (DON), Social Services Director (SSD) and Regional Director of Clinical Services (RDCS) to ensure Residents code status is appropriately care planned, code status in PCC and Resident paper chart reconcile and no discrepancies found between Hospice Chart and facility hard chart. No discrepancies were found. 7. On Friday [DATE] Quality Assurance Performance Improvement (QAPI) Committee met to review policies on Advance Directives SS 124, Abuse and Neglect N 1265, N 140 Physician Orders, SS 260 Resident Rights, CPR N 302 and process for verifying code status on admit and readmit, determine Root Cause Analysis and begin immediate actions plan. There were no changes made to policies. There was a process implemented for verifying code status on admit and readmit to prevent future occurrences. The new process will include Physician orders from last 24 hours will be printed by Unit Manager (UM) every morning Monday - Friday and brought to the morning clinical meeting for review. When there is a change in Code Status Social Worker will address and verify Code Status with Resident and /or RP and update Advanced Directive Sheet. When a Resident is admitted or readmitted the admitting nurse will notify the physician, Resident and Representative if appropriate to verify code status and update Advanced Directive. This will allow for Residents wishes for Advanced Directives and Code Status to be honored in the event there is a change in Code Status between Clinical Meetings. Attendees was Director of Nursing (DON), Executive Director (ED), Regional Director of Clinical Services (RDCS) , Social Services Director (SSD) , Minimum Data Set (MDS) Nurse , Business Office Manager (BOM) , Human Resources Director (HRD) ,Infection Control Preventionist Licensed Practical Nurse (ICP-LPN), Activities Director (AD) , Therapy Manager and Unit Manager - Registered Nurse (UM-RN). The Medical Director attended via telephone. Monitoring will include #8 and #9. 8. Quality Monitoring of code status and Advanced Directives began by the Social Services Director and continues weekly for 4 weeks then monthly for 2 months. Monitoring includes ensuring DNR order noted on hard chart and signed by physician, Comprehensive Care Plan reflects current code status, Code status on demographic sheet in Electronic Health Record (EHR) reconciles with code status noted on the Residents paper chart, Care Plan and Advanced Directive Form. 9. Regional Director of Clinical Services began monitoring morning clinical meeting twice weekly for 2 weeks, then weekly for 2 weeks then monthly for 2 months to ensure physician orders were being reviewed in clinical meeting to include code status physician orders. 10. On Friday [DATE] Regional Director of Clinical Services (RDCS) conducted education with the Director Nursing (DON), Executive Director (ED) and the Social Services Director (SSD) on Advance Directives SS 124, Care Plans N 1015, Abuse and Neglect N 1265, N 140 Physician Orders, SS 260 Resident Rights, CPR N 302 and Process for verifying code status on admit and readmit. Physician orders from last 24 hours will be printed by Unit Manager (UM) every morning Monday - Friday and brought to the morning clinical meeting for review. When there is a change in Code Status Social Worker will address and verify Code Status with Resident and /or RP and update Advanced Directive Sheet. When a Resident is admitted or readmitted the admitting nurse will notify the physician, Resident and Representative if appropriate to verify code status and update Advanced Directive. This will allow for Residents wishes for Advanced Directives and Code Status to be honored in the event there is a change in Code Status between Clinical Meetings. 11. On Friday, [DATE], the Regional Director of Clinical Services (RDCS) conducted education with the Executive Director (ED), Director of Nursing (DON), and Social Services Director (SSD) on Comprehensive Care Plans and ensuring Care plans are comprehensive to include code status. The Comprehensive Care Plan will be implemented within 7 days after completing the comprehensive assessment. 12. On Friday [DATE] DON initiated education to all Licensed Nurses on Advance Directives SS 124, Abuse and Neglect N 1265, Care Plans 1015, N 140 Physician Orders, SS 260 Resident Rights, CPR N 302 and process for verifying code status on admit and readmit. Physician orders from last 24 hours will be printed by Unit Manager (UM) every morning Monday - Friday and brought to the morning clinical meeting for review. When there is a change in Code Status Social Worker will address and verify Code Status with Resident and /or RP and update Advanced Directive Sheet. When a Resident is admitted or readmitted the admitting nurse will notify the physician, Resident and Representative if appropriate to verify code status and update Advanced Directive. This will allow for Residents wishes for Advanced Directives and Code Status to be honored in the event there is a change in Code Status between Clinical Meetings. Education was completed on [DATE]. Education with new hires will be done in orientation. All corrective actions were completed as of [DATE] and the facility alleges the IJ removed on [DATE]. Validation: On [DATE], the SA validated through record review and interview the facility reported the incident to the SA via email on [DATE]. On [DATE], the SA validated through record review and interview that 100 % audit of Code Status was conducted by the Social Services Director (SSD) to ensure the hard chart code status order, Advanced Directive sheet, and code status order in PCC match. No other discrepancies were noted through record reviews and interviews. On [DATE], the SA validated through record reviews and interviews the Social Services Director and Regional Director of Clinical Services initiated and completed on [DATE] notification of all Residents and /or Resident Representatives (RR) to verify and review wishes for an Advanced Directive to include Code Status. On [DATE], the SA validated through record review and interviews the DON verified the code status for 2 Residents currently on Hospice and reviewed the Hospice charts for any code status discrepancies. There were no discrepancies noted. The Director of Nursing (DON) combined Hospice charts with the facility hard chart. On [DATE], the SA validated through record review and interviews 100% audit of all Residents physician orders was initiated and completed on [DATE] by the Regional Director of Clinical Services (RDCS), Director of Nursing (DON) and the Social Services Director (SSD). On [DATE], the SA validated through record review and interviews Care Plans was initiated and completed on [DATE]. Care Plans were reviewed by the Director of Nursing (DON), Social Services Director (SSD) and Regional Director of Clinical Services (RDCS) to ensure Residents code status is appropriately care planned, code status in PCC and Resident paper chart reconcile and no discrepancies found between Hospice Chart and facility hard chart. No discrepancies were found. On [DATE], the SA validated through record review and interviews Quality Assurance Performance Improvement (QAPI) Committee met to review policies on Advance Directives SS 124, Abuse and Neglect N 1265, N 140 Physician Orders, SS 260 Resident Rights, CPR N 302 and process for verifying code status on admit and readmit, determine Root Cause Analysis and begin immediate actions plan. There were no changes made to policies. There was a process implemented for verifying code status on admit and readmit to prevent future occurrences. The new process will include Physician orders from last 24 hours will be printed by Unit Manager (UM) every morning Monday - Friday and brought to the morning clinical meeting for review. When there is a change in Code Status Social Worker will address and verify Code Status with Resident and /or RP and update Advanced Directive Sheet. When a Resident is admitted or readmitted the admitting nurse will notify the physician, Resident and Representative if appropriate to verify code status and update Advanced Directive. This will allow for Residents wishes for Advanced Directives and Code Status to be honored in the event there is a change in Code Status between Clinical Meetings. Attendees was Director of Nursing (DON), Executive Director (ED), Regional Director of Clinical Services (RDCS) , Social Services Director (SSD) , Minimum Data Set (MDS) Nurse , Business Office Manager (BOM) , Human Resources Director (HRD) ,Infection Control Preventionist Licensed Practical Nurse (ICP-LPN), Activities Director (AD) , Therapy Manager and Unit Manager - Registered Nurse (UM-RN). The Medical Director attended via telephone. Monitoring will include #8 and #9. On [DATE], the SA validated through record review and interviews Quality Monitoring of code status and Advanced Directives began by the Social Services Director and continues weekly for 4 weeks then monthly for 2 months. Monitoring includes ensuring DNR order noted on hard chart and signed by physician, Comprehensive Care Plan reflects current code status, Code status on demographic sheet in Electronic Health Record (EHR) reconciles with code status noted on the Residents paper chart, Care Plan and Advanced Directive Form. On [DATE], the SA validated through record review and interviews the Regional Director of Clinical Services began monitoring morning clinical meeting twice weekly for 2 weeks, then weekly for 2 weeks then monthly for 2 months to ensure physician orders were being reviewed in clinical meeting to include code status physician orders. On [DATE], the SA validated through record review and interviews the Regional Director of Clinical Services (RDCS) conducted education with the Director Nursing (DON), Executive Director (ED) and the Social Services Director (SSD) on Advance Directives SS 124, Care Plans N 1015, Abuse and Neglect N 1265, N 140 Physician Orders, SS 260 Resident Rights, CPR N 302 and Process for verifying code status on admit and readmit. Physician orders from last 24 hours will be printed by Unit Manager (UM) every morning Monday - Friday and brought to the morning clinical meeting for review. When there is a change in Code Status Social Worker will address and verify Code Status with Resident and /or RP and update Advanced Directive Sheet. When a Resident is admitted or readmitted the admitting nurse will notify the physician, Resident and Representative if appropriate to verify code status and update Advanced Directive. This will allow for Residents wishes for Advanced Directives and Code Status to be honored in the event there is a change in Code Status between Clinical Meetings. On [DATE], the SA validated through record review and interviews the Regional Director of Clinical Services (RDCS) conducted education with the Executive Director (ED), Director of Nursing (DON), and Social Services Director (SSD) on Comprehensive Care Plans and ensuring Care plans are comprehensive to include code status. The Comprehensive Care Plan will be implemented within 7 days after completing the comprehensive assessment. On [DATE], the SA validated through record review and interviews DON initiated education to all Licensed Nurses on Advance Directives SS 124, Abuse and Neglect N 1265, Care Plans 1015, N 140 Physician Orders, SS 260 Resident Rights, CPR N 302, and process for verifying code status on admit and readmit. Physician orders from the last 24 hours will be printed by Unit Manager (UM) every morning Monday - Friday and brought to the morning clinical meeting for review. When there is a change in Code Status, the Social Worker will address and verify Code Status with Resident and /or RP and update Advanced Directive Sheet. When a Resident is admitted or readmitted the admitting nurse will notify the physician, Resident and Representative if appropriate to verify code status and update Advanced Directive. This will allow for Residents wishes for Advanced Directives and Code Status to be honored in the event there is a change in Code Status between Clinical Meetings. Education was completed on [DATE]. Education with new hires will be done in orientation.

Based on staff interviews, recorded review, facility investigation review and policy review the facility failed to provide adequate staff supervision to prevent Resident #1's elopement from the facility on 5/25/21 after 9:45 AM. The facility staff did not know Resident #1 was off the facility grounds until he was seen by Housekeeping (HK) #1 an off-duty staff who was driving on the four (4)-lane highway. This concern was identified for one (1) of six (6) residents reviewed for wandering behavior and risk for elopement. Facility staff were not aware that Resident #1 left the facility without staff knowledge or supervision until approximately 10:00 AM on 4/25/2021. Housekeeper (HK) #1 reported Resident #1 was seen walking down the side of the four-lane highway HK #1 was driving on with no staff supervision. Resident #1 had been assessed for a wander guard which did not alarm when the resident exited through the window. Registered Nurse (RN) #1 and HK #2 went to Resident #1's room and interviewed his roommate (Resident #2). Resident #2 stated that Resident #1 climbed out the window. The window was intact, and the screen had been put back in place. RN #1 drove to the site where Resident #1 was walking, 0.2 miles from the facility. Resident #1 refused to return to the facility and the police were notified by RN #1 at approximately 10:10 AM. The police arrived and called an ambulance. Ambulance transported the resident to the local emergency room . Resident #1 was assessed at the emergency room and found to have an abrasion to the elbow. Resident #1 left the hospital with his family and refused to return to the facility; he was discharged from the facility on 4/25/21. Facility failed to report the incident to SA until May 5, 2021 at 6:05 PM. Resident #1 had an Interview Mental Status Brief (BIMS) score of 13, indicating intact cognitive skills for daily decision making. The facility's failure to provide adequate supervision to prevent an elopement for Resident #1, who was an elopement and wander risk, allowed the resident to leave the facility, unnoticed and unsupervised until HK #1 reported she found Resident #1 walking down the four- lane highway. This situation placed Resident #1 and other residents with wandering behaviors and at risk of elopement, in a likelihood for serious injury, harm, impairment, or death. On 5/5/2021, the SA identified an Immediate Jeopardy (IJ), and Substandard Quality of Care (SQC), which began on 4/25/2021, when Resident #1 exited the facility through a window and was found approximately 20 minutes later walking down the side a busy 4-lane highway. The IJ and SQC existed at: 42 CFR(s): 483.25 (d)(1)(2)- Free of Accidents, Hazards/ Supervision/Devices (F 689) - Scope and Severity J. The SA notified the facility's Administrator of the IJ and SQC on 5/5/2021 at 4:10 PM, and provided the IJ template to the Administrator. The facility provided an acceptable Removal Plan on 5/5/2021, in which the facility alleged all corrective actions were completed to remove the IJ and SQC 5/5/2021, and the IJ was removed on 5/6/2021. The SA determined the IJ and SQC was removed on 5/6/2021, prior to exit, and the scope and severity for 42 CFR(s): 483.25 (d)(1)(2)- Free of Accidents, Hazards/ Supervision/Devices (689) was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy, Elopement/Wandering Risk Guidelines, dated 8/01/2020, revealed, it is the policy of this facility to evaluate and identify patients/ residents that are at risk for elopement and develop individualized interventions. Review of the facility's policy, Missing Patient/Resident, dated 8/1/2020, revealed an elopement occurs when a patient/resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so, placing the patient /resident at risk for harm or injury. On 5/7/21 at 8:46 AM it was revealed in an interview with the Administrator that the facility did not have a policy for supervision. Review of the facility investigation confirmed the last time Resident #1 was seen was at 9:45 AM. At 10:08 AM an off-shift housekeeper was passing and saw the resident walking. Resident was on the side of the road walking and the CNA got to him at 10:10 AM. The facility's investigation revealed they immediately completed a count of all residents to ensure that other residents were accounted for with no concerns noted. Exit doors and windows were checked by the Regional Vice President of Operations (RVPO) and were operating correctly. Observations on 5/7/21 at 10:05 AM revealed the resident walked approximately 136 steps from his room to the four- lane highway. The area had thick pine straw, pinecones, sticks and up a steep embankment. The speed limit on the highway was posted at 45 miles per hour. On 5/7/21 at 10:05 AM till 10:10 AM approximately 91 cars were observed to pass the nursing home on the busy four-lane highway. Record review of AccuWeather, an internet weather forecasting site, revealed the documented weather temperature for the city on 4/25/21 was approximately 79 degrees. On 5/5/21 at 2:35 PM, it was revealed in an interview with HK #2, they received a call on 4/25/21 at 10:05 AM (it was a Sunday). The staff kept saying it's an emergency, its and emergency, I think I saw a man wearing Resident #1's jacket walking down the side of highway. See if Resident #1 is in his room. HK #2 was in another resident's room mopping and getting ready to go on break. HK #2 ran to Resident #1's room to see if Resident #1 was in there and Resident #1's roommate, Resident #2, stated Resident #1 went out the window. HK #2 told the LPN #1 and CNA #1. LPN #1 stated they just saw Resident #1. They went running to his room and the roommate was sitting on the side of his bed and told them he went out the widow and they went running. HK #2 went back to the room and had to pull up the blind and the window was open, and the screen was in place. Then HK #2 went on break. In an interview on 5/6/2021 at 11:30 AM with HK #1 it was confirmed on Sunday, April 25, HK #1 was driving up the highway when HK #1 saw a person walking on the side of the road in the grass not far from the facility. HK #1 stated she was unable to see their face, because their face was turned away from the road. The jacket looked like a jacket HK #1 had washed for Resident #1 and was worried it was Resident #1 walking down the road. HK #1 confirmed she called the facility. HK #1 confirmed it was hot that day. During an interview on 5/6/21 at 2:20 PM, it was revealed that LPN# 1 went to check on Resident #1 and Resident #2 stated roommate went out the window. LPN #1 ran out the front door and the CNA #1 was in her car and said come on and we drove up the highway about 0.2 miles and got to the resident first. Then RN #1 arrived. CNA #1 was called on 5/5/21 at 2:49 PM, on 5/6/21 at 12:06 PM and 5/6/21 at 2:42 PM but was unable to be reached. Registered Nurse (RN) #1 was interviewed on 5/7/21 at 9:47 AM, and revealed it was RN #1's first day when the resident got out. RN #1 is employed by an agency. It was further confirmed someone called the housekeeper and stated they saw Resident #1 walking down the highway. RN #1 ran to Resident #1's room and the window was open, and the screws were out, but the screen was in place. LPN # 1 and a CNA (not sure of her name) went out the building and RN #1 jumped in my car. Resident #1 was on the side of the highway and Resident #1 refused to come back. Resident #1 was between the nursing home and the 1st subdivision. Resident #1 tried to hit LPN#1 with the cane. RN #1 called the police, the Resident #1's family and the Director of Nursing (DON). The police called the Paramedics because Resident #1 refused to go back to the facility. We were able to get Resident #1 to sit in one of the staff's car. A civilian man stopped and asked if he could help, and we told him no. We tried to assess Resident #1 for injuries, but the resident kept swinging. Resident #1's brother agreed to meet at the hospital. Resident #1 told us that his brother had told the resident the day before to meet him on Interstate 20. (The resident was going the wrong way.) The resident was not in any distress. RN# 1 stated she remembered the roommate, Resident #2, saying Resident #1 had been working on the window for two days prior to leaving. Record review of Resident #1's Admission Record revealed he was admitted to the facility on [DATE] with diagnoses to include Alcoholic [CONDITION(S)] of the Liver and Hypertension. Review of Resident #1's Quarterly Minimum Data Set (MDS) dated 2/ 11/21, revealed Resident #1 was coded as having a Brief Interview for Mental Status (BIMS) of 13 which indicated he was cognitively intact. Record review of a Nurses Progress Note dated 4/25/21 at 11:04 AM, revealed that at 10:05 AM RN #1 was notified by housekeeping that Resident #1 was not in his room and that she received a call that the resident had been seen walking up the highway. Resident #1's room was searched quickly per nurse and the roommate stated that Resident #1 went out the window. Resident #1 was found walking up the highway, alert to person and place, respirations even without difficulty, and wander guard in place. Review of the emergency room report dated 4/25/21 documented no injuries. On 5/7/21 at 8:57 AM, an interview with the Medical Director confirmed the day before yesterday, 5/5/21, they did review the policy for elopement and missing person to ensure it does not happen again. The facility implemented the following Immediate Jeopardy (IJ) Removal Plan/Corrective Actions on 5/5/2021. In response to the IJ and SQC cited at 4:10 PM on 5/5/21, the facility submitted a brief summary of the event, including an IJ Removal Plan and Corrective Actions, taken by the facility to remove the IJ. REMOVAL PLAN Brief Summary of Events: At 4:10 PM on May 5, 2021, the State Agency (SA) surveyors notified the facility's Executive Director/Administrator (ED) of an immediate jeopardy, which began on 4/25/2021 related to the facility's failure to supervise and failure to report to SA when Resident #1 was not located within the facility. An Immediate Jeopardy template was provided to the facility ED by SA. Facility staff were not aware Resident #1 left the facility without staff knowledge or supervision until approximately 10:00 AM on 4/25/2021. HK #1 reported Resident #1 was seen walking down the side of the four-lane highway she was driving on with no staff supervision. Resident #1 had been assessed for a wander guard which did not alarm when the resident exited through the window. RN #1 and HK #2 went to Resident #1's room and interviewed his roommate (Resident #2). Resident #2 stated that Resident #1 climbed out the window. The window was intact, and the screen had been put back in place. RN #1 drove to the site where Resident #1 was walking, 0.2 miles from the facility. Resident #1 refused to return to the facility and the police were notified by RN #1 at approximately 10:10 AM. The police arrived and called an ambulance. Ambulance transported the resident to the local emergency room . Resident #1 was assessed at the emergency room and found to have an abrasion to the elbow. Resident #1 left the hospital with his family and refused to return to the facility; he was discharged from the facility on 4/25/21. Facility failed to report the incident to SA until May 5, 2021 at 6:05 PM. Resident #1 had a BIMS score of 13. Corrective Actions: 1. On 4/25/2021 at approximately 10:00 AM Licensed Practical Nurse (LPN) #2 and LPN #3 checked to ensure current residents were accounted for in the facility. All current residents were accounted for except Resident #1. 2. On April 25, 2021 at 2:00 PM Regional Vice President of Operations (RVPO) completed an audit of the facility to ensure the windows and doors were secure. Room number 124's window casing was noted to be bent and one of the two screws that prevented the window from being raised had been broken at the frame. The window was repaired and properly secured. Windows and doors in the facility were found to be secured. 3. A Quality Assurance Performance Improvement (QAPI) meeting was held on Sunday, April 25, 2021 at 2:00 PM with the Medical Director, ED, Director of Nursing (DON), Regional Director of Clinical Services (RDCS) #1, RN#I and RVPO to discuss the opportunity of improvement, assess current situation of the missing resident, root-cause analysis, and the plan of correction to include in-service education to the facility staff related to Resident #1 exiting facility unsupervised. After review of timeline and witness statements it was identified that Resident #1 was noted to be in his room at 9:45 AM by LPN #1. There were no changes to policies and procedures regarding Missing Resident Procedure, Elopement Drill and Elopement /Wandering Risk Guideline. It was identified through the root-cause analysis that Resident #1 had voiced the desire to go home. Residents that have the cognitive status to make their own decisions and are able to make their own decisions will have discharge planning initiated and be discharged to a safe location. 4. On April 26, 2021 at 1:30 PM RDCS #1 conducted an education regarding Missing Person Drill with 18 Certified Nursing Assistants (CNA), 8 LPN's, 1 Human Resources Director (HRD), 1 Therapist, 1 ED, 1 DON, 1 Business Office Manager (BOM), and 1 Activities Director (AD). Employees were able to locate Missing Person within 10 minutes. 5. On April 26, 2021 at 2:30 PM RDCS #1 conducted an education regarding Missing Person Drill with 1 BOM, 1 Social Services Director (SSD), 1 AD, 1 Staffing Coordinator (SC), 1 Dietary Manager (DM), 13 CNA's, 2 RN's, 10 LPN's, 1 Housekeeping Manager (HM) and 1 Business Development Coordinator (BDC). 6. On April 26, 2021, an evaluation of all current residents for elopement risk was initiated. The evaluation of elopement risk was completed by DON, RN #1, LPN #4, LPN #5, LPN #6, LPN #1 on April 29, 2021. There were no new Residents identified to be at risk for elopement. Residents that were identified to be at risk for elopement had a care plan to include elopement risk and all wander guards were checked to ensure proper placement and function. Proper placement and function of wander guards were assessed on April 26, 2021 and May 5, 2021 by LPN #7, RDCS #1 and Minimum Data Set Nurse - LPN (MDS). 7. On May 5, 2021 at 5:00 PM, RCDS #1 and RCDS #2 conducted education regarding Missing Resident Procedure, Elopement Drill and Elopement /Wandering Risk Guideline and Abuse, Neglect, Exploitation & Misappropriation with 5 LPN's, 7 CNA's, 1 SSD, 1 B0M, 1 BDC, 1 HM, 1 AD , 1 SC, 1 ED and 1 HRD. 8. On May 5, 2021 at 6:00 PM, Senior Executive Director (SED), educated the ED and RDCS #1 on ensuring of reporting of alleged violations. 9. On May 5, 2021 at 6:05 PM, the ED reported the elopement to the SA and State Attorney General. 10. A QAPI meeting was held on May 5, 2021 at 6:05 PM with the Medical Director, ED, DON, RDCS #1, RDCS#2, HRD, Medical Records Clerk, MDS, and SED to discuss the opportunity of improvement, assess current situation of the elopement, root-cause analysis, reviewed current policy and procedures to ensure appropriate supervision of residents. There were no changes to policies and procedures regarding Missing Resident Procedure, Elopement Drill and Elopement /Wandering Risk Guideline. It was identified through the root-cause analysis that Resident #1 had voiced the desire to go home. Residents that have the cognitive status to make their own decisions and are able to make their own decisions will have discharge planning initiated and be discharged to a safe location. 11. No staff will be allowed to work until completion of Missing Resident Procedure, Elopement Drill and Elopement /Wandering Risk Guideline and Abuse, Neglect, Exploitation & Misappropriation education. The facility alleges all corrective action to remove the immediate jeopardy was completed as of May 5, 2021, and the Immediate Jeopardy was removed on May 6, 2021. On 5/7/21, the SA validated the facility's investigation of the incident and implementation of the IJ Removal Plan/Corrective Action through observations, facility record review and interviews. 1. SA validated through record review and interviews on April 26, 2021 at 1:30 PM RDCS #1 conducted an education regarding Missing Person Drill with 18 Certified Nursing Assistants (CNA), 8 LPN's, 1 Human Resources Director (HRD), 1 Therapist, 1 ED, 1 DON, 1 Business Office Manager (BOM), and 1 Activities Director (AD). Employees were able to locate Missing Person within 10 minutes. 2. SA validated through record review and interviews, on April 26, 2021 at 2:30 PM RDCS #1 conducted an education regarding Missing Person Drill with 1 BOM, 1 Social Services Director (SSD), 1 AD, 1 Staffing Coordinator (SC), 1 Dietary Manager (DM), 13 CNA's, 2 RN's, 10 LPN's, 1 Housekeeping Manager (HM) and 1 Business Development Coordinator (BDC). 3. SA validated through record review and interviews, on April 26, 2021, an evaluation of all current residents for elopement risk was initiated. The evaluation of elopement risk was completed by DON, RN #1, LPN #4, LPN #5, LPN #6, LPN #1 on April 29, 2021. There were no new residents identified to be at risk for elopement. Residents that were identified to be at risk for elopement had a care plan to include elopement risk and all wander guards were checked to ensure proper placement and function. Proper placement and function of wander guards were assessed on April 26, 2021 and May 5, 2021 by LPN #7, RDCS #1 and Minimum Data Set Nurse - LPN (MDS). 4. SA validated through record review and interviews, on May 5, 2021 at 5:00 PM, RCDS #1 and RCDS #2 conducted education regarding Missing Resident Procedure, Elopement Drill and Elopement /Wandering Risk Guideline and Abuse, Neglect, Exploitation & Misappropriation with 5 LPN's, 7 CNA's, 1 SSD, 1 B0M, 1 BDC, 1 HM, 1 AD, 1 SC, 1 ED and 1 HRD. 5. SA validated through record review and interviews, on May 5, 2021 at 6:00 PM, Senior Executive Director (SED), educated the ED and RDCS #1 on ensuring of reporting of alleged violations. 6. SA validated through record review and interviews, on May 5, 2021 at 6:05 PM, the ED reported the elopement to the SA and State Attorney General. A QAPI meeting was held on May 5, 2021 at 6:05 PM with the Medical Director, ED, DON, RDCS #1, RDCS#2, HRD, Medical Records Clerk, MDS, and SED to discuss the opportunity of improvement, assess current situation of the elopement, root-cause analysis, reviewed current policy and procedures to ensure appropriate supervision of residents. There were no changes to policies and procedures regarding Missing Resident Procedure, Elopement Drill and Elopement /Wandering Risk Guideline. It was identified through the root-cause analysis that Resident #1 had voiced the desire to go home. Residents that have the cognitive status to make their own decisions and are able to make their own decisions will have discharge planning initiated and be discharged to a safe location. 7. The SA validated through interview with the Administrator that no staff will be allowed to work until completion of Missing Resident Procedure, Elopement Drill and Elopement /Wandering Risk Guideline and Abuse, Neglect, Exploitation & Misappropriation education. The facility alleges all corrective action to remove the immediate jeopardy was completed as of May 5, 2021, and the Immediate Jeopardy was removed on May 6, 2021.

Based on staff interviews, record review, facility investigation review and facility policy review, the facility failed to report an incident and investigation, when Resident #1 eloped from the facility on 4/25/21 after 9:45 AM, to the State Survey Agency. The facility staff did not know Resident #1 was off the facility grounds until he was seen by HK #1 an off-duty staff who was driving on the four-lane highway. This concern was identified for one of (1 )of six (6) residents reviewed for wandering behavior and risk for elopement. The State Agency (SA) conducted a Complaint Investigation, CI# , on 5/4/2021 through 5/7/2021 and substantiated CI # related to an elopement and failure to report to the State Survey Agency in accordance with State law through established procedures. Resident #1 was missing, unsupervised and away from the facility for approximately twenty minutes. The facility staff was not aware of Resident #1's absence until he was discovered walking down a busy four-lane highway by an off-duty staff traveling past the facility at 10:00 AM. Housekeeper (HK) #1 reported Resident #1 was seen walking down the side of the four-lane highway. Resident #1 had been assessed for a wander guard which did not alarm when the resident exited through the window. Registered Nurse (RN) #1 and HK #2 went to Resident #1's room and interviewed his roommate (Resident #2). Resident #2 stated that Resident #1 climbed out the window. The window was intact, and the screen had been put back in place. RN #1 drove to the site where Resident #1 was walking, 0.2 miles from the facility. Resident #1 refused to return to the facility and the police were notified by RN #1 at approximately 10:10 AM. The police arrived and called an ambulance. The ambulance transported the resident to the local emergency room . Resident #1 left the hospital with his family and refused to return to the facility. He was discharged from the facility on 4/25/21.The facility failed to report the incident to the SA until May 5, 2021 at 6:05 PM. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The facility's failure to report an elopement for Resident #1 placed Resident #1 and other residents with wandering behaviors and at risk of elopement, in a situation that has caused or is likely to cause serious injury, harm, impairment, or death. The SA identified an Immediate Jeopardy (IJ), and Substandard Quality of Care (SQC), which began on 4/25/2021, when the facility failed to report the elopement of Resident #1. The SA notified the facility's Administrator of the IJ and SQC on 5/5/2021 at 4:10 PM and provided the IJ Template to the Administrator. The facility provided an acceptable Removal Plan on 5/5/2021, in which the facility alleged all corrective actions were completed to remove the IJ on 5/5/2021 and the IJ was removed on 5/6/2021. The SA determined the IJ was removed on 5/6/2021, prior to exit, and the scope and severity for 42 CFR §483.12(c)(1)(4) - F 609, was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy, Abuse, Neglect, Exploitation & Misappropriation, dated 11/28/2017, revealed 7) Reporting/Response .Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken The Abuse Coordinator of The Company will refer any or all incidents and reports of resident abuse to the appropriate state agencies. Review of the facility investigation confirmed the last time Resident #1 was seen was on 4/25/2021,at 9:45 AM. At 10:08 AM, an off-shift housekeeper was passing and saw the resident walking. Resident was on the side of the road walking and the CNA got to him at 10:10 AM. The facility's investigation revealed they immediately completed a count of all residents to ensure that other residents were accounted for with no concerns noted. Exit doors and windows were checked by the Regional Vice President of Operations (RVPO) and were operating correctly. On 5/5/2021 at 10:17 AM, it was revealed in an interview with the Administrator and confirmed with Regional Director of Clinical Services (RDCS) #1 they had not reported this incident to the SA. They both stated Resident #1 had a BIMS of 13 and knew the address he wanted to go to and how to get there. Resident #1 had stated in the past he wanted to go home. Resident #1 had been homeless in the past. We were working on a discharge plan. Resident #1's sister visited last week and wanted Resident #1 to stay here at the facility. Record review of the Admission Record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #1 was coded as having a Brief Interview for Mental Status (BIMS) of 13 which indicated Resident #1 was cognitively intact. The facility provided the following Immediate Jeopardy (IJ) Removal Plan on 5/5/2021. Removal Plan In response to the IJ and SQC cited at 4:10 PM on 5/5/21, the facility submitted a brief summary of the events, including an IJ Removal Plan and Corrective Actions, taken by the facility to remove the IJ. Brief Summary of Events: At 4:10 PM on May 5, 2021, the State Agency (SA) surveyors notified the facility's Executive Director/Administrator (ED) of an immediate jeopardy, which began on 4/25/2021 related to the facility's failure to supervise and failure to report to SA when Resident #1 was not located within the facility. An Immediate Jeopardy template was provided to the facility ED by SA. Facility staff were not aware Resident #1 left the facility without staff knowledge or supervision until approximately 10:00 AM on 4/25/2021. HK #1 reported Resident #1 was seen walking down the side of the four-lane highway she was driving on with no staff supervision. Resident #1 had been assessed for a wander guard which did not alarm when the resident exited through the window. RN #1 and HK #2 went to Resident #1's room and interviewed his roommate (Resident #2). Resident #2 stated that Resident #1 climbed out the window. The window was intact, and the screen had been put back in place. RN #1 drove to the site where Resident #1 was walking, 0.2 miles from the facility. Resident #1 refused to return to the facility and the police were notified by RN #1 at approximately 10:10 AM. The police arrived and called an ambulance. Ambulance transported the resident to the local emergency room . Resident #1 was assessed at the emergency room and found to have an abrasion to the elbow. Resident #1 left the hospital with his family and refused to return to the facility; he was discharged from the facility on 4/25/21. Facility failed to report the incident to SA until May 5, 2021 at 6:05 PM. Resident #1 had a BIMS score of 13. Corrective Actions: 1. On 4/25/2021 at approximately 10:00 AM, Licensed Practical Nurse (LPN) #2 and LPN #3 checked to ensure current residents were accounted for in the facility. All current residents were accounted for except Resident #1. 2. On April 25, 2021 at 2:00 PM, the Regional Vice President of Operations (RVPO) completed an audit of the facility to ensure the windows and doors were secure. room [ROOM NUMBER]'s window casing was noted to be bent and one of the two screws that prevented the window from being raised had been broken at the frame. The window was repaired and properly secured. Windows and doors in the facility were found to be secured. 3. A Quality Assurance Performance Improvement (QAPI) meeting was held on Sunday, April 25, 2021 at 2:00 PM with the Medical Director, Executive Director (ED), Director of Nursing (DON), Regional Director of Clinical Services (RDCS) #1, RN#1 and RVPO to discuss the opportunity of improvement, assess current situation of the missing resident, root-cause analysis, and the plan of correction to include in-service education to the facility staff related to Resident #1 exiting facility unsupervised. After review of timeline and witness statements it was identified that Resident #1 was noted to be in his room at 9:45 AM by LPN #1. There were no changes to policies and procedures regarding Missing Resident Procedure, Elopement Drill and Elopement /Wandering Risk Guideline. It was identified through the root-cause analysis that Resident #1 had voiced the desire to go home. Residents that have the cognitive status to make their own decisions and are able to make their own decisions will have discharge planning initiated and be discharged to a safe location. 4. On April 26, 2021 at 1:30 PM RDCS #1 conducted an education regarding Missing Person Drill with 18 Certified Nursing Assistants (CNA), 8 LPN's, 1 Human Resources Director (HRD), 1 Therapist, 1 ED, 1 DON, 1 Business Office Manager (BOM), and 1 Activities Director (AD). Employees were able to locate Missing Person within 10 minutes. 5. On April 26, 2021 at 2:30 PM RDCS #1 conducted an education regarding Missing Person Drill with 1 BOM, 1 Social Services Director (SSD), 1 AD, 1 Staffing Coordinator (SC), 1 Dietary Manager (DM), 13 CNA's, 2 RN's, 10 LPN's, 1 Housekeeping Manager (HM) and 1 Business Development Coordinator (BDC). 6. On April 26, 2021, an evaluation of all current residents for elopement risk was initiated. The evaluation of elopement risk was completed by DON, RN #1, LPN #4, LPN #5, LPN #6, LPN #1 on April 29, 2021. There were no new residents identified to be at risk for elopement. Residents that were identified to be at risk for elopement had a care plan to include elopement risk and all wander guards were checked to ensure proper placement and function. Proper placement and function of wander guards were assessed on April 26, 2021 and May 5, 2021 by LPN #7, RDCS #1 and Minimum Data Set Nurse - LPN (MDS) 7. On May 5, 2021 at 5:00 PM, RCDS #1 and RCDS #2 conducted education regarding Missing Resident Procedure, Elopement Drill and Elopement /Wandering Risk Guideline and Abuse, Neglect, Exploitation & Misappropriation with 5 LPN's, 7 CNA's, 1 SSD, 1 B0M, 1 BDC, 1 HM, 1 AD , 1 SC, 1 ED and 1 HRD. 8. On May 5, 2021 at 6:00 PM, Senior Executive Director (SED), educated the ED and RDCS #1 on ensuring of reporting of alleged violations. 9. On May 5, 2021 at 6:05 PM, the ED reported the elopement to the SA and State Attorney General. 10. A QAPI meeting was held on May 5, 2021 at 6:05 PM with the Medical Director, ED, DON, RDCS #1, RDCS#2, HRD, Medical Records Clerk, MDS, and SED to discuss the opportunity of improvement, assess current situation of the elopement, root-cause analysis, reviewed current policy and procedures to ensure appropriate supervision of residents. There were no changes to policies and procedures regarding Missing Resident Procedure, Elopement Drill and Elopement /Wandering Risk Guideline. It was identified through the root-cause analysis that Resident #1 had voiced the desire to go home. Residents that have the cognitive status to make their own decisions and are able to make their own decisions will have discharge planning initiated and be discharged to a safe location. 11. No staff will be allowed to work until completion of Missing Resident Procedure, Elopement Drill and Elopement /Wandering Risk Guideline and Abuse, Neglect, Exploitation & Misappropriation education. The facility alleges all corrective actions to remove the Immediate Jeopardy was completed as of May 5, 2021, and the Immediate Jeopardy was removed on May 6, 2021. On 5/7/2021, the SA validated the facility's investigation of the incident and implementation of the IJ Removal Plan/Corrective Action through observations, facility record review and interviews. 1. SA validated through record review and interviews on April 26, 2021 at 1:30 PM RDCS #1 conducted an education regarding Missing Person Drill with 18 Certified Nursing Assistants (CNA), 8 LPN's, 1 Human Resources Director (HRD), 1 Therapist, 1 ED, 1 DON, 1 Business Office Manager (BOM), and 1 Activities Director (AD). Employees were able to locate Missing Person within 10 minutes. 2. SA validated through record review and interviews on April 26, 2021 at 2:30 PM RDCS #1 conducted an education regarding Missing Person Drill with 1 BOM, 1 Social Services Director (SSD), 1 AD, 1 Staffing Coordinator (SC), 1 Dietary Manager (DM), 13 CNA's, 2 RN's, 10 LPN's, 1 Housekeeping Manager (HM) and 1 Business Development Coordinator (BDC). 3. SA validated through record review and interviews,on April 26, 2021, an evaluation of all current residents for elopement risk was initiated. The evaluation of elopement risk was completed by the DON, RN #1, LPN #4, LPN #5, LPN #6, LPN #1 on April 29, 2021. There were no new Residents identified to be at risk for elopement. Residents that were identified to be at risk for elopement had a care plan to include elopement risk. All wander guards were checked to ensure proper placement and function. Proper placement and function of wander guards were assessed on April 26, 2021 and May 5, 2021 by LPN #7, RDCS #1 and Minimum Data Set Nurse - LPN (MDS). 4. SA validated through record review and interviews, on May 5, 2021 at 5:00 PM, RCDS #1 and RCDS #2 conducted education regarding Missing Resident Procedure, Elopement Drill and Elopement /Wandering Risk Guideline and Abuse, Neglect, Exploitation & Misappropriation with 5 LPN's, 7 CNA's, 1 SSD, 1 B0M, 1 BDC, 1 HM, 1 AD, 1 SC, 1 ED and 1 HRD. 5. SA validated through record review and interviews, on May 5, 2021 at 6:00 PM, Senior Executive Director (SED), educated the ED and RDCS #1 on ensuring of reporting of alleged violations. 6. SA validated through record review and interviews, on May 5, 2021 at 6:05 PM, the ED reported the elopement to the SA and State Attorney General. A QAPI meeting was held on May 5, 2021 at 6:05 PM with the Medical Director, ED, DON, RDCS #1, RDCS#2, HRD, Medical Records Clerk, MDS, and SED to discuss the opportunity of improvement, assess current situation of the elopement, root-cause analysis, reviewed current policy and procedures to ensure appropriate supervision of residents. There were no changes to policies and procedures regarding Missing Resident Procedure, Elopement Drill and Elopement /Wandering Risk Guideline. It was identified through the root-cause analysis that Resident #1 had voiced the desire to go home. Residents that have the cognitive status to make their own decisions and are able to make their own decisions will have discharge planning initiated and be discharged to a safe location. 7. The SA validated through interview with the Administrator that no staff will be allowed to work until completion of Missing Resident Procedure, Elopement Drill and Elopement /Wandering Risk Guideline and Abuse, Neglect, Exploitation & Misappropriation education are completed. The facility alleges all corrective action to remove the immediate jeopardy was completed as of May 5, 2021, and the Immediate Jeopardy was removed on May 6, 2021.

Based on observation, record review and staff interview, the facility failed to provide adequate supervision to ensure Resident #1 did not elope from the facility for one (1) of five (5) residents reviewed, Resident #1. Resident #1, who was assessed and care planned for an elopement risk, was discovered missing from the facility on 8/30/16 at approximately 11:35 PM, and was located approximately 0.7 miles from the facility at 12:35 AM on 8/31/16, by the Police department and was taken to the local hospital then returned to the facility without apparent injury. This resulted in Resident #1 being out of the building unassisted approximately one (1) hour and 25 minutes. (11:10 PM, when first missing until 12:35 AM, when the resident was located). The lack of supervision for a resident with a history of wandering and exit-seeking behaviors placed this and other residents at risk in a situation that was likely to cause serious harm, injury, impairment or death. Based on the facility's corrective actions, initiated and completed as of 09/01/16, prior to the State Agency's entrance on 09/07/16, the State Agency (SA) determined the Immediate Jeopardy and Substandard Quality of Care to be Past Non-Compliance and removed as of 9/2/16. Findings include: Review of the Elopement Risk policy, dated 11/20/14, revealed it is the policy that on admission and quarterly, all residents will be assessed for elopement risk by nursing. If the resident is identified as an elopement risk based on the assessment, the care plan will reflect the interventions (i.e. Wander Guard or Code Alert) and desired outcomes. Review and/or revise care plan following attempt to leave the facility. Residents identified as at risk for elopement will require nursing to check residents regularly and document on the Safety Checks. Review of Elopement Education, attached to the policy, revealed Elopement is unsupervised or unassisted flight from the facility. Wandering is mobility with no apparent goal. Under the section How is wandering managed: Attempt to identify the cause of wandering and develop plans to address the cause. Conduct regular rounds to secure the whereabouts of residents at risk. Use alarm devices to notify staff of exiting residents and patients. When the resident begins to pace and wander, divert his or her attention by offering an activity or giving a repetitive task to do. Review of the Missing Resident Search policy, dated 11/30/14, revealed: An organized search is conducted immediately when a resident is determined missing. Review of the written report submitted by the facility, dated 9/2/16, revealed Resident #1 exited the facility on 8/30/16 without knowledge or assistance from the staff and was found approximately 0.7 miles from the facility in a wooded apartment complex. Resident #1 was seen by the staff on 8/30/16 at 10:50 PM, by the RN #1, when she redirected the resident from the enclosed courtyard and checked the Wander Guard for function. The Certified Nursing Assistant (CNA) #1 could not locate Resident #1 on 8/30/16 at 11:10 PM, and again at 11:36 PM, and staff began an initial missing resident search at that time and notified the Director of Nursing (DON), Police Department and Physician, with an attempt to notify the Responsible Party. Resident #1 was located by the Police Department on 8/31/16 at 12:35 AM, in a wooded apartment complex area without apparent injury. Review of the Clinical Record for Resident #1 revealed an Interdisciplinary Progress Note (IDPN), dated 08/30/16 at 10:50 PM, in which RN #1 observed Resident #1 in the enclosed courtyard and escorted the Resident back to her room. At approximately 11:10 PM, Certified Nursing Assistant #1 asked RN #1 if the Resident was in the hospital, since CNA #1 had not observed the Resident since reporting to work on the 11:00 PM to 7:00 AM shift. RN #1 reported to CNA #1 of having escorted Resident #1 to her room at approximately 10:50 PM, and stated, She is here. At approximately 11:35 PM, CNA #1 had still not observed Resident #1, and reported the information to RN #1. A search of the building and grounds was then initiated, but the facility was unable to locate Resident #1. The local police department notified the facility they had located the Resident at approximately 12:35 AM on 08/31/16 in a wooded apartment complex area. Review of and IDPN dated 8/31/16 at 5:00 AM, revealed Resident #1 was assessed and found to be free of injury or bruises past return from the emergency room . The Wander Guard was intact and functioning. The Physician and RP were notified of Resident #1's return to the facility. 1:1 observation was initiated per physician's orders [REDACTED].>Review of Resident #1's clinical record revealed elopement assessments dated 7/30/15, 4/1/16, 4/15/16, and 7/14/16 which indicated Resident #1 was an elopement risk and wore a Wander Guard device. An elopement assessment dated [DATE] indicated Resident #1 had eloped from the facility and continued to be at risk for elopement. Review of Resident #1's Care Plan dated 07/19/16, revealed a goal which included, Resident will not leave building unattended. Review of an Elopement Risk Alert, dated 7/30/15, which was located in the Elopement Book at each nurse's station, revealed a photo and description of Resident #1 indicating she was ambulatory and wore a Wander Guard device. Observation, on 09/08/16 at 12:20 PM, of the area Resident #1 eloped from revealed the facility driveway had an upward slope toward the four (4) lane highway. The speed limit on the highway was 55 miles per hour (mph). The terrain for the highway was hilly, and there were some steep slopes down from the highway. There were several wooded areas by the highway. Resident #1 ambulated approximately 0.7 miles from the facility, and entered an apartment complex area. The highway had two (2) lights on each light pole in the middle of this divided highway. The apartment complex had street lights as well. There was a 10 mph posted speed limit in the apartment complex. Observation of the area behind the tenant's apartment building revealed one (1) side of the knoll had a retaining wall, and was steep. The other side of the knoll had a gradual slope, which was the likely path of entry to the small wooded area. There was also a street light on the knoll with two (2) lights. This totaled approximately 1,964 steps from the front door of the facility to the area on the knoll where Resident #1 was located by the local police. Interview, on 09/08/16 at 12:50 PM, with the apartment manager, revealed a tenant had reported seeing someone in the trees behind their apartment, and called 911 on the night Resident #1 eloped. Observation, on 09/12/16 between 10:55 PM and 11:05 PM, revealed 12 vehicles were traveling in the two (2) lanes farther from the facility, and 21 vehicles were traveling in the two (2) lanes next to the facility. Interview and observation of Resident #1 on 9/8/16 at 11:30 AM, revealed she was alert with some confusion. A staff member was present in the room. Resident #1 stated the staff member was her cousin. A Wander Guard device was noted to the right ankle. Resident #1 was difficult to understand. Further observations on 9/8/16 at 2:20 PM, revealed Resident #1 was ambulating ad lib with a staff member present. Resident #1 stated how much do they pay here. Resident #1 had a Wander Guard device on her right ankle. Interview, on 09/07/16 at 11:15 PM, with RN #1 revealed she did not immediately begin a search since she had observed Resident #1 at 10:50 PM on 8/30/16. RN #1 stated CNA #1 reported Resident #1 was not in her room, but the resident often goes to other resident's rooms. When CNA #1 stated a second time that Resident #1 could not be found then we began a search and notified the Director of Nursing (DON) and the Police. RN #1 also reported another resident had been returned to the facility by the ambulance during the time Resident #1 eloped from the facility, and Resident #1 could have exited the building when the ambulance personnel were entering or exiting the building. (Unsampled Resident #A). RN #1 stated if the door is held open for a period of time, the alarm sounds like the Wander Guard. Interview, on 09/09/16 at 7:10 AM, with RN #1 revealed she did not recall an alarm sounding during the time Resident #1 eloped from the facility. Review of Unsampled A's IDPN dated 8/30/16 at 11:10 PM, revealed the resident was returned to the facility via ambulance. Attempts were made to interview the ambulance personnel on 9/8/16 at 7:50 PM, 9/9/16 at 9:55 AM leaving messages without success of interview. Interview with CNA #1 on 9/14/16 at 4:20 PM, revealed she was assigned to Resident #1 on 8/30/16 for the 11 PM-7 AM shift. CNA #1 stated Resident #1 was not in her room and she answered some call lights and after not finding Resident #1 for a second time, she reported to RN #1, who said she hadn't seen her. CNA #1's written statement dated 8/30/16, revealed she didn't see Resident #1 after she clocked in at 11:00 PM and did rounds. CNA #1 reported going to the Nurse's Station and asked the nurse if Resident #1 was in the hospital and she said no, that she'd seen her. CNA #1 reported she answered call lights and then couldn't find Resident #1 a second time and reported to the nurse and they started a search. Interview, on 09/09/16 at 7:10 AM, with CNA #2 revealed she had been working the night Resident #1 eloped, but did not recall hearing a door alarm or the front door bell during the time Resident #1 eloped. Interview, on 09/09/16 at 8:45 AM, with CNA #3, revealed she did not recall hearing a door alarm during the time Resident #1 eloped. Interview, on 09/12/16 at 10:15 AM, with CNA #4, revealed Resident #1 would, at times, believe she had to leave to get children. Interview, on 09/12/16 at 3:10 PM, with Licensed Practical Nurse (LPN) #1, revealed on the day Resident #1 eloped, Resident #1 had come in LPN #1's office to talk twice, and had been looking for a woman who owed her money. LPN #1 stated Resident #1 stayed with her until about 9:15 PM. As LPN #1 was leaving the facility, at approximately 9:30 PM, she told the nurses at the Nurses' Station they needed to keep an eye on her since she had been trying to locate a woman who owed her money. LPN #1 did not identify a particular staff member she relayed this information to. LPN #1 also stated when the facility first admitted Resident #1; the Resident would fold clothes, and believed a woman needed to pay her for her services. LPN #1 also stated the woman Resident #1 was looking for on the night of her elopement was the same woman she previously looked for to pay Resident #1 for folding clothes. (There were no staff members who recalled being told by LPN #1 to watch Resident #1 closely.) Interview with LPN #2 on 9/9/16 at 11:25 AM, revealed Resident #1 was a wanderer, that's why the Wander Guard bracelet is on. Interview on 09/13/16 at 4:40 PM, with LPN #2 revealed Resident #1 was just walking around the day of the elopement, and was looking out the staff exit door at the Nurses' Station on the 200 hall. Although LPN #2 could not recall if Resident #1 pushed on the staff exit door, she did instruct Resident #1 to move away from the door and had no further incident. Interview, on 09/12/16 at 4:15 PM, with Resident #1's Responsible Party (RP) revealed prior to admission to the facility, she lived with Resident #1 and stated between 3:00 AM and 4:00 AM, Resident #1 would attempt to wander out of the house. The RP also stated, If you don't see her, you need to look for her, which referred to Resident #1. The RP also stated the facility was made aware on admission of Resident #1's history of wandering/elopement. Interview, on 09/12/16 at 6:55 PM, with Police Officer #1, revealed he had received a call from dispatch on 08/31/16 at approximately 12:10 AM, to respond to a 911 call about a female in the woods at a local apartment complex. The Police Officer stated the female was able to report her name (Resident #1), and stated she lived in Jackson. Resident #1 was found sitting in the woods, and stated a man was trying to kill her. Resident #1 also stated she had been shot in the leg, but no injury was found. Police Officer #1 stated she was squatting on the knoll, and she had most likely walked up the slope instead of climbing the retaining wall. Police Officer #1 stated Resident #1 was taken to the hospital to be examined. Interview, on 09/12/16 at 11:30 PM, with CNA #5 revealed although she did not see Resident #1 on the night she eloped, sometimes the Resident would push on the exit doors to open them. CNA #5 also stated the staff would, normally, watch her close when exit-seeking behaviors were noted. Also, CNA #5 stated when Resident #1 was experiencing exit seeking behaviors, the staff would give her a snack, toilet her and take Resident #1 to bed stating that usually satisfied the Resident. Interview, on 09/13/16 at 10:25 AM with the Activity Director (AD) revealed Resident #1 would stand at the staff entrance door (on the hall in which Resident #1 resided) on the 200 hall. The AD stated she would bring Resident #1 into her office, which was located by the staff entrance door, and that Resident #1 liked to be sprayed with perfume. The day Resident #1 eloped, the AD stated Resident #1 was exit seeking. Resident #1 would go to the staff entrance door on the 200 hall, the front lobby entrance door, and the emergency exit door on the 100 hall on the day she eloped. The AD stated she gave Resident #1 candy bars to distract her. Interview with the DON on 9/8/16 at 10:15 AM, revealed the facility investigated and reported the elopement of Resident #1 on 8/30/16. The time line was reviewed for the elopement. The DON stated prior to the elopement, the CNAs and Nurses rotated every hour checks of Resident #1, but there was no documentation. The DON stated she was notified of Resident #1's elopement and the facility's search for the resident. The DON stated she came to the facility after she was notified of Resident #1's elopement at 11:49 PM on 08/30/16. The facility staff had already initiated the search prior to the notification, but had been unsuccessful locating the Resident. The DON stated she reviewed the binders for residents at risk for wandering and elopement to ensure all three (3) residents with Wanderguard devices, and thus residents at risk for elopement, were included in the binders. The DON stated she implemented inservicing facility staff on 08/31/16 at 1:30 AM on the Elopement and Missing Resident Policies. The DON stated all residents were accounted for and assessments were done for all residents for the risk of elopement. Care plans were reviewed and/or updated for those three (3) residents identified at risk for elopement. The DON stated Resident #1 was placed on 1:1 visual observation for increased supervision and the other two (2) residents were placed on every 15 minute visual observation, thus ensuring increased supervision for those at risk for elopement. Review of the Admission Record revealed the facility admitted Resident #1 on 07/30/15 with diagnoses, which included Schizophrenia, Dementia and Bipolar disorder. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/18/16 revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating Resident #1 had severe cognitive impairment. Ambulation/locomotion documented Resident #1 required supervision/set up and no impairment with Range of Motion. Review of the quarterly MDS, with an ARD of 09/01/16, revealed Resident #1 scored 11 of 15 on the BIMS which indicated moderate cognitive impairment. Ambulation/locomotion documented Resident #1 required no assistance and no impairment with Range of Motion. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on 09/07/16: Description of Incident: 1. On 8/30/16 at 10:50 PM, RN#1 redirected Resident #1 from the courtyard of the facility to her room. She then went to her medication cart retrieved the transponder testing device for the wander guard bracelet. RN #1 then returned to Resident#1's room and tested her wander guard bracelet. The wander guard bracelet was functioning properly. On 8/30/16 at approximately 11:10 PM, CNA#1 noticed that Resident #1 was not in her room, at that time CNA #1 asked RN #1 if Resident #1 was in the hospital, because CNA #1 had been given report earlier that another one of her residents was in the hospital. It was not uncommon for Resident #1 to visit the courtyard and travel to other rooms in the facility. RN #1 told CNA #1 that Resident #1 was not in the hospital, and that she had just redirected Resident #1 from the courtyard. CNA #1 then was suddenly summonsed to another resident's room where she provided incontinent care. After completing care, CNA #1 went to Resident #1's room again. On 8/30/16, at approximately 11:35 PM, Resident #1 could not be located in the facility. At approximately 11:35 PM on 8/30/16, a search was initiated for Resident #1 by RN #1 and CNA #1. Facility protocol for missing resident was initiated at 11:35 PM. At 11:49 PM, the Director of Nursing (DON) was notified that Resident #1 was missing from the facility. At 11:52 PM RN #1 notified the Police Department that Resident #1 was missing from the facility and a description was given of Resident #1. At 11:55 PM RN #1 attempted to reach Resident #1's Responsible Party by telephone without success. At approximately 12:35 AM on 8/31/16, Resident #1 was located north of the facility off of Highway 39 in an Apartment Complex located approximately 0.7 miles from the facility, by the Police Department. At that time the police took Resident #1 to the hospital for an evaluation where she was noted to have no injuries. On 8/31/16 at 3:15 AM, Resident #1 was returned to the facility by the DON. The resident was assessed and showered at this time and placed on 1:1 observation until further notice, without further incident. The results of the head to toe assessment by RN#1 revealed no injuries. It is suspected that Resident #1, who was fully clothed in street clothes and wearing shoes, exited the facility through the front door at approximately 11:10 PM, while the Emergency Medical Services (EMS) personnel were transporting another resident by stretcher through the double front doors. Measures Implemented: 2. On 08/30/16, at approximately 11:40 PM, RN #1 validated placement and function of wander guard devices for the two (2) remaining residents residing in the facility that had previously been identified as an elopement risk. Then, at approximately 11:45 PM, RN #1 completed a head count of all residents of the facility. All other 74 residents of the facility were present and accounted for. The other two (2) residents previously assessed as an elopement risk were visually observed. Placement and functioning of the wander guard device was tested by using a transponder testing device by RN #1. Wander guard bracelets were functioning. 3. On 08/31/16, at 1:10 AM, all exit doors were checked by the Maintenance Director to ensure security and that they were locked with no deficits noted. At 1:20 AM, the Maintenance Director and the Director of Nursing (DON) visually checked the other two (2) residents at risk for elopement and tested their wander guard device with the transponder Testing Device. No deficits were found. On 08/31/16, at approximately 1:30 AM, the elopement books were checked by the DON to ensure that all books contained pictures and demographics. Elopement books were current and no issues were identified. At 3:15 AM, Resident #1 was re-evaluated by the DON for elopement risk; Resident #1's Care Plan and Kardex were updated to reflect the actual elopement. 4. On 08/31/16, at 1:00 AM, the two (2) residents previously identified for being at risk for elopement were placed on every 15 minute safety checks and are currently continuing every 15 minute safety checks without incident. At 3:20 AM, the Attending Physician was notified of Resident #1's safe return to the facility and was in agreement with the 1:1 observation plan. A new Physician order [REDACTED]. On 08/31/16, at 9:00 AM, new elopement risk evaluations were initiated on all residents in the facility and this was completed by Licensed Practical Nurse (LPN) #1, Registered Nurse (RN) #2, and RN #3. No new residents were identified to be at risk for elopement. At 3:00 PM on 08/31/16, an independent outside contractor arrived to check the wander guard system for proper functioning with no problems identified. The Independent outside contractor also checked all exit doors at this time for proper functioning with no problems identified. The Independent outside contractor, as an extra precaution, Amplified the enunciator panel at Nurses Station #1. Signage posted at the front door stated NOTICE TO VISITORS- safety devices are placed on residents for their protection. Safety devices may be, but not limited to belts, wrists, and or ankle bracelets. Please do not remove safety devices from residents. If a resident asks you to remove a safety device, please alert the Administrator, Director of Nurses, or Charge Nurses. On 09/01/16, at 8:00 AM, a red sign was posted with the following information STOP. Attention all visitors-please be mindful when entering and exiting the door that we have residents that will seek exit from this facility that are not safe to do so. Do not hold the door for extended lengths of time; enter and exit quickly. This also applies to EMS (Emergency Medical Services) and all vendors of this facility. Please be aware of residents when entering and exiting the facility. On 09/01/16 at 8:00 AM, signage was placed at the front door under the keypad with the following information Staff please remember to check outside when alarm is silenced by keypad (The purpose of this is to remind staff to ensure a resident is not outside of the door.) As an extra precaution the monitoring of the functioning of the wander guard bracelet was increased from daily to every shift by the RN/LPN on 09/01/16. Initial Quality Assurance Meeting: 5. On 08/31/16, a Quality Assurance Committee Meeting was held at 9:00 AM with the following staff in attendance: DON, Administrator, Resident #1's Attending Physician via phone, (Facility medical director was out of the country), RN #2, Admissions Coordinator, Medical Records, Central Supply, and the Director of Rehabilitation. During this meeting the Missing Resident Policy, Elopement Policy, and In-services were discussed, as well as, review of current investigation and root cause analysis. Supervision of residents at risk for elopement was reviewed. Recommendations made to continue 1:1 observation plan for Resident #1 and every 15 minute safety checks on the other two (2) residents previously identified at risk for elopement. Training/In-services: 6. On 08/31/16, at 1:30 AM, the following policies were reviewed by the DON with the staff on duty at that time. This review continued beginning on 7:00 AM to 3:00 PM shift 08/31/2016, to all other staff of the facility: Elopement Policy and Missing Resident Policy. Staff was in-serviced on the following topic with emphasis on: If a resident that is at risk for elopement cannot be located immediately staff are to begin missing resident guideline immediately, completion of walking rounds at the beginning and end of shift, process for responding to a sounding door alarm, and remaining at the front door during the entire entry and exit when EMS is transporting a resident. Six (6) out of six (6) RNs, 14 out of 14 LPNS, 36 out of 36 Certified Nursing Assistants (CNAs), 14 out of 14 Department Heads, eight (8) out of eight (8) Dietary Employees, nine (9) out of nine (9) Housekeepers, and five (5) out of five (5) Rehabilitation Therapy Staff Members have completed this Policy Review and In-service. No staff was allowed to work until they received the review on the above mentioned policies and in-services. Audits: 7. Resident #1's Care Plan and assessment were audited for elopement prevention by the DON on August 31, 2016, at 3:15 AM, and was found to be comprehensive and accurate. On August 31, 2016, at 3:45 AM, the DON reviewed two (2) other residents, previously found to be at risk for elopement, Care Plans and assessments and found them to be comprehensive and accurate. On 09/01/16, at 3:00 PM, an audit was completed to ensure that all residents had a new and updated elopement risk assessment, which identified no new residents at risk for elopement. On 09/01/16, at 10:00 AM, daily audits using the Risk Management/Quality Improvement Daily Collection Form were initiated by the DON/Administrator to validate and document the following: documentation of every 15 minute checks for identified at risk residents, documentation of 1:1 observation for Resident #1, documentation of the wander guard placement and function on the Medication Administration Record every shift, documentation of door alarm checks every shift, Elopement books up-to date and accurate audited daily. Compliance was noted on all. These audits continue daily without incident. LPNs/RNs who are assigned to residents at risk for elopement check functioning and placement every shift of wander guard devices and document such on the Medication Administration Record. On 09/01/16, an elopement drill was conducted by the Maintenance Director with the 3:00 PM to 11:00 PM staff and continued on all three (3) shifts. Systemic Changes for QA Monitoring: 8. On 09/01/16, signage was placed at the front door for visitors, transportation providers, and Emergency Medical Services. Beginning on 09/01/16, all new hires will be in-serviced on elopement prevention, how to respond immediately to a missing person, and how to respond to an alarming door. Residents with exit seeking behavior are discussed daily/weekly in the Clinical Meeting. Residents with new onset of exit seeking behaviors will be placed on increased supervision and documented on the Safety Check form by the assigned RN, LPN or Certified Nursing Assistant (CNA). Visitors are directed to use only the front door and staff is now required to primarily use the 200 hall door to enter and exit the building. The purpose of this was to reduce the number of common exits to be monitored. Notification: 9. At 11:49 PM on 08/30/16, the Director of Nursing (DON) was notified that Resident #1 was missing from the facility. On 08/30/16 at 11:52 PM, the local Police Department was notified of the elopement. On 08/30/16 at 11:55 PM, RN #1 attempted to reach Resident #1's Responsible Party by phone several times with each attempt being unsuccessful. On 08/31/16 at 12:00 AM, Resident #1's attending physician was notified Resident #1 was missing from facility. On 08/31/16 at 1:00 AM, RN #1 continued to make attempts to contact Resident #1's Responsible Party with each attempt being unsuccessful. On 08/31/16 at 2:15 AM, RN #1 successfully contacted Resident #1's Responsible Party. The Responsible Party was notified of the elopement and that resident was at a local hospital reportedly without injuries. On 08/31/16 at 3:20 AM the Resident#1's Attending Physician and Responsible Party was notified of resident was back in the facility and free of injuries. On 08/31/16 at 5:30 PM. the Mississippi State Department of Health was notified via voicemail by the DON of the elopement. On 08/31/16 at 6:16 PM, the Mississippi Attorney General's office was notified of the elopement. The facility alleged the Corrective Action Plan (CAP) was completed by 09/01/16. The State Agency (SA) validated the facility's corrective action on 09/14/16. 1. The SA validated the facility's investigation of Resident # 1's elopement on 08/30/16, and return to the facility on [DATE] uninjured. The SA verified this by record review, interviews/written statements of staff and the local Police Officer (no formal report completed) and written reports to the SA. 2. The SA validated by staff interviews, review of the facility's investigation, review of statements and Interdisciplinary Progress Notes that on 08/30/16 all of the remaining 74 residents of the facility were accounted for. The two (2) remaining residents residing in the facility that had previously been identified as an elopement risk were visually observed and function/placement of the Wander Guard device was tested without concerns. 3. The SA verified through record review, observation, and interview with the Maintenance Director that all exit doors were checked for function to ensure they were secured and locked on 8/31/16. Maintenance also checked the function of the Wander Guard devices for the two (2) identified residents at risk for elopement. Observation of exit doors during survey revealed they were locked, secured and functioning. Elopement books were reviewed and all three (3) identified residents at risk for elopement were present. Review of Resident #1's care plan revealed an update on 8/31/16 for the elopement event. 4. The SA verified through review of Resident Safety Checks, Interdisciplinary Progress Notes, physician's orders [REDACTED]. checks with documentation and continued without incident. The Attending Physician was notified of Resident #1's elopement and safe return to the facility. A new Physician order [REDACTED]. New elopement risk evaluations were documented for all residents in the facility and this was completed by Licensed Practical Nurse (LPN) #1, Registered Nurse (RN) #2, and RN #3. No new residents were identified to be at risk for elopement. Review of an invoice dated 8/31/16 revealed an independent outside contractor arrived to check wander guard system for proper functioning and no problems were identified. The Independent outside contractor also checked all exit doors at this time for proper functioning with no problems identified. The door alarm was activated and the enunciation was loud and clear. Signage was observed to be posted at the front door which noted NOTICE TO VISITORS- safety devices are placed on residents for their protection. Safety devices may be, but not limited to belts, wrists, and or ankle bracelets. Please do not remove safety devices from residents. If a resident asks you to remove a safety device, please alert the Administrator, Director of Nurses, or Charge Nurses . A red sign was posted with the following information STOP. Attention all visitors-please be mindful when entering and exiting the door that we have residents that will seek exit from this facility that are not safe to do so. Do not hold the door for extended lengths of time; enter and exit quickly. This also applies to EMS (Emergency Medical Services) and all vendors of this facility. Please be aware of residents when entering and exiting the facility. The front door under the keypad read, Staff please remember to check outside when alarm is silenced by keypad. The MAR documented the functioning of the wander guard bracelet every shift by the RN/LPN starting on 09/01/16 for all (3) residents identified as elopement risk. 5. The SA verified through review of the Quality Assurance attendance record and agenda, and staff interviews, that on 08/31/16, a Quality Assurance Committee Meeting was held at 9:00 AM, with the following staff in attendance: DON, Administrator, Resident #1's Attending Physician via phone, (Facility medical director was out of the country), RN #2, Admissions Coordinator, Medical Records, Central Supply, and the Director of Rehabilitation. During this meeting the Missing Resident Policy, Elopement Policy, a

Based on record review, policy review and staff interview, the facility failed to develop a care plan to include interventions of supervision of residents at risk for elopement as evidenced by no specific visual checks for one (1) of five (5) residents reviewed, Resident #1. Resident #1 left the facility unattended and was located approximately 0.7 miles from the facility and was returned unharmed. The failure to develop the care plan for increased supervision, resulted in Resident #1 leaving the building unattended and put Resident #1 and other residents at risk for elopement in a situation that was likely to cause serious harm, injury, impairment or death. Based on the facility's implementation of corrective actions as of 9/1/16, initiated prior to the State Agency (SA) entrance on 9/7/16, the SA determined the Immediate Jeopardy to be Past Non-Compliance and removed as of 9/2/16. Findings include: Review of the facility policy entitled Plans of Care, revised 09/01/15, revealed, The facility will develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical , nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan is reviewed and updated at least quarterly, and as needed to ensure needs are addressed. Review of Resident #1's Care Plan revealed a Problem, dated 07/19/16, for Behavior/Mood which included Wandering and Exit Seeking Behavior. The Goal included, Resident will not leave building unattended. Interventions included: Elopement Risk Assessment, Personal wander prevention device-check for placement each shift and function daily, anticipate and address resident needs, and check exit door alarms daily. There was no intervention for increased supervision of visual checks for this resident with known exit seeking behaviors. This care plan was updated 8/31/16 for an actual elopement with interventions for Wanderguard alarm checks every shift for placement and function, and 1:1 supervision until further notice. Review of a facility written report, dated 9/2/16, revealed Resident #1 left the building unattended on 8/30/16, after being redirected to her room from the enclosed courtyard by the RN #1. Resident #1 was last seen by staff at approximately 10:50 PM. At 11:36 PM the Certified Nursing Assistant (CNA) was unable to locate Resident #1 and the facility began a search. Resident #1 was located approximately 0.7 miles from the facility by the Police Department and returned to the facility after an exam at the local hospital, without injury. Interview, on 09/07/16 at 11:15 PM, with Registered Nurse (RN) #1 revealed Resident #1 had been in the enclosed courtyard on 08/30/16 at 10:50 PM. At that time RN #1 brought Resident #1 back to her room, where Resident #1 sat on the side of the bed. RN #1 stated she did not immediately look for Resident #1 when CNA #1 reported Resident #1 was not in her room. RN #1 was aware Resident #1 wandered. RN #1 did not attempt any interventions from the Care Plan other than to check the function of the wander guard. RN #1 revealed there was no documented times on the care plan for visual checks of the resident. Interview with the Director of Nursing (DON) on 9/8/16 at 10:15 AM, revealed prior to Resident #1's elopement on 8/30/16, the nurses and CNAs rotating checking the resident's wherabouts every hour, but nothing was documented. The DON acknowledged Resident #1's care plan was reviewed and updated to include the elopement and 1:1 supervision and wander guard checks for placement and function every shift after the resident had exited the building on 8/30/16. Interview with LPN #1 on 9/12/16 at 3:10 PM, revealed she developed and reviewed care plans. LPN #1 acknowledged Resident #1 had a care plan in place that the resident will not leave the building unattended. She acknowledged there should be interventions in place to prevent the resident from leaving the building. Review of the Admission Record revealed the facility admitted Resident #1 on 07/30/15, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/18/16 revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating Resident #1 had severe cognitive impairment. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/01/16, revealed Resident #1 scored 11 of 15 on the Brief Interview for Mental Status (BIMS) which indicated moderate cognitive impairment. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on 09/07/16: Description of Incident: 1. On 8/30/16 at 10:50 PM, RN#1 redirected Resident #1 from the courtyard of the facility to her room. She then went to her medication cart retrieved the transponder testing device for the wander guard bracelet. RN #1 then returned to Resident#1's room and tested her wander guard bracelet. The wander guard bracelet was functioning properly. On 8/30/16 at approximately 11:10 PM, CNA#1 noticed that Resident #1 was not in her room, at that time CNA #1 asked RN #1 if Resident #1 was in the hospital, because CNA #1 had been given report earlier that another one of her residents was in the hospital. It was not uncommon for Resident #1 to visit the courtyard and travel to other rooms in the facility. RN #1 told CNA #1 that Resident #1 was not in the hospital, and that she had just redirected Resident #1 from the courtyard. CNA #1 then was suddenly summonsed to another resident's room where she provided incontinent care. After completing care, CNA #1 went to Resident #1's room again. On 8/30/16, at approximately 11:35 PM, Resident #1 could not be located in the facility. At approximately 11:35 PM on 8/30/16, a search was initiated for Resident #1 by RN #1 and CNA #1. Facility protocol for missing resident was initiated at 11:35 PM. At 11:49 PM, the Director of Nursing (DON) was notified that Resident #1 was missing from the facility. At 11:52 PM RN #1 notified the Police Department that Resident #1 was missing from the facility and a description was given of Resident #1. At 11:55 PM RN #1 attempted to reach Resident #1's Responsible Party by telephone without success. At approximately 12:35 AM on 8/31/16, Resident #1 was located north of the facility off of Highway 39 in an Apartment Complex located approximately 0.7 miles from the facility, by the Police Department. At that time the police took Resident #1 to the hospital for an evaluation where she was noted to have no injuries. On 8/31/16 at 3:15 AM, Resident #1 was returned to the facility by the DON. The resident was assessed and showered at this time and placed on 1:1 observation until further notice, without further incident. The results of the head to toe assessment by RN#1 revealed no injuries. It is suspected that Resident #1, who was fully clothed in street clothes and wearing shoes, exited the facility through the front door at approximately 11:10 PM, while the Emergency Medical Services (EMS) personnel were transporting another resident by stretcher through the double front doors. Measures Implemented: 2. On 08/30/16, at approximately 11:40 PM, RN #1 validated placement and function of wander guard devices for the two (2) remaining residents residing in the facility that had previously been identified as an elopement risk. Then, at approximately 11:45 PM, RN #1 completed a head count of all residents of the facility. All other 74 residents of the facility were present and accounted for. The other two (2) residents previously assessed as an elopement risk were visually observed. Placement and functioning of the wander guard device was tested by using a transponder testing device by RN #1. Wander guard bracelets were functioning. 3. On 08/31/16, at 1:10 AM, all exit doors were checked by the Maintenance Director to ensure security and that they were locked with no deficits noted. At 1:20 AM, the Maintenance Director and the Director of Nursing (DON) visually checked the other two (2) residents at risk for elopement and tested their wander guard device with the transponder Testing Device. No deficits were found. On 08/31/16, at approximately 1:30 AM, the elopement books were checked by the DON to ensure that all books contained pictures and demographics. Elopement books were current and no issues were identified. At 3:15 AM, Resident #1 was re-evaluated by the DON for elopement risk; Resident #1's Care Plan and Kardex were updated to reflect the actual elopement. 4. On 08/31/16, at 1:00 AM, the two (2) residents previously identified for being at risk for elopement were placed on every 15 minute safety checks and are currently continuing every 15 minute safety checks without incident. At 3:20 AM, the Attending Physician was notified of Resident #1's safe return to the facility and was in agreement with the 1:1 observation plan. A new Physician Order was obtained for 1:1 observation until further notice. On 08/31/16, at 9:00 AM, new elopement risk evaluations were initiated on all residents in the facility and this was completed by Licensed Practical Nurse (LPN) #1, Registered Nurse (RN) #2, and RN #3. No new residents were identified to be at risk for elopement. At 3:00 PM on 08/31/16, an independent outside contractor arrived to check the wander guard system for proper functioning with no problems identified. The Independent outside contractor also checked all exit doors at this time for proper functioning with no problems identified. The Independent outside contractor, as an extra precaution, Amplified the enunciator panel at Nurses Station #1. Signage posted at the front door stated NOTICE TO VISITORS- safety devices are placed on residents for their protection. Safety devices may be, but not limited to belts, wrists, and or ankle bracelets. Please do not remove safety devices from residents. If a resident asks you to remove a safety device, please alert the Administrator, Director of Nurses, or Charge Nurses. On 09/01/16, at 8:00 AM, a red sign was posted with the following information STOP. Attention all visitors-please be mindful when entering and exiting the door that we have residents that will seek exit from this facility that are not safe to do so. Do not hold the door for extended lengths of time; enter and exit quickly. This also applies to EMS (Emergency Medical Services) and all vendors of this facility. Please be aware of residents when entering and exiting the facility. On 09/01/16 at 8:00 AM, signage was placed at the front door under the keypad with the following information Staff please remember to check outside when alarm is silenced by keypad (The purpose of this is to remind staff to ensure a resident is not outside of the door.) As an extra precaution the monitoring of the functioning of the wander guard bracelet was increased from daily to every shift by the RN/LPN on 09/01/16. Initial Quality Assurance Meeting: 5. On 08/31/16, a Quality Assurance Committee Meeting was held at 9:00 AM with the following staff in attendance: DON, Administrator, Resident #1's Attending Physician via phone, (Facility medical director was out of the country), RN #2, Admissions Coordinator, Medical Records, Central Supply, and the Director of Rehabilitation. During this meeting the Missing Resident Policy, Elopement Policy, and In-services were discussed, as well as, review of current investigation and root cause analysis. Supervision of residents at risk for elopement was reviewed. Recommendations made to continue 1:1 observation plan for Resident #1 and every 15 minute safety checks on the other two (2) residents previously identified at risk for elopement. Training/In-services: 6. On 08/31/16, at 1:30 AM, the following policies were reviewed by the DON with the staff on duty at that time. This review continued beginning on 7:00 AM to 3:00 PM shift 08/31/2016, to all other staff of the facility: Elopement Policy and Missing Resident Policy. Staff was in-serviced on the following topic with emphasis on: If a resident that is at risk for elopement cannot be located immediately staff are to begin missing resident guideline immediately, completion of walking rounds at the beginning and end of shift, process for responding to a sounding door alarm, and remaining at the front door during the entire entry and exit when EMS is transporting a resident. Six (6) out of six (6) RNs, 14 out of 14 LPNS, 36 out of 36 Certified Nursing Assistants (CNAs), 14 out of 14 Department Heads, eight (8) out of eight (8) Dietary Employees, nine (9) out of nine (9) Housekeepers, and five (5) out of five (5) Rehabilitation Therapy Staff Members have completed this Policy Review and In-service. No staff was allowed to work until they received the review on the above mentioned policies and in-services. Audits: 7. Resident #1's Care Plan and assessment were audited for elopement prevention by the DON on August 31, 2016, at 3:15 AM, and was found to be comprehensive and accurate. On August 31, 2016, at 3:45 AM, the DON reviewed two (2) other residents, previously found to be at risk for elopement, Care Plans and assessments and found them to be comprehensive and accurate. On 09/01/16, at 3:00 PM, an audit was completed to ensure that all residents had a new and updated elopement risk assessment, which identified no new residents at risk for elopement. On 09/01/16, at 10:00 AM, daily audits using the Risk Management/Quality Improvement Daily Collection Form were initiated by the DON/Administrator to validate and document the following: documentation of every 15 minute checks for identified at risk residents, documentation of 1:1 observation for Resident #1, documentation of the wander guard placement and function on the Medication Administration Record [REDACTED]. Compliance was noted on all. These audits continue daily without incident. LPNs/RNs who are assigned to residents at risk for elopement check functioning and placement every shift of wander guard devices and document such on the Medication Administration Record. On 09/01/16, an elopement drill was conducted by the Maintenance Director with the 3:00 PM to 11:00 PM staff and continued on all three (3) shifts. Systemic Changes for QA Monitoring: 8. On 09/01/16, signage was placed at the front door for visitors, transportation providers, and Emergency Medical Services. Beginning on 09/01/16, all new hires will be in-serviced on elopement prevention, how to respond immediately to a missing person, and how to respond to an alarming door. Residents with exit seeking behavior are discussed daily/weekly in the Clinical Meeting. Residents with new onset of exit seeking behaviors will be placed on increased supervision and documented on the Safety Check form by the assigned RN, LPN or Certified Nursing Assistant (CNA). Visitors are directed to use only the front door and staff is now required to primarily use the 200 hall door to enter and exit the building. The purpose of this was to reduce the number of common exits to be monitored. Notification: 9. At 11:49 PM on 08/30/16, the Director of Nursing (DON) was notified that Resident #1 was missing from the facility. On 08/30/16 at 11:52 PM, the local Police Department was notified of the elopement. On 08/30/16 at 11:55 PM, RN #1 attempted to reach Resident #1's Responsible Party by phone several times with each attempt being unsuccessful. On 08/31/16 at 12:00 AM, Resident #1's attending physician was notified Resident #1 was missing from facility. On 08/31/16 at 1:00 AM, RN #1 continued to make attempts to contact Resident #1's Responsible Party with each attempt being unsuccessful. On 08/31/16 at 2:15 AM, RN #1 successfully contacted Resident #1's Responsible Party. The Responsible Party was notified of the elopement and that resident was at a local hospital reportedly without injuries. On 08/31/16 at 3:20 AM the Resident#1's Attending Physician and Responsible Party was notified of resident was back in the facility and free of injuries. On 08/31/16 at 5:30 PM. the Mississippi State Department of Health was notified via voicemail by the DON of the elopement. On 08/31/16 at 6:16 PM, the Mississippi Attorney General's office was notified of the elopement. The facility alleged the Corrective Action Plan (CAP) was completed by 09/01/16. The State Agency (SA) validated the facility's corrective action on 09/14/16. 1. The SA validated the facility's investigation of Resident # 1's elopement on 08/30/16, and return to the facility on [DATE] uninjured. The SA verified this by record review, interviews/written statements of staff and the local Police Officer (no formal report completed) and written reports to the SA. 2. The SA validated by staff interviews, review of the facility's investigation, review of statements and Interdisciplinary Progress Notes that on 08/30/16 all of the remaining 74 residents of the facility were accounted for. The two (2) remaining residents residing in the facility that had previously been identified as an elopement risk were visually observed and function/placement of the Wander Guard device was tested without concerns. 3. The SA verified through record review, observation, and interview with the Maintenance Director that all exit doors were checked for function to ensure they were secured and locked on 8/31/16. Maintenance also checked the function of the Wander Guard devices for the two (2) identified residents at risk for elopement. Observation of exit doors during survey revealed they were locked, secured and functioning. Elopement books were reviewed and all three (3) identified residents at risk for elopement were present. Review of Resident #1's care plan revealed an update on 8/31/16 for the elopement event. 4. The SA verified through review of Resident Safety Checks, Interdisciplinary Progress Notes, Physician's Orders, review of Elopement Risk forms, review of the independent contractor invoice, review and observation of the signage at the main entrance to the facility, review of the Medication Administration Record [REDACTED]. The Attending Physician was notified of Resident #1's elopement and safe return to the facility. A new Physician order for [REDACTED].#1, Registered Nurse (RN) #2, and RN #3. No new residents were identified to be at risk for elopement. Review of an invoice dated 8/31/16 revealed an independent outside contractor arrived to check wander guard system for proper functioning and no problems were identified. The Independent outside contractor also checked all exit doors at this time for proper functioning with no problems identified. The door alarm was activated and the enunciation was loud and clear. Signage was observed to be posted at the front door which noted NOTICE TO VISITORS- safety devices are placed on residents for their protection. Safety devices may be, but not limited to belts, wrists, and or ankle bracelets. Please do not remove safety devices from residents. If a resident asks you to remove a safety device, please alert the Administrator, Director of Nurses, or Charge Nurses . A red sign was posted with the following information STOP. Attention all visitors-please be mindful when entering and exiting the door that we have residents that will seek exit from this facility that are not safe to do so. Do not hold the door for extended lengths of time; enter and exit quickly. This also applies to EMS (Emergency Medical Services) and all vendors of this facility. Please be aware of residents when entering and exiting the facility. The front door under the keypad read, Staff please remember to check outside when alarm is silenced by keypad. The MAR indicated [REDACTED]. 5. The SA verified through review of the Quality Assurance attendance record and agenda, and staff interviews, that on 08/31/16, a Quality Assurance Committee Meeting was held at 9:00 AM, with the following staff in attendance: DON, Administrator, Resident #1's Attending Physician via phone, (Facility medical director was out of the country), RN #2, Admissions Coordinator, Medical Records, Central Supply, and the Director of Rehabilitation. During this meeting the Missing Resident Policy, Elopement Policy, and In-services were discussed, as well as, review of current investigation and root cause analysis. Supervision of residents at risk for elopement was reviewed. Recommendations made to continue 1:1 observation plan for Resident #1 and every 15 minutes safety checks on the other two (2) residents previously identified at risk for elopement. 6. The SA verified through review of in-service records singed by staff, and staff interviews, that on 08/31/16, at 1:30 AM, the following policies were reviewed by the DON with the staff on duty at that time and continued beginning on 7:00 AM to 3:00 PM shift 08/31/2016, to all other staff of the facility: Elopement Policy and Missing Resident Policy. Staff was in-serviced on the following topic with emphasis on: If a resident that is at risk for elopement cannot be located immediately staff are to begin missing resident guideline immediately, completion of walking rounds at the beginning and end of shift, process for responding to a sounding door alarm, and remaining at the front door during the entire entry and exit when EMS is transporting a resident. Six (6) out of six (6) RNs, 14 out of 14 LPNS, 36 out of 36 Certified Nursing Assistants (CNAs), 14 out of 14 Department Heads, eight (8) out of eight (8) Dietary Employees, nine (9) out of nine (9) Housekeepers, five (5) out of five (5) Rehabilitation Therapy Staff Members have completed this Policy Review and In-service. No staff was allowed to work until they received the review on the above mentioned policies and in-services. 7. The SA verified through record review, review of the facility's investigation and audits, review of the Risk Management/Quality Improvement Daily Collection Form Elopement Drills and staff interview, that Resident #1's Care Plan and risk assessment were reviewed and updated to include the elopement and 1:1 observation. The two (2) other residents previously found to be at risk for elopement had reviews of the Care Plans and assessments and were updated for every 15 minute observations. On 09/01/16 an audit was completed and documented to ensure that all residents had a new and updated elopement risk assessment, which identified no new residents at risk for elopement. On 09/01/16, at 10:00 AM, daily audits were initiated and documented on the Risk Management/ Quality Improvement Daily Collection Form to include the following: documentation of every 15 minute checks for identified at risk residents, documentation of 1:1 observation for Resident #1, documentation of the wander guard placement and function on the Medication Administration Record [REDACTED]. These audits continue daily without incident. On 09/01/16, an elopement drill was documented by the Maintenance Director with the 3:00 PM to 11:00 PM staff with continued drills the 11-7 shift and 7-3 shift. 8. The SA verified through record review, observation, review of new hire orientation, and staff interview, that on 09/01/16, signage was placed at the front door for visitors, transportation providers, and Emergency Medical Services. Beginning on 09/01/16, all new hires, per orientation packet, will be in-serviced on elopement prevention, how to respond immediately to a missing person, and how to respond to an alarming door. Residents with exit seeking behavior are discussed daily/weekly in the Clinical Meeting per staff interviews. Per staff interview, residents with new onset of exit seeking behaviors will be placed on increased supervision and documented on the Safety Check form by the assigned RN, LPN or Certified Nursing Assistant (CNA). There had been no new residents identified since 9/1/16. Observation revealed no entrance from any doors except the front and 200 hall entrance doors. 9. The SA verified through record review, review of the facility investigation and report, staff interview and Attending Physician interview, that at 11:49 PM on 08/30/16, the Director of Nursing (DON) was notified that Resident #1 was missing from the facility. On 08/30/16 at 11:52 PM, the local Police Department was notified of the elopement. On 08/30/16 at 11:55 PM, RN #1 attempted to reach Resident #1's Responsible Party by phone several times with each attempt being unsuccessful. On 08/31/16 at 12:00 AM, Resident #1's Attending Physician was notified Resident #1 was missing from the facility. On 08/31/16 at 1:00 AM, RN #1 continued to make attempts to contact Resident #1's responsible party with each attempt being unsuccessful. On 08/31/16 at 2:15 AM, RN #1 successfully contacted Resident #1's responsible party. The responsible party was notified of the elopement and that resident was at a local hospital reportedly without injuries. On 08/31/16 at 3:20 AM the Resident#1's Attending Physician and responsible party was notified the resident was back in the facility and free of injuries. On 08/31/16 at 5:30 PM, the Mississippi State Department of Health was notified via voicemail by the DON of the elopement. On 08/31/16 at 6:16 PM, the Mississippi Attorney General's office was notified of the elopement.

Based on observation, physician orders, dietary assessment, facility policy review, staff interview, and review of professional standards of nursing practice, the facility failed to provide care according to professional standards of following physician orders [REDACTED].#4 being admitted to the hospital on two occasions with a [DIAGNOSES REDACTED].#2, #4, #7, #8 and #9) Resident #4 was admitted to the local hospital with severe dehydration on 8/26/14. The resident was admitted a second time on 9/19/14 again with severe dehydration. The facility failed to assure a dependent resident who required hydration/feeding by a feeding tube received the recommended fluid to meet his needs and to prevent dehydration. The facility's failure to record and monitor intake received, and document accurate intake resulted a situation that led to Resident #4's severe dehydration with the likelihood to cause serious injury, harm, impairment, or death to the others residents with tube feedings. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 8/26/14 with the resident's first hospitalization with a severe dehydration [DIAGNOSES REDACTED]. The facility's Administrator was notified of the Immediate Jeopardy and Substandard Quality of Care on 10/1/14. An acceptable credible Allegation of Compliance was received on 10/3/14 in which the facility alleged the Immediate Jeopardy was removed on 10/4/14. Findings Include: A review of the facility's policy entitled "Hydration Policy", revised 4/30/14, stated, "All residents will receive sufficient fluid intake to maintain proper hydration and health. Fluids will be provided daily to all residents with meals, between meals, and at bedtime, with the exception of those who are NPO (nothing by mouth) or on a purposeful restriction of fluid status unless calculated in their fluid allowance." Review of the facility's policy entitled "Intake and Output", revised 8/31/2011, revealed "Clinical Services personnel will maintain a record of intake and output in keeping with the physician orders [REDACTED]." The policy further stated, "3. Each shift the licensed nurse will record the intake and the output. 4. Total the intake at the end of each shift and record on the intake and output record. 5. Total the intake for the twenty-four hour period." A review of "Nursing Skills and Procedures", Eighth Edition, by Perry and Potter, on page 166, under the heading "Enteral Nutrition via a Gastrostomy or Jejunostomy Tube", the document read, "13 Have registered dietician recommend total free water requirement per day and obtain health care provider's order." Under the heading "Recording and Reporting", the document read, "Record volume of formula and any additional water on intake and output form." Resident #4 A review of the Dietary Assessment by the Registered Dietician, dated 6/25/14, read Resident #4 had a PEG (Percutaneous Endoscopic Gastrostomy) (feeding) tube and the resident's fluid needs were calculated as 2,130 cubic centimeters (cc) a day. A review of Resident #4's record revealed Physician Orders, dated 6/30/14, 7/23/14 and 8/28/14, which read, "Total fluid volume intake Q 24 (every 24) hours at 12 AM of Enteral feeding and flushes." A review of the Dietary Assessment by the Registered Dietician, dated 6/25/14, stated, Resident #4's fluid needs were calculated as 2,130 cubic centimeters (cc) a day. A review of the Medication Administration Record (MAR) for the months of July 2014, August 2014, and September 2014 failed to have consistent and accurate fluid amounts documented. The highest amount recorded on the MAR per day was 1,300 cc. Other blocks of the MAR were illegible, left blank, or had initials where the amounts should have been recorded. The 11-7 shift was responsible for totaling the daily intake. Interview with Certified Nurses Assistant (CNA) #1 on 6:55 AM revealed the CNA worked the 11- 7 shift. CNA #1 verified Resident #4's pump would alarm at times during her shift. She stated she would get the nurse if the alarm was sounding. Interview with Licensed Practical Nurse (LPN) #1, on 10/4/14 at 7:10 AM, revealed Resident #4's feeding pump would alarm during her shift because it would clog and need flushing. The facility admitted Resident #4 to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4 has a gastrostomy tube, and is dependent on staff for all feeding and flushes. The facility transferred Resident #4 to the hospital on [DATE]; therefore no observation was available. Resident #2 A review of admission orders [REDACTED]. The admission orders [REDACTED]. Review of a physician's orders [REDACTED].@ 60 cc/hr X 22 hr ([MEDICATION NAME] 1.5 at 60 cubic centimeters an hour times 22 hours); Flush with 60 cc H20 (water) when turning pump on/off; Flush Peg with 150 cc H20 every 6 (six) hours. A review of Resident #2's MAR for September 2014 (admission on 9/22/14) failed to provide any documentation of any formula totals or flushes the resident received since admission to the facility. A review of Resident #2's Admission MDS (Minimum Data Set) with an Assessment Reference Date of 9/29/14 revealed the resident was totally dependent on staff for nutrition. The facility admitted Resident #2 to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #7 A review of Physician order [REDACTED]. H20 AC/PC meds (sixty cubic centimeters of water before and after medications); Total fluid volume intake Q 24 hrs (every twenty-four hours) at 12 AM of Enteral feedings and flushes." A review of the Medication Administration Records (MARs) for August and September 2014 failed to provide documentation of Resident #7's intake. A review of the Registered Dietician's "Dietary Enteral Review" had Resident #7's fluid needs calculated as requiring 2091-2509 ml (milliliters) every day. Review of the August and September 2014 MARs had recordings of 960 for seven days for the month of August, and for one day for the month of September. All other days were illegible or left bank. A review of the current MDS (Minimum Data Set) with an Assessment Reference Date of 9/26/14 revealed Resident #7 required total care for eating and all nutrition was through a gastrostomy tube. Resident #7 was admitted by the facility on 10/13/11 with [DIAGNOSES REDACTED]. Resident #8 A review of Physician order [REDACTED]. H20 A/P meds (medications); Total fluid volume intake Q 24 hrs (every twenty-four hours) at 12 AM of Enteral feedings and flushes." A review of Medication Administration Records (MARs) for September 2014 revealed daily recordings of 960 cc intake for each day of the month. A review of the Registered Dietician's "Dietary Enteral Review" revealed Resident #8's fluid needs had been calculated as 1811 cc a day. The formula and flushes would have provided 1861 cc each day. The facility failed to provide documentation that ensured Resident # 8 received feedings and flushes as calculated to meet her dietary needs. The facility admitted Resident #8 on 9/26/08 with [DIAGNOSES REDACTED]. A review of the current MDS with an Assessment Reference Date of 9/15/14 for Resident # 8 revealed the resident required total care for eating, and a gastrostomy tube administered all feedings. Resident # 9 A review of the Physicians Orders dated October 2014 revealed Resident #9 had tube feeding orders which had been initiated on 8/20/14 which stated, "[MEDICATION NAME] 1.5. Cal Liquid Give 80 ML/HR X 16 HRS (eighty milliliters an hour times 16 hours); Flush Peg Tube with 30 cc H20 A/P meds (30 cubic centimeters of water before and after medications); Flush Peg Tube with 30 cc H20 (30 cubic centimeters of water) when turning pump on and off; Total fluid volume intake Q 24 hrs (every 24 hours) at 12 AM of enteral feedings and flushes." A review of Medication Administration Records (MARs) for September 2014 revealed daily recordings of from 960 to 1460 cc. There were also blocks that were left blank and others were illegible. A review of Resident #9's Registered Dietician's "Dietary Enteral Review" revealed the resident's fluid needs had been calculated to be between 1765 and 2006 cc of fluid each day. The ordered feedings and flushed would have provide 2413 cc a day. The facility failed to provide documentation that ensured Resident # 9 received feedings and flushes as calculated to meet him nutritional and fluid needs. Review of Resident #9's record revealed the facility had admitted him on 8/20/14 with [DIAGNOSES REDACTED]. A review of the current MDS with an ARD of 8/29/14 reveal Resident #9 was totally dependent for eating and received all nutrition by way of a gastrostomy tube. An interview with the Director of Nursing (DON) and the Assistant Director of Nursing, on 10/3/14 at 11:00 AM, confirmed the documentation for tube feeding intakes did not meet each resident's needs. The DON confirmed none of the records, (with the exception of a new admit (Resident #6)), that the facility had reviewed had complete documentation. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 10/3/14 for the Immediate Jeopardy and Substandard Quality of Care (SQC). Review of the facility's AoC revealed the facility took the following actions to remove the immediacy: On 9/19/14 Resident #4 was admitted to the hospital with [REDACTED].#4 had decreased level of consciousness and decreased blood pressure. Resident #4 did not return to the facility after discharge from the hospital. 1. Beginning on 10/1/14 and ending 10/3/14, twenty out of twenty residents' identified to be at risk for dehydration were audited including a review of labs, physician orders, medication administration records, and visual assessment of signs and symptoms of dehydration. Based on review there were no abnormal findings. 2. The twenty care plans for residents at risk of dehydration were updated beginning 10/1/14 and ending 10/3/14 3. On 10/1/14, to identify other residents that have the potential to be affected, a 100% chart audit of all enteral fed residents' was performed by the Director of Clinical Services/Director of Nursing (DCS/DON), Assistant Director of Clinical Services (ADCS), Regional Director of Clinical Services (RDCS), Social Worker, and Minimum Data Set (MDS) Coordinator. Physician orders, labs, and medication administration records were reviewed. There were nine residents noted without 24 hour total intake documentation. Medication Administration Records (MAR) were immediately updated on these residents to include a breakdown of intake for each 8 hour shift. 4. On 10/1/14, the enteral fed residents were visually assessed with [REDACTED]. 5. On 10/3/14, a complete metabolic profile and a renal function panel were ordered for all enteral fed residents. 6. On 10/1/14 and 10/2/14, the DCS/DON and ADCS educated all full time and prn RNs and LPNs on the new process of the updated Medication Administration Record and educated on the following policies: a. Initiating Enteral Feeding N-425, which covered initiating feeding as ordered by the physician, assessing resident's tolerance to the feeding based upon absence of unusual diarrhea, abdominal cramping, gastric retention of feeding, and glycosuria, flushing the tube per physician order, totaling flushes and enteral formula, and documenting in the medical record. b. Intake and Output N-1510, which covered maintaining a record of intake and output in keeping with physician orders [REDACTED]. c. Dehydration Prevention for Environmental or Medical Causes N-1169 which included signs and symptoms of dehydration such as poor skin turgor, flushed dry skin, coated tongue, decreased urine output, irritability, confusion, temperature subnormal or elevated, rapid pulse, or rapid respiration. d. 100% of Certified Nursing Assistants were educated on Dehydration Prevention for Environmental or Medical Causes N-1169. 7. An emergency Quality Assurance (QA) meeting was conducted to review and implement this allegation of compliance on 10/2/14 at 8:30 AM CST and included the Medical Director, Executive Director (ED), DCS/DON, RDCS, and ADCS. The topics discussed were accidents and incidents, dehydration, change in MARs, and review of Resident #4's medical record. No employee will be authorized to work until education is completed. There are no contracted nurses employed at this facility. The facility alleged the Immediate Jeopardy was removed on 10/4/14.

Based on care plan review, Medication Administration Record [REDACTED]. (Residents #2, #4, #7, #8 and #9) Resident #4 was admitted to the local hospital with severe dehydration on 8/26/14. The resident was admitted a second time on 9/19/14 again with severe dehydration. The facility failed to assure a dependent resident who required hydration/feeding by a feeding tube received the recommended fluid to meet his needs and to prevent dehydration. The facility's failure to follow the care plan caused Resident #4 to be hospitalized two separate times with dehydration and was likely to cause serious injury, harm, impairment or death for Residents #2, #4, #7, #8 and #9. This situation was determined to be an Immediate Jeopardy (IJ) which began on 8/26/14. The facility's Administrator was notified of the Immediate Jeopardy and Substandard quality of Care on 10/1/14. An acceptable Allegation of Compliance was received on 10/3/14 in which the facility alleged the Immediate Jeopardy was removed on 10/4/14. Findings Include: Review of the facility's policy entitled, "Care Plan", revised 2/27/14 revealed: "All direct care staff must always know, understand and follow their Resident's Care Plan. If unable to implement any part of the plan, notify your Clinical Nurse or, Care Planning Coordinator, so that this can be documented, or the Care Plan changed if necessary." Resident #4 A review of the Resident's Care Plan related to tube feeding risk of dehydration, dated 8/1/14, revealed approaches as: "Monitor lab data as ordered. Free water flushes per order." Review of the Physician Orders, dated 6/30/14, 7/23/14 and 8/28/14, read, "Total fluid volume intake Q 24 (every 24) hours at 12 AM of Enteral feeding and flushes." The facility admitted Resident #4 to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4 has a gastrostomy tube, and is dependent on staff for all feeding and flushes. Resident #2 Review of the Resident's initial Care Plan related to tube feedings, dated 9/22/14, revealed approaches as: Flush with 25 cc (cubic centimeters) of water every 1 hour and flush with 60 cc of water before and after meals. A review of admission orders [REDACTED]@ 60 cc/hr X 22 hr ([MEDICATION NAME] 1.5 at 60 cubic centimeters an hour times 22 hours); Flush with 60 cc H20 (water) when turning pump on/off; Flush Peg with 150 cc H20 every 6 (six) hours. A review of Resident #2's MAR for September 2014 failed to provide any documentation of any formula or flushes the resident received since admission to the facility. The facility admitted Resident #2 on 9/22/14 with [DIAGNOSES REDACTED]. A review of Resident #2's Admission MDS (Minimum Data Set) with an Assessment Reference Date of 9/29/14 revealed the resident was totally dependent on staff for nutrition. Resident #7 A review of the resident's Care Plan related to risk for complications related to tube feeding dated 9/29/14 revealed approaches as: "Flush tube with 60 cc of water before and after medications. Flush tube with 150 cc of water every 4 hours." A review of Physician order [REDACTED]. H20 AC/PC meds (sixty cubic centimeters of water before and after medications); Total fluid volume intake Q 24 hrs (every twenty-four hours) at 12 AM of Enteral feedings and flushes." A review of the Medication Administration Records (MARs) for August and September 2014 failed to provide documentation of Resident #7's intake. The MAR indicated [REDACTED]. Resident #7 was admitted by the facility on 10/13/11 with [DIAGNOSES REDACTED]. A review of the current MDS (Minimum Data Set) with an Assessment Reference Date of 9/26/14 revealed Resident #7 required total care for eating and all nutrition was through a gastrostomy tube. Resident #8 Review of Care Plan for Risk of Dehydration for Resident # 8 related to diuretic use and feeding tube, dated 9/19/14, listed approaches for flushes/feedings as ordered. A review of Physician order [REDACTED]. H20 A/P meds (medications); Total fluid volume intake Q 24 hrs (every twenty-four hours) at 12 AM of Enteral feedings and flushes." The facility admitted Resident #8 on 9/26/08 with [DIAGNOSES REDACTED]. A review of the current MDS with an Assessment Reference Date of 9/15/14 for Resident #8 revealed the resident required total care for eating, and a gastrostomy tube administered all feedings. Resident # 9 Review of Care Plan for PEG tube for adequate nutritional intake, revealed approaches to flush PEG tube with 30 cc of water when turn pump on or off. Flush PEG tube with 30 cc of water when administering meds before and after. Record total fluid intake every 24 hours at 12:00 AM nightly. Record on MAR (Medication Administration Record). A review of the Physicians Orders dated October 2014 revealed Resident #9 had tube feeding orders which had been initiated on 8/20/14 which stated, "[MEDICATION NAME] 1.5. Cal Liquid Give 80 ML/HR X 16 HRS (eighty milliliters an hour times sixteen hours); Flush Peg Tube with 30 cc H20 A/P meds (30 cubic centimeters of water before and after medications); Flush Peg Tube with 30 cc H20 (30 cubic centimeters of water) when turning pump on and off; Total fluid volume intake Q 24 hrs (every twenty-four hours) at 12 AM of enteral feedings and flushes." A review of Medication Administration Records (MARs) for September 2014 revealed daily recordings of from 960 to 1460 cc. There were also blocks that were left blank and others were illegible. Review of Resident #9's face sheet revealed the facility admitted the resident on 8/20/14 with [DIAGNOSES REDACTED]. A review of the current MDS with an ARD of 8/29/14 reveal Resident #9 was totally dependent for eating and received all nutrition by way of a gastrostomy tube. On 10/3/14 at 11:00 AM, during an interview with the Director of Nursing (DON), she stated she was aware and confirmed documentation for tube feedings were "all a mess". She stated none of the records the facility had reviewed, with the exception of new resident admitted on [DATE] (Resident #6), were documented correctly. The DON also confirmed the documentation for tube feeding intakes which included formula and flushes had not been recorded as directed by orders and care plan. An interview with the Administrator on 10/17/14 at 12 noon, after the survey exit, revealed it was the responsibility of the MDS nurse/ care plan coordinator to make sure careplans were in place. It was also the unit manager's, DON's, and ADON's job to keep the care plan updated as needed. Review of the six sampled residents' Minimum Data Set (MDS) Care Area Assessments (CAAs) revealed all six triggered for dehydration and the facility developed care plans addressing their risk of dehydration. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 10/3/14 for the Immediate Jeopardy and Substandard Quality of Care (SQC). Review of the facility's AoC revealed the facility took the following actions to remove the immediacy: On 9/19/14 Resident #4 was admitted to the hospital with [REDACTED].#4 had decreased level of consciousness and decreased blood pressure. Resident #4 did not return to the facility after discharge from the hospital. 1. Beginning on 10/1/14 and ending 10/3/14, twenty out of twenty residents' identified to be at risk for dehydration were audited including a review of labs, physician orders, medication administration records, and visual assessment of signs and symptoms of dehydration. Based on review there were no abnormal findings. 2. The twenty care plans for residents at risk of dehydration were updated beginning 10/1/14 and ending 10/3/14 3. On 10/1/14, to identify other residents that have the potential to be affected, a 100% chart audit of all enteral fed residents' was performed by the Director of Clinical Services/Director of Nursing (DCS/DON), Assistant Director of Clinical Services (ADCS), Regional Director of Clinical Services (RDCS), Social Worker, and Minimum Data Set (MDS) Coordinator. Physician orders, labs, and medication administration records were reviewed. There were nine residents noted without 24 hour total intake documentation. Medication Administration Records (MAR) were immediately updated on these residents to include a breakdown of intake for each 8 hour shift. 4. On 10/1/14, the enteral fed residents were visually assessed with [REDACTED]. 5. On 10/3/14, a complete metabolic profile and a renal function panel were ordered for all enteral fed residents. 6. On 10/1/14 and 10/2/14, the DCS/DON and ADCS educated all full time and prn RNs and LPNs on the new process of the updated Medication Administration Record [REDACTED] a. Initiating Enteral Feeding N-425, which covered initiating feeding as ordered by the physician, assessing resident's tolerance to the feeding based upon absence of unusual diarrhea, abdominal cramping, gastric retention of feeding, and glycosuria, flushing the tube per physician order, totaling flushes and enteral formula, and documenting in the medical record. b. Intake and Output N-1510, which covered maintaining a record of intake and output in keeping with physician orders [REDACTED]. c. Dehydration Prevention for Environmental or Medical Causes N-1169 which included signs and symptoms of dehydration such as poor skin turgor, flushed dry skin, coated tongue, decreased urine output, irritability, confusion, temperature subnormal or elevated, rapid pulse, or rapid respiration. d. 100% of Certified Nursing Assistants were educated on Dehydration Prevention for Environmental or Medical Causes N-1169. 7. An emergency Quality Assurance (QA) meeting was conducted to review and implement this allegation of compliance on 10/2/14 at 8:30 AM CST and included the Medical Director, Executive Director (ED), DCS/DON, RDCS, and ADCS. The topics discussed were accidents and incidents, dehydration, change in MARs, and review of Resident #4's medical record. No employee will be authorized to work until education is completed. There are no contracted nurses employed at this facility. The facility alleged the Immediate Jeopardy was removed on 10/4/14. On 10/4/14, the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy: The acceptable credible Allegation of Compliance was verified by staff interviews and record review of in-services on 10/4/14 across multiple disciplines beginning at 6:45 AM through 1:30 PM. A review of the facility's audit verified twenty (20) residents had been identified to be at risk for dehydration with no adverse findings. A review of seventeen (17) resident records verified care plans had been updated for risk of dehydration. A review of the 17 resident records verified new Medication Administration Records were initiated to include intake for each 8 hour shift. The surveyor visualized eight of eight tube fed residents in the facility with no visual s/s dehydration noted. Record Review for all residents who required Enteral feeding revealed lab had been drawn for Complete Metabolic Profiles and Renal Function Panels. The State Agency verified by interviews, including LPNs, RNs and CNAs, the content of in-services held on 10/1/14 through 10/2/14. Five (5) Registered Nurses and eight (8) Licensed Practical Nurses verified being in-serviced on policies related to Enteral Feeding of residents which included Intake and Output, and preventing and monitoring for signs and symptoms of dehydration. Eighteen (18) Certified Nursing Assistants verified being in-serviced on Dehydration Prevention. A review of the Emergency Quality Assurance meeting sign in sheets verified the Medical Director, the Executive Director, the Director of Nursing, Assistant Director of Nursing and the Regional Director of Clinical Services attended the meeting.

Based on record review, policy review and staff interview, the facility failed to ensure accurate ordered documentation was obtained related to gastrostomy intake for five (5) of six (6) residents reviewed for intake needs. This resulted in the inability of the facility to recognize intake of Resident #4 related to dehydration and had the likelihood for residents to develop complications related to gastrostomy. (Residents #2, #4, #7, #8 and #9) Resident #4 was admitted to the local hospital with severe dehydration on 8/26/14. The resident was admitted a second time on 9/19/14 again with severe dehydration. The facility failed to assure a dependent resident who required hydration/feeding by a feeding tube received the recommended fluid to meet his needs and to prevent dehydration. The facility's failure to document accurate intake for Residents #2, #4, #7, #8 and #9 caused Resident #4 to be admitted the the hospital with severe dehydration and was likely to cause serious injury, harm, impairment or death to others residents. This situation was determined to be an Immediate Jeopardy (IJ) which began on 8/26/14. The facility's Administrator was notified of the Immediate Jeopardy and Substandard quality of Care on 10/1/14. An acceptable Allegation of Compliance was received on 10/3/14 in which the facility alleged the Immediate Jeopardy was removed on 10/4/14. Findings Included: Resident #4 Review of the facility's policy entitled "Intake and Output" with a revision date of 8/31/2011 revealed "Clinical Services personnel will maintain a record of intake and output in keeping with the physician orders [REDACTED]." The policy further stated, "3. Each shift the licensed nurse will record the intake and the output. 4. Total the intake at the end of each shift and record on the intake and output record. 5. Total the intake for the twenty-four hour period." A review of the Dietary Assessment by the Registered Dietician, dated 6/25/14, stated Resident #4's fluid needs were calculated as 2,130 cubic centimeters (cc) a day. Physician order [REDACTED]." Review of the Medication Administration Record (MAR) for the months of July 2014, August 2014 and September 2014 failed to have consistent and accurate amounts documented. The highest amount recorded on the MARs was 1,300 cc. Some blocks were left blank or had initials where the amounts should have been recorded. Others were illegible. The facility admitted Resident #4 to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4 has a gastrostomy tube, and is dependent on staff for all feeding and flushes. Resident #2 A review of admission orders [REDACTED]@ 60 cc/hr X 22 hr ([MEDICATION NAME] 1.5 at 60 cubic centimeters an hour times 22 hours); Flush with 60 cc H20 (water) when turning pump on/off; Flush Peg with 150 cc H20 every 6 (six) hours. A review of Resident #2's MAR for September 2014 failed to provide any documentation of any formula or flushes the resident received since admission to the facility. A review of Resident #2's Admission MDS (Minimum Data Set) with an Assessment Reference Date of 9/29/14 revealed the resident was totally dependent on staff for nutrition. The facility admitted Resident #2 to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #7 A review of Physician order [REDACTED]. meds (60 cubic centimeters of water before and after medications); Total fluid volume intake Q 24 hrs (every 24 hours) at 12 AM of Enteral feedings and flushes." A review of the Medication Administration Records (MARs) for August and September 2014 had recordings of 960 for seven days for the month of August, and for one day for the month of September. All other days were illegible or left bank. A review of the current MDS (Minimum Data Set) with an Assessment Reference Date of 9/26/14 revealed Resident #7 required total care for eating and all nutrition was through a gastrostomy tube. Resident #7 was admitted by the facility on 10/13/11 with [DIAGNOSES REDACTED]. Resident #8 A review of Physician order [REDACTED]. H20 A/P meds (medications); Total fluid volume intake Q 24 hrs (every 24 hours) at 12 AM of Enteral feedings and flushes." A review of Medication Administration Records (MARs) for September 2014 revealed daily recordings of 960 for each day of the month. The facility failed to provide documentation that ensured Resident #8 received feedings and flushes as calculated to meet her dietary needs. A review of the current MDS with an Assessment Reference Date of 9/15/14 for Resident #8 revealed the resident required total care for eating, and a gastrostomy tube administered all feedings. The facility admitted Resident #8 on 9/26/08 with [DIAGNOSES REDACTED]. Resident #9 Physicians Orders, dated October 2014, reviewed and revealed Resident #9 had tube feeding orders, initiated on 8/20/14, which read, "[MEDICATION NAME] 1.5. Cal Liquid Give 80 ML/HR X 16 HRS (80 milliliters an hour times 16 hours); Flush Peg Tube with 30 cc H20 A/P meds (30 cubic centimeters of water before and after medications); Flush Peg Tube with 30 cc H20 (30 cubic centimeters of water) when turning pump on and off; Total fluid volume intake Q 24 hrs (every 24 hours) at 12 AM of enteral feedings and flushes." A review of Medication Administration Records (MARs) for September 2014 revealed daily recordings of from 960 to 1460 cc. There were also blocks that were left blank and others were illegible. The facility failed to provide documentation that ensured Resident #9 received feedings and flushes as calculated to meet him nutritional and fluid needs. Review of Resident #9's record revealed admission on 8/20/14 with [DIAGNOSES REDACTED]. A review of the current MDS with an ARD of 8/29/14 reveal Resident #9 was totally dependent for eating and received all nutrition by way of a gastrostomy tube. During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), on 10/3/14 at 11:00 AM, the DON stated she was aware and confirmed documentation for tube feedings were "all a mess". She confirmed none of the records reviewed were documented correctly except the new resident admitted on [DATE] (Resident #6). The DON and the ADON confirmed the documentation for tube feeding intakes, which included formula and flushes, had not been recorded as directed by policy and what was recorded did not meet each resident's needs for all the sampled residents except one (Resident #6). Interview with the ADON, on 10/3/14 at 2:13 PM, revealed Resident #6 was the only resident with appropriate documentationrelated to intake. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 10/3/14 for the Immediate Jeopardy and Substandard Quality of Care (SQC). Review of the facility's AoC revealed the facility took the following actions to remove the immediacy: On 9/19/14 Resident #4 was admitted to the hospital with [REDACTED].#4 had decreased level of consciousness and decreased blood pressure. Resident #4 did not return to the facility after discharge from the hospital. 1. Beginning on 10/1/14 and ending 10/3/14, twenty out of twenty residents' identified to be at risk for dehydration were audited including a review of labs, physician orders, medication administration records, and visual assessment of signs and symptoms of dehydration. Based on review there were no abnormal findings. 2. The twenty care plans for residents at risk of dehydration were updated beginning 10/1/14 and ending 10/3/14 3. On 10/1/14, to identify other residents that have the potential to be affected, a 100% chart audit of all enteral fed residents' was performed by the Director of Clinical Services/Director of Nursing (DCS/DON), Assistant Director of Clinical Services (ADCS), Regional Director of Clinical Services (RDCS), Social Worker, and Minimum Data Set (MDS) Coordinator. Physician orders, labs, and medication administration records were reviewed. There were nine residents noted without 24 hour total intake documentation. Medication Administration Records (MAR) were immediately updated on these residents to include a breakdown of intake for each 8 hour shift. 4. On 10/1/14, the enteral fed residents were visually assessed with [REDACTED]. 5. On 10/3/14, a complete metabolic profile and a renal function panel were ordered for all enteral fed residents. 6. On 10/1/14 and 10/2/14, the DCS/DON and ADCS educated all full time and prn RNs and LPNs on the new process of the updated Medication Administration Record and educated on the following policies: a. Initiating Enteral Feeding N-425, which covered initiating feeding as ordered by the physician, assessing resident's tolerance to the feeding based upon absence of unusual diarrhea, abdominal cramping, gastric retention of feeding, and glycosuria, flushing the tube per physician order, totaling flushes and enteral formula, and documenting in the medical record. b. Intake and Output N-1510, which covered maintaining a record of intake and output in keeping with physician orders [REDACTED]. c. Dehydration Prevention for Environmental or Medical Causes N-1169 which included signs and symptoms of dehydration such as poor skin turgor, flushed dry skin, coated tongue, decreased urine output, irritability, confusion, temperature subnormal or elevated, rapid pulse, or rapid respiration. d. 100% of Certified Nursing Assistants were educated on Dehydration Prevention for Environmental or Medical Causes N-1169. 7. An emergency Quality Assurance (QA) meeting was conducted to review and implement this allegation of compliance on 10/2/14 at 8:30 AM CST and included the Medical Director, Executive Director (ED), DCS/DON, RDCS, and ADCS. The topics discussed were accidents and incidents, dehydration, change in MARs, and review of Resident #4's medical record. No employee will be authorized to work until education is completed. There are no contracted nurses employed at this facility. The facility alleged the Immediate Jeopardy was removed on 10/4/14. On 10/4/14, the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy: The acceptable credible Allegation of Compliance was verified by staff interviews and record review of in-services on 10/4/14 across multiple disciplines beginning at 6:45 AM through 1:30 PM. A review of the facility's audit verified twenty (20) residents had been identified to be at risk for dehydration with no adverse findings. A review of seventeen (17) resident records verified care plans had been updated for risk of dehydration. A review of the 17 resident records verified new Medication Administration Records were initiated to include intake for each 8 hour shift. The surveyor visualized eight of eight tube fed residents in the facility with no visual s/s dehydration noted. Record Review for all residents who required Enteral feeding revealed lab had been drawn for Complete Metabolic Profiles and Renal Function Panels. The State Agency verified by interviews, including LPNs, RNs and CNAs, the content of in-services held on 10/1/14 through 10/2/14. Five (5) Registered Nurses and eight (8) Licensed Practical Nurses verified being in-serviced on policies related to Enteral Feeding of residents which included Intake and Output, and preventing and monitoring for signs and symptoms of dehydration. Eighteen (18) Certified Nursing Assistants verified being in-serviced on Dehydration Prevention. A review of the Emergency Quality Assurance meeting sign in sheets verified the Medical Director, the Executive Director, the Director of Nursing, Assistant Director of Nursing and the Regional Director of Clinical Services attended the meeting.

Based on care plan review, facility policy review, and staff interview, the facility failed to identify, address, or develop a plan of care for van transportation for one (1) of one (1) residents in the facility with a motorized scooter. (Resident #5) Resident #5 sustained an injury related to the use of a motorized scooter while being transported in the facility van. On 9/26/14 at 5:00 PM, Resident #5 was on an outing on the facility van. When the van made a left hand turn, the motorized scooter upon which she was sitting turned over in the van resulting in a fracture to Resident #5's left clavicle (collar bone). The facility's failure to address and implement safe interventions for transporting a resident in a motorized scooter caused a situation that was likely to cause serious injury, harm, impairment or death to other residents. This situation was determined to be an Immediate Jeopardy (IJ) which began on 9/26/14. The facility's administrator was notified of the Immediate Jeopardy and Substandard Quality of Care (SQC) on 10/1/14. An acceptable Allegation of Compliance was received on 10/3/14 in which the facility alleged the Immediate Jeopardy was removed on 10/4/14. Findings Include: The facility's policy entitled, "Care Plan", revised 2/27/14, documented an interdisciplinary plan of care will be established for every resident to ensure the residents' needs are met. Resident #5 A review of Resident #5's current plan of care revealed the resident had not been care planned for the use of a motorized scooter until 9/29/14 which was three days after the resident was injured riding on the scooter during transport in the facility's van. On 10/2/14 at 4:30 PM, an interview with the Director of Nursing (DON) confirmed the motorized scooter was not care planned for use during transports in the facility van. On 10/2/14 at 11:00 AM, an interview with Van Driver #1 revealed she had been driving the van for a long time. She stated when she first started driving the van, she was instructed to never transport a resident in a geri-chair, but at no time, was she told not to transport on a scooter. On 10/2/14 at 10:10 AM, an interview with Van Driver #2 revealed she had always transported the resident while sitting on the scooter. Van Driver #2 stated she had not been told to not transport a resident on a scooter. A review of the accident report for Resident #5 revealed the resident had sustained a fractured left clavicle (collar bone) during a transport on 9/26/14 in the facility van. Record review for Resident #5 revealed the facility admitted the resident on 10/10/11 with [DIAGNOSES REDACTED]. A review of the most current Minimum Data Set revealed Resident #5 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident had no cognitive deficits. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 10/3/14 for the Immediate Jeopardy and Substandard Quality of Care (SQC). Review of the facility's AoC revealed the facility took the following actions to remove the immediacy: On 9/26/2014, Resident #5 was being transported on our facility van. At the time of the transport, Resident #5's motorized scooter tipped over, resulting in a fractured clavicle. Resident #5 was transported to the emergency department for evaluation and care. 1. The Van Driver was suspended on 9/27/2014 pending termination. 2. On 9/29/2014, the Executive Director educated the Back-up Van Driver, Maintenance Director, and Maintenance Assistant on the proper use of the van lift and tie downs and seat belts and manufacturers ' recommendations. Included in the educational material was a statement that only standard wheelchairs are to be transported in the van. No power chairs or scooters will be transported in the facility van. 3. On 9/29/2014 at approximately 11:00 AM the Back-up Van Driver, Maintenance Director, and Maintenance Assistant educated the facility DCS/DON and other 7-3 nurses and Certified Nurses Assistants on the proper use of the lift as well as the tie down and seat belt systems on the facility van. 4. On 10/1/2014, the facility ED educated all department heads including the ADCS/ADON, Unit Managers, MDS Coordinator, Medical Records clerk, Maintenance Director, Maintenance Assistant, Activity Director, Business Office Manager, Human Resources Coordinator (HRC), Social Services Director, Central Supply Clerk, Admissions Director, Dietary Manager, and Housekeeping Supervisor on the proper use of the van lift and tie downs and seat belts and manufacturers ' recommendations. Included in the educational material was a statement that only standard wheelchairs are to be transported in the van. The proper use of the van lift and tie downs and seat belts and manufacturers ' recommendations was included. No power chairs or scooters will be transported in the facility van. 5. On 10/1/2014, the facility ED, backup Van Driver, and Maintenance staff continued education with RNs, LPNs, and CNAs to include a return demonstration on the proper use of the van lift and tie downs and seat belts and manufacturers ' recommendations, a statement that only standard wheelchairs are to be transported in the van. No power chairs or scooters will be transported in the facility van. 6. On 10/2/2014, the backup Van Driver continued education with LPNs and CNAs. The facility ADCS continued education with LPNs on the proper use of the van lift and tie downs and seat belts and manufacturers ' recommendations. Included in the educational material was a statement that only standard wheelchairs are to be transported in the van. No power chairs or scooters will be transported in the facility van. 7. 82 employees have worked at the facility in the past 30 days. Of those employees, 82 have been educated on the use of the van lift and the safety measures to secure wheelchairs for transport in the van. 8. All newly hired employees will receive training on the proper use of the lift and safety systems on the van. 9. An emergency Quality Assurance (QA) meeting was conducted to review and implement this allegation of compliance on 10/2/14 at 8:30 AM CST and included the Medical Director, Executive Director (ED), DCS/DON, RDCS, and ADCS. The topics discussed were accidents and incidents, dehydration, change in MARs, and review of Resident #4 ' s medical record. The ED will report to the Quality Assurance Committee to insure compliance that all new hires are educated before being authorized to work. 10. A 100% audit of facility residents reveal only one resident utilizes a motorized wheelchair or scooter. No employee will be authorized to work until education is completed. The facility alleges the Immediate Jeopardy was removed on 10/4/2014. Interview with the Administrator and review of disciplinary action form verified the van driver was suspended on 9/27/14. Review of in-service sign in sheet verified the back-up van driver, the Maintenance Director and the Maintenance Assistant had been in-serviced related to safe transport of residents. Review of sign-in sheets verified the DON and 7-3 nurses and CNAs had been in-serviced on proper use of the lift van and the tie down and seat belt systems of the van. Review of sign in sheets revealed all department heads were in-serviced on use of the lift van. Interview with 31 employees verified they had been in-serviced related to safe transport of residents, adhering to manufacturer's recommendations, and safety to secure residents for transport in the van. A review of the Emergency Quality Assurance meeting sign in sheets verified the Medical Director, the Executive Director, the Director of Nursing, Assistant Director of Nursing and the Regional Director of Clinical Services attended the meeting.

Based on record review, policy review and staff interview, the facility failed to monitor intake as ordered to prevent a resident from becoming dehydrated for one (1) of six (6) residents reviewed for risk of Dehydration on two separate occasions. (Resident #4) The facility transferred Resident #4 to the hospital on [DATE] with an admitting [DIAGNOSES REDACTED].#4 had a second admission to the hospital on [DATE] with an admission [DIAGNOSES REDACTED].#4 had a gastrostomy tube with continuous feedings and intermittent flushes as recommended by the Registered Dietician. The facility's failure to ensure an accurate, physician ordered, accounting of Resident #4's Enteral intake resulted in Resident #4 becoming dehydrated and was likely to cause serious injury, harm, impairment or death to other residents. This situation was determined to be an Immediate Jeopardy (IJ) which began on 8/26/14. The facility ' s administrator was notified of the Immediate Jeopardy and Substandard Quality of Care (SQC) on 10/1/14. An acceptable Allegation of Compliance was received on 10/3/14 in which State Agency determined the Immediate Jeopardy was removed on 10/4/14. Findings Include: A review of the facility's policy entitled "Hydration Policy", revised 4/30/14, stated, "All residents will receive sufficient fluid intake to maintain proper hydration and health. Fluids will be provided daily to all residents with meals, between meals, and at bedtime, with the exception of those who are NPO (nothing by mouth) or on a purposeful restriction of fluid status unless calculated in their fluid allowance." Review of the facility's policy entitled "Intake and Output" revised 8/31/2011 revealed "Clinical Services personnel will maintain a record of intake and output in keeping with the physician orders [REDACTED]." The policy further stated, "3. Each shift the licensed nurse will record the intake and the output. 4. Total the intake at the end of each shift and record on the intake and output record. 5. Total the intake for the twenty-four hour period." A review of the History and Physical (H&P) from the local hospital revealed Resident #4 was admitted [DATE]. The H&P documented, "The patient was found to be severely dehydrated with a blood pressure of 88/72." A review of the hospital obtained laboratory results dated [DATE] revealed the resident had a sodium of 151 and a calculated osmolarity of 324.9 which indicated severe dehydration. On 8/28/14, a Discharge Summary from the local hospital revealed the resident had been rehydrated and was to return to the facility. Upon discharge, laboratory results showed the resident's sodium was 146 with the dehydration resolved. A review of the facility's Physician order [REDACTED]. Flush PEG with 180 cc H20 (water) Q 4 hrs (every four hours). Flush PEG with 60 cc H20 with meds. Flush tube with 100 cc H20 when turning pump off at 11 AM. Total fluid volume intake Q 24 hrs at 12 AM of Enteral feeding and flushes." A review of the Registered Dietician's Dietary Assessment, dated 6/25/14, read that Resident #4's fluid needs were calculated to be 2,130 cubic centimeters (cc) a day. A review of the July 2014, August 2014 and September 2014 Medication Administration Record (MAR) for Resident #4 revealed the highest amount recorded on the MAR was 1,300 cc. Blocks on the MAR were illegible, left blank, or had initials where the amounts should have been recorded. On 9/19/14, Resident #4 was again admitted to the local hospital. The admission H&P documented, "He was severely dehydrated and hypotensive with a blood pressure in the 70's systolic, 74/54." A review of Resident #4's hospital admission laboratory results dated [DATE] revealed sodium was 161 and osmolarity was 371.5, again indicating severe dehydration. On 10/2/14 at 10:45 AM, during an interview with the Director of Nursing (DON), she stated that Resident #4 pinched his tube off at times, but she didn't think it affected what he received through the tube. The DON stated whenever a resident had a dietary problem, there were forms to notify the RD but any problems were usually discussed in the morning meeting and brought to Dietary Department's attention. There was no documentation provided which addressed Resident #4's hydration status during the morning meetings. An interview with the facility's Registered Dietician (RD), on 10/1/14 at 11:30 AM, revealed she had been following Resident #4 on each of her visits to the facility. She stated her calculations should have met Resident #4's needs for calories and fluid. The RD stated she had no knowledge of any problems the resident had with the feeding pump or pinching the tube off. She stated the facility had never reported it to her. If aware, she could have tried other alternatives such as bolus feedings. She stated she had increased the water amounts several times due to the resident's abnormal sodium levels. On 10/2/14 at 11:00 AM, an interview with Resident #4's attending physician revealed he had been aware of Resident #4's high sodium levels. He stated he had discontinued the resident's diuretic, thinking it was keeping him too dry. The physician stated he did get notified of abnormal laboratory values everyday and did remember seeing sodium levels of 150 for Resident #4. He stated his Nurse Practitioner was also very good to notify him of any changes. On 10/3/14 at 11:00 AM, interviews with the DON and the Assistant Director of Nurses confirmed the documentation for tube feeding intakes was inaccurately documented and the amount of fluid intake documented by the facility did not meet the resident's needs. The DON stated she had initiated new MARs to accurately reflect the resident's intake starting in the month of October 2014. The facility admitted Resident #4 to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4 had a gastrostomy tube, and was dependent on staff for all feeding and flushes. The facility transferred Resident #4 to the hospital on [DATE]. Resident #4 was discharged from the hospital on [DATE] with discharge [DIAGNOSES REDACTED]. Resident #4 did not return to the facility upon discharge from the hospital, but was instead discharged to another long term care facility. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 10/3/14 for the Immediate Jeopardy and Substandard Quality of Care (SQC). Review of the facility's AoC revealed the facility took the following actions to remove the immediacy: On 9/19/14 Resident #4 was admitted to the hospital with [REDACTED].#4 had decreased level of consciousness and decreased blood pressure. Resident #4 did not return to the facility after discharge from the hospital. 1. Beginning on 10/1/14 and ending 10/3/14, twenty out of twenty residents' identified to be at risk for dehydration were audited including a review of labs, physician orders, medication administration records, and visual assessment of signs and symptoms of dehydration. Based on review there were no abnormal findings. 2. The twenty care plans for residents at risk of dehydration were updated beginning 10/1/14 and ending 10/3/14 3. On 10/1/14, to identify other residents that have the potential to be affected, a 100% chart audit of all enteral fed residents' was performed by the Director of Clinical Services/Director of Nursing (DCS/DON), Assistant Director of Clinical Services (ADCS), Regional Director of Clinical Services (RDCS), Social Worker, and Minimum Data Set (MDS) Coordinator. Physician orders, labs, and medication administration records were reviewed. There were nine residents noted without 24 hour total intake documentation. Medication Administration Records (MAR) were immediately updated on these residents to include a breakdown of intake for each 8 hour shift. 4. On 10/1/14, the enteral fed residents were visually assessed with [REDACTED]. 5. On 10/3/14, a complete metabolic profile and a renal function panel were ordered for all enteral fed residents. 6. On 10/1/14 and 10/2/14, the DCS/DON and ADCS educated all full time and prn RNs and LPNs on the new process of the updated Medication Administration Record and educated on the following policies: a. Initiating Enteral Feeding N-425, which covered initiating feeding as ordered by the physician, assessing resident's tolerance to the feeding based upon absence of unusual diarrhea, abdominal cramping, gastric retention of feeding, and glycosuria, flushing the tube per physician order, totaling flushes and enteral formula, and documenting in the medical record. b. Intake and Output N-1510, which covered maintaining a record of intake and output in keeping with physician orders [REDACTED]. c. Dehydration Prevention for Environmental or Medical Causes N-1169 which included signs and symptoms of dehydration such as poor skin turgor, flushed dry skin, coated tongue, decreased urine output, irritability, confusion, temperature subnormal or elevated, rapid pulse, or rapid respiration. d. 100% of Certified Nursing Assistants were educated on Dehydration Prevention for Environmental or Medical Causes N-1169. 7. An emergency Quality Assurance (QA) meeting was conducted to review and implement this allegation of compliance on 10/2/14 at 8:30 AM CST and included the Medical Director, Executive Director (ED), DCS/DON, RDCS, and ADCS. The topics discussed were accidents and incidents, dehydration, change in MARs, and review of Resident #4's medical record. No employee will be authorized to work until education is completed. There are no contracted nurses employed at this facility. The facility alleged the Immediate Jeopardy was removed on 10/4/14. On 10/4/14, the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy: The acceptable credible Allegation of Compliance was verified by staff interviews and record review of in-services on 10/4/14 across multiple disciplines beginning at 6:45 AM through 1:30 PM. A review of the facility's audit verified twenty (20) residents had been identified to be at risk for dehydration with no adverse findings. A review of seventeen (17) resident records verified care plans had been updated for risk of dehydration. A review of the 17 resident records verified new Medication Administration Records were initiated to include intake for each 8 hour shift. The surveyor visualized eight of eight tube fed residents in the facility with no visual s/s dehydration noted. Record Review for all residents who required Enteral feeding revealed orders had been drawn for Complete Metabolic Profiles and Renal Function Panels. The State Agency verified by interviews, including LPNs, RNs and CNAs, the content of in-services held on 10/1/14 through 10/2/14. Five (5) Registered Nurses and eight (8) Licensed Practical Nurses verified being in-serviced on policies related to Enteral Feeding of residents which included Intake and Output, and preventing and monitoring for signs and symptoms of dehydration. Eighteen (18) Certified Nursing Assistants verified being in-serviced on Dehydration Prevention. A review of the Emergency Quality Assurance meeting sign in sheets verified the Medical Director, the Executive Director, the Director of Nursing, Assistant Director of Nursing and the Regional Director of Clinical Services attended the meeting.

Based on record review, policy review, observation, staff, and resident interview, the facility failed to remove a resident from a motorized scooter during a van transport which caused an avoidable fracture for one (1) of ten (10) residents reviewed. (Resident # 5) Resident #5 had the scooter for approximately one year and had gone on multiple outings in the facility van. Resident #5 was the only resident at the facility with a motorized scooter. On 9/26/14 at 5:00 PM, Resident #5 was loaded onto the van by facility staff while sitting on her motorized scooted, and was subsequently transported while remaining seated on the scooter. The facility staff failed to follow the manufactures warning and use the intended safety devices to ensure safe transport. Resident #5 was on an outing on the facility van. When the driver made a left turn, the scooter turned over and Resident #5 suffered a fall in the van which resulted in a fracture to Resident #5's left clavicle (collar bone) during the transport in the facility lift van. The facility's failure to follow their policy for identifying risks and the failure to heed the manufacturer's recommendations for the use of the motorized scooter caused Resident #5 to suffer a fractured left clavicle and caused a situation could likely cause serious injury, harm, impairment or death to other residents. This situation was determined to be an Immediate Jeopardy (IJ) which began on 9/26/14. The facility's administrator was notified of the Immediate Jeopardy and Substandard Quality of Care (SQC) on 10/1/14. An acceptable Allegation of Compliance was received on 10/3/14 in which the facility alleged the Immediate Jeopardy was removed on 10/4/14. Findings Include: A review of the facility's policy entitled "Fall Risk", revised 3/3/14, stated, "To identify risk factors which place the resident at risk for falls and to facilitate the developments of interventions to minimize or prevent falls to the extent possible." A review of the "User's Manual" for the motorized scooter stated, "Warning! Never sit on your (Travel Scooter) when it is being used in connection with any type of lift/elevation product. Your (Travel Scooter) was not designed with such use in mind). (Manufacturer's Name) recommends that you do not remain seated in your (Travel Scooter) while traveling in a motor vehicle. The (travel scooter) should be stowed in the trunk of a car or in the back of a truck or van with the batteries removed and properly stored. Warning! Although your (travel scooter) may be equipped with a positioning belt, this belt is not designed to provide restraint during motor vehicle transport. Anyone traveling in a motor vehicle should be properly secured in the motor vehicle seat with safety belts fastened securely." A review of the facility's investigation report of the fall/injury that occurred on 9/26/14 at 5:00 PM revealed; The van driver took Resident #5 on an outing to a local department store. During the transporting of the resident back to the facility, the driver was making a left hand turn at an intersection when the scooter tipped over causing the resident to fall while still sitting on the motorized scooter. The driver was unable to get the resident up from the floor of the van and the local emergency medical service (EMS) was called. EMS arrived on site and assessed Resident #5 for injuries. The resident declined going to the emergency room for treatment. The EMS personnel helped the driver place the resident back on the scooter and the van returned to the facility. The facility's investigation showed the van driver had neglected to properly secure the scooter for transport which resulted in the scooter turning over and causing injury to Resident #5. When Resident #5 returned to the facility, she asked to be taken to the hospital. Resident #5 was diagnosed with [REDACTED]. A review of the witness statement, written by the Van Driver #1, revealed when she made the left hand turn, the scooter turned over with Resident #5 still sitting on it. The driver stated she call the facility and asked them to call the EMS to help get the resident up. She stated when EMS arrived they asked Resident #5 if she wanted to go to the hospital and the resident said no. The driver stated at that time the resident did complain of pain in her left shoulder. The driver stated she had hooked the right lock down and the front lock down. She stated she did not use the big seat belt and could not remember if she hooked the left lock down. She stated in the statement, "I can't remember if I put the left lock on." During an observation and interview, on 10/1/14 at 4:15 PM, Resident #5 was observed sitting up in a manual wheelchair in her room. Her left arm was noted in an immobilizer. Resident #5 stated she got hurt when she and the van driver had made a trip to (local department store). The resident stated on the return trip, the van was stopped at a red light. She stated the light turned green and the driver was making a left turn when she felt the scooter tipping over to the right. Resident #5 stated she fell over on her right side, striking her head, her right shoulder and her right knee. She stated the scooter was partially on her left shoulder and the scooter's seat belt was still attached around her waist. Resident #5 stated she had been transported in the scooter for as long as she had the scooter in the facility which was approximately a year. Resident #5 stated the van driver had used only one strap to secure the front of the scooter. She stated the driver did not apply the van's abdominal belt or shoulder strap to her during the transport. On 10/2/14 at 11:00 AM, an interview with Van Driver #1 revealed she had been driving the van for a long time. She stated when she first started driving the van, she was in-serviced. She stated she had been instructed to never transport a resident in a geri-chair because the safety straps would not secure the geri-chair. She stated at no time was she in-serviced not to transport on a scooter. Van Driver #1 stated she always used a four point system to secure the scooter but during the transport of Resident #5 on 9/26/14, she got distracted and evidently failed to secure the back of the scooter. She stated she had never used the abdominal belt or the shoulder strap during transport of the scooter because they did not fit. On 10/2/14 at 10:10 AM, an interview with Van Driver #2 revealed she had often transported Resident #5 in the lift van. She stated she had always transported the resident while sitting on the scooter. The alternate van driver stated she had been in-serviced on loading and unloading a resident in a wheelchair but had never been instructed not to transport a resident in a scooter. Record review of the Physician order [REDACTED].#5 on 10/10/11 with [DIAGNOSES REDACTED]. A review of the most current Minimum Data Set revealed Resident #5 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident had no cognitive deficits. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 10/3/14 for the Immediate Jeopardy and Substandard Quality of Care (SQC). Review of the facility's AoC revealed the facility took the following actions to remove the immediacy: On 9/26/2014, Resident #5 was being transported on our facility van. At the time of the transport, Resident #5's motorized scooter tipped over, resulting in a fractured clavicle. Resident #5 was transported to the emergency department for evaluation and care. 1. The Van Driver was suspended on 9/27/2014 pending termination. 2. On 9/29/2014, the Executive Director educated the Back-up Van Driver, Maintenance Director, and Maintenance Assistant on the proper use of the van lift and tie downs and seat belts and manufacturers ' recommendations. Included in the educational material was a statement that only standard wheelchairs are to be transported in the van. No power chairs or scooters will be transported in the facility van. 3. On 9/29/2014 at approximately 11:00 AM the Back-up Van Driver, Maintenance Director, and Maintenance Assistant educated the facility DCS/DON and other 7-3 nurses and Certified Nurses Assistants on the proper use of the lift as well as the tie down and seat belt systems on the facility van. 4. On 10/1/2014, the facility ED educated all department heads including the ADCS/ADON, Unit Managers, MDS Coordinator, Medical Records clerk, Maintenance Director, Maintenance Assistant, Activity Director, Business Office Manager, Human Resources Coordinator (HRC), Social Services Director, Central Supply Clerk, Admissions Director, Dietary Manager, and Housekeeping Supervisor on the proper use of the van lift and tie downs and seat belts and manufacturers ' recommendations. Included in the educational material was a statement that only standard wheelchairs are to be transported in the van. The proper use of the van lift and tie downs and seat belts and manufacturers ' recommendations was included. No power chairs or scooters will be transported in the facility van. 5. On 10/1/2014, the facility ED, backup Van Driver, and Maintenance staff continued education with RNs, LPNs, and CNAs to include a return demonstration on the proper use of the van lift and tie downs and seat belts and manufacturers ' recommendations, a statement that only standard wheelchairs are to be transported in the van. No power chairs or scooters will be transported in the facility van. 6. On 10/2/2014, the backup Van Driver continued education with LPNs and CNAs. The facility ADCS continued education with LPNs on the proper use of the van lift and tie downs and seat belts and manufacturers ' recommendations. Included in the educational material was a statement that only standard wheelchairs are to be transported in the van. No power chairs or scooters will be transported in the facility van. 7. 82 employees have worked at the facility in the past 30 days. Of those employees, 82 have been educated on the use of the van lift and the safety measures to secure wheelchairs for transport in the van. 8. All newly hired employees will receive training on the proper use of the lift and safety systems on the van. 9. An emergency Quality Assurance (QA) meeting was conducted to review and implement this allegation of compliance on 10/2/14 at 8:30 AM CST and included the Medical Director, Executive Director (ED), DCS/DON, RDCS, and ADCS. The topics discussed were accidents and incidents, dehydration, change in MARs, and review of Resident #4 ' s medical record. The ED will report to the Quality Assurance Committee to insure compliance that all new hires are educated before being authorized to work. 10. A 100% audit of facility residents reveal only one resident utilizes a motorized wheelchair or scooter. No employee will be authorized to work until education is completed. The facility alleges the Immediate Jeopardy was removed on 10/4/2014. Interview with the Administrator and review of disciplinary action form verified the van driver was suspended on 9/27/14. Review of in-service sign in sheet verified the back-up van driver, the Maintenance Director and the Maintenance Assistant had been in-serviced related to safe transport of residents. Review of sign-in sheets verified the DON and 7-3 nurses and CNAs had been in-serviced on proper use of the lift van and the tie down and seat belt systems of the van. Review of sign in sheets revealed all department heads were in-serviced on use of the lift van. Interview with 31 employees verified they had been in-serviced related to safe transport of residents, adhering to manufacturer's recommendations, and safety to secure residents for transport in the van. A review of the Emergency Quality Assurance meeting sign in sheets verified the Medical Director, the Executive Director, the Director of Nursing, Assistant Director of Nursing and the Regional Director of Clinical Services attended the meeting.

2 Based on record review, policy review and staff interview, the facility failed to ensure accurate ordered documentation was obtained related to gastrostomy intake for five (5) of six (6) residents reviewed for intake needs. This resulted in the inability of the facility to recognize intake of Resident #4 related to dehydration and had the likelihood for residents to develop complications related to gastrostomy. (Residents #2, #4, #7, #8 and #9) Resident #4 was admitted to the local hospital with severe dehydration on 8/26/14. The resident was admitted a second time on 9/19/14 again with severe dehydration. The facility failed to assure a dependent resident who required hydration/feeding by a feeding tube received the recommended fluid to meet his needs and to prevent dehydration. The facility's failure to document accurate intake for Residents #2, #4, #7, #8 and #9 caused Resident #4 to be admitted the the hospital with severe dehydration and was likely to cause serious injury, harm, impairment or death to others residents. This situation was determined to be an Immediate Jeopardy (IJ) which began on 8/26/14. The facility's Administrator was notified of the Immediate Jeopardy and Substandard quality of Care on 10/1/14. An acceptable Allegation of Compliance was received on 10/3/14 in which the facility alleged the Immediate Jeopardy was removed on 10/4/14. Findings Included: Resident #4 Review of the facility's policy entitled Intake and Output with a revision date of 8/31/2011 revealed Clinical Services personnel will maintain a record of intake and output in keeping with the physician orders [REDACTED]. The policy further stated, 3. Each shift the licensed nurse will record the intake and the output. 4. Total the intake at the end of each shift and record on the intake and output record. 5. Total the intake for the twenty-four hour period. A review of the Dietary Assessment by the Registered Dietician, dated 6/25/14, stated Resident #4's fluid needs were calculated as 2,130 cubic centimeters (cc) a day. Physician order [REDACTED]. Review of the Medication Administration Record (MAR) for the months of July 2014, August 2014 and September 2014 failed to have consistent and accurate amounts documented. The highest amount recorded on the MARs was 1,300 cc. Some blocks were left blank or had initials where the amounts should have been recorded. Others were illegible. The facility admitted Resident #4 to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4 has a gastrostomy tube, and is dependent on staff for all feeding and flushes. Resident #2 A review of admission orders [REDACTED]@ 60 cc/hr X 22 hr ([MEDICATION NAME] 1.5 at 60 cubic centimeters an hour times 22 hours); Flush with 60 cc H20 (water) when turning pump on/off; Flush Peg with 150 cc H20 every 6 (six) hours. A review of Resident #2's MAR for September 2014 failed to provide any documentation of any formula or flushes the resident received since admission to the facility. A review of Resident #2's Admission MDS (Minimum Data Set) with an Assessment Reference Date of 9/29/14 revealed the resident was totally dependent on staff for nutrition. The facility admitted Resident #2 to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #7 A review of Physician order [REDACTED]. meds (60 cubic centimeters of water before and after medications); Total fluid volume intake Q 24 hrs (every 24 hours) at 12 AM of Enteral feedings and flushes. A review of the Medication Administration Records (MARs) for August and September 2014 had recordings of 960 for seven days for the month of August, and for one day for the month of September. All other days were illegible or left bank. A review of the current MDS (Minimum Data Set) with an Assessment Reference Date of 9/26/14 revealed Resident #7 required total care for eating and all nutrition was through a gastrostomy tube. Resident #7 was admitted by the facility on 10/13/11 with [DIAGNOSES REDACTED]. Resident #8 A review of Physician order [REDACTED]. H20 A/P meds (medications); Total fluid volume intake Q 24 hrs (every 24 hours) at 12 AM of Enteral feedings and flushes. A review of Medication Administration Records (MARs) for September 2014 revealed daily recordings of 960 for each day of the month. The facility failed to provide documentation that ensured Resident #8 received feedings and flushes as calculated to meet her dietary needs. A review of the current MDS with an Assessment Reference Date of 9/15/14 for Resident #8 revealed the resident required total care for eating, and a gastrostomy tube administered all feedings. The facility admitted Resident #8 on 9/26/08 with [DIAGNOSES REDACTED]. Resident #9 Physicians Orders, dated October 2014, reviewed and revealed Resident #9 had tube feeding orders, initiated on 8/20/14, which read, [MEDICATION NAME] 1.5. Cal Liquid Give 80 ML/HR X 16 HRS (80 milliliters an hour times 16 hours); Flush Peg Tube with 30 cc H20 A/P meds (30 cubic centimeters of water before and after medications); Flush Peg Tube with 30 cc H20 (30 cubic centimeters of water) when turning pump on and off; Total fluid volume intake Q 24 hrs (every 24 hours) at 12 AM of enteral feedings and flushes. A review of Medication Administration Records (MARs) for September 2014 revealed daily recordings of from 960 to 1460 cc. There were also blocks that were left blank and others were illegible. The facility failed to provide documentation that ensured Resident #9 received feedings and flushes as calculated to meet him nutritional and fluid needs. Review of Resident #9's record revealed admission on 8/20/14 with [DIAGNOSES REDACTED]. A review of the current MDS with an ARD of 8/29/14 reveal Resident #9 was totally dependent for eating and received all nutrition by way of a gastrostomy tube. During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), on 10/3/14 at 11:00 AM, the DON stated she was aware and confirmed documentation for tube feedings were all a mess. She confirmed none of the records reviewed were documented correctly except the new resident admitted on [DATE] (Resident #6). The DON and the ADON confirmed the documentation for tube feeding intakes, which included formula and flushes, had not been recorded as directed by policy and what was recorded did not meet each resident's needs for all the sampled residents except one (Resident #6). Interview with the ADON, on 10/3/14 at 2:13 PM, revealed Resident #6 was the only resident with appropriate documentationrelated to intake. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 10/3/14 for the Immediate Jeopardy and Substandard Quality of Care (SQC). Review of the facility's AoC revealed the facility took the following actions to remove the immediacy: On 9/19/14 Resident #4 was admitted to the hospital with [REDACTED].#4 had decreased level of consciousness and decreased blood pressure. Resident #4 did not return to the facility after discharge from the hospital. 1. Beginning on 10/1/14 and ending 10/3/14, twenty out of twenty residents' identified to be at risk for dehydration were audited including a review of labs, physician orders, medication administration records, and visual assessment of signs and symptoms of dehydration. Based on review there were no abnormal findings. 2. The twenty care plans for residents at risk of dehydration were updated beginning 10/1/14 and ending 10/3/14 3. On 10/1/14, to identify other residents that have the potential to be affected, a 100% chart audit of all enteral fed residents' was performed by the Director of Clinical Services/Director of Nursing (DCS/DON), Assistant Director of Clinical Services (ADCS), Regional Director of Clinical Services (RDCS), Social Worker, and Minimum Data Set (MDS) Coordinator. Physician orders, labs, and medication administration records were reviewed. There were nine residents noted without 24 hour total intake documentation. Medication Administration Records (MAR) were immediately updated on these residents to include a breakdown of intake for each 8 hour shift. 4. On 10/1/14, the enteral fed residents were visually assessed with [REDACTED]. 5. On 10/3/14, a complete metabolic profile and a renal function panel were ordered for all enteral fed residents. 6. On 10/1/14 and 10/2/14, the DCS/DON and ADCS educated all full time and prn RNs and LPNs on the new process of the updated Medication Administration Record and educated on the following policies: a. Initiating Enteral Feeding N-425, which covered initiating feeding as ordered by the physician, assessing resident's tolerance to the feeding based upon absence of unusual diarrhea, abdominal cramping, gastric retention of feeding, and glycosuria, flushing the tube per physician order, totaling flushes and enteral formula, and documenting in the medical record. b. Intake and Output N-1510, which covered maintaining a record of intake and output in keeping with physician orders [REDACTED]. c. Dehydration Prevention for Environmental or Medical Causes N-1169 which included signs and symptoms of dehydration such as poor skin turgor, flushed dry skin, coated tongue, decreased urine output, irritability, confusion, temperature subnormal or elevated, rapid pulse, or rapid respiration. d. 100% of Certified Nursing Assistants were educated on Dehydration Prevention for Environmental or Medical Causes N-1169. 7. An emergency Quality Assurance (QA) meeting was conducted to review and implement this allegation of compliance on 10/2/14 at 8:30 AM CST and included the Medical Director, Executive Director (ED), DCS/DON, RDCS, and ADCS. The topics discussed were accidents and incidents, dehydration, change in MARs, and review of Resident #4's medical record. No employee will be authorized to work until education is completed. There are no contracted nurses employed at this facility. The facility alleged the Immediate Jeopardy was removed on 10/4/14. On 10/4/14, the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy: The acceptable credible Allegation of Compliance was verified by staff interviews and record review of in-services on 10/4/14 across multiple disciplines beginning at 6:45 AM through 1:30 PM. A review of the facility's audit verified twenty (20) residents had been identified to be at risk for dehydration with no adverse findings. A review of seventeen (17) resident records verified care plans had been updated for risk of dehydration. A review of the 17 resident records verified new Medication Administration Records were initiated to include intake for each 8 hour shift. The surveyor visualized eight of eight tube fed residents in the facility with no visual s/s dehydration noted. Record Review for all residents who required Enteral feeding revealed lab had been drawn for Complete Metabolic Profiles and Renal Function Panels. The State Agency verified by interviews, including LPNs, RNs and CNAs, the content of in-services held on 10/1/14 through 10/2/14. Five (5) Registered Nurses and eight (8) Licensed Practical Nurses verified being in-serviced on policies related to Enteral Feeding of residents which included Intake and Output, and preventing and monitoring for signs and symptoms of dehydration. Eighteen (18) Certified Nursing Assistants verified being in-serviced on Dehydration Prevention. A review of the Emergency Quality Assurance meeting sign in sheets verified the Medical Director, the Executive Director, the Director of Nursing, Assistant Director of Nursing and the Regional Director of Clinical Services attended the meeting.

2 Based on care plan review, Medication Administration Record [REDACTED]. (Residents #2, #4, #7, #8 and #9) Resident #4 was admitted to the local hospital with severe dehydration on 8/26/14. The resident was admitted a second time on 9/19/14 again with severe dehydration. The facility failed to assure a dependent resident who required hydration/feeding by a feeding tube received the recommended fluid to meet his needs and to prevent dehydration. The facility's failure to follow the care plan caused Resident #4 to be hospitalized two separate times with dehydration and was likely to cause serious injury, harm, impairment or death for Residents #2, #4, #7, #8 and #9. This situation was determined to be an Immediate Jeopardy (IJ) which began on 8/26/14. The facility's Administrator was notified of the Immediate Jeopardy and Substandard quality of Care on 10/1/14. An acceptable Allegation of Compliance was received on 10/3/14 in which the facility alleged the Immediate Jeopardy was removed on 10/4/14. Findings Include: Review of the facility's policy entitled, Care Plan, revised 2/27/14 revealed: All direct care staff must always know, understand and follow their Resident's Care Plan. If unable to implement any part of the plan, notify your Clinical Nurse or, Care Planning Coordinator, so that this can be documented, or the Care Plan changed if necessary. Resident #4 A review of the Resident's Care Plan related to tube feeding risk of dehydration, dated 8/1/14, revealed approaches as: Monitor lab data as ordered. Free water flushes per order. Review of the Physician Orders, dated 6/30/14, 7/23/14 and 8/28/14, read, Total fluid volume intake Q 24 (every 24) hours at 12 AM of Enteral feeding and flushes. The facility admitted Resident #4 to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4 has a gastrostomy tube, and is dependent on staff for all feeding and flushes. Resident #2 Review of the Resident's initial Care Plan related to tube feedings, dated 9/22/14, revealed approaches as: Flush with 25 cc (cubic centimeters) of water every 1 hour and flush with 60 cc of water before and after meals. A review of admission orders [REDACTED]@ 60 cc/hr X 22 hr ([MEDICATION NAME] 1.5 at 60 cubic centimeters an hour times 22 hours); Flush with 60 cc H20 (water) when turning pump on/off; Flush Peg with 150 cc H20 every 6 (six) hours. A review of Resident #2's MAR for September 2014 failed to provide any documentation of any formula or flushes the resident received since admission to the facility. The facility admitted Resident #2 on 9/22/14 with [DIAGNOSES REDACTED]. A review of Resident #2's Admission MDS (Minimum Data Set) with an Assessment Reference Date of 9/29/14 revealed the resident was totally dependent on staff for nutrition. Resident #7 A review of the resident's Care Plan related to risk for complications related to tube feeding dated 9/29/14 revealed approaches as: Flush tube with 60 cc of water before and after medications. Flush tube with 150 cc of water every 4 hours. A review of Physician order [REDACTED]. H20 AC/PC meds (sixty cubic centimeters of water before and after medications); Total fluid volume intake Q 24 hrs (every twenty-four hours) at 12 AM of Enteral feedings and flushes. A review of the Medication Administration Records (MARs) for August and September 2014 failed to provide documentation of Resident #7's intake. The MAR indicated [REDACTED]. Resident #7 was admitted by the facility on 10/13/11 with [DIAGNOSES REDACTED]. A review of the current MDS (Minimum Data Set) with an Assessment Reference Date of 9/26/14 revealed Resident #7 required total care for eating and all nutrition was through a gastrostomy tube. Resident #8 Review of Care Plan for Risk of Dehydration for Resident # 8 related to diuretic use and feeding tube, dated 9/19/14, listed approaches for flushes/feedings as ordered. A review of Physician order [REDACTED]. H20 A/P meds (medications); Total fluid volume intake Q 24 hrs (every twenty-four hours) at 12 AM of Enteral feedings and flushes. The facility admitted Resident #8 on 9/26/08 with [DIAGNOSES REDACTED]. A review of the current MDS with an Assessment Reference Date of 9/15/14 for Resident #8 revealed the resident required total care for eating, and a gastrostomy tube administered all feedings. Resident # 9 Review of Care Plan for PEG tube for adequate nutritional intake, revealed approaches to flush PEG tube with 30 cc of water when turn pump on or off. Flush PEG tube with 30 cc of water when administering meds before and after. Record total fluid intake every 24 hours at 12:00 AM nightly. Record on MAR (Medication Administration Record). A review of the Physicians Orders dated October 2014 revealed Resident #9 had tube feeding orders which had been initiated on 8/20/14 which stated, [MEDICATION NAME] 1.5. Cal Liquid Give 80 ML/HR X 16 HRS (eighty milliliters an hour times sixteen hours); Flush Peg Tube with 30 cc H20 A/P meds (30 cubic centimeters of water before and after medications); Flush Peg Tube with 30 cc H20 (30 cubic centimeters of water) when turning pump on and off; Total fluid volume intake Q 24 hrs (every twenty-four hours) at 12 AM of enteral feedings and flushes. A review of Medication Administration Records (MARs) for September 2014 revealed daily recordings of from 960 to 1460 cc. There were also blocks that were left blank and others were illegible. Review of Resident #9's face sheet revealed the facility admitted the resident on 8/20/14 with [DIAGNOSES REDACTED]. A review of the current MDS with an ARD of 8/29/14 reveal Resident #9 was totally dependent for eating and received all nutrition by way of a gastrostomy tube. On 10/3/14 at 11:00 AM, during an interview with the Director of Nursing (DON), she stated she was aware and confirmed documentation for tube feedings were all a mess. She stated none of the records the facility had reviewed, with the exception of new resident admitted on [DATE] (Resident #6), were documented correctly. The DON also confirmed the documentation for tube feeding intakes which included formula and flushes had not been recorded as directed by orders and care plan. An interview with the Administrator on 10/17/14 at 12 noon, after the survey exit, revealed it was the responsibility of the MDS nurse/ care plan coordinator to make sure careplans were in place. It was also the unit manager's, DON's, and ADON's job to keep the care plan updated as needed. Review of the six sampled residents' Minimum Data Set (MDS) Care Area Assessments (CAAs) revealed all six triggered for dehydration and the facility developed care plans addressing their risk of dehydration. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 10/3/14 for the Immediate Jeopardy and Substandard Quality of Care (SQC). Review of the facility's AoC revealed the facility took the following actions to remove the immediacy: On 9/19/14 Resident #4 was admitted to the hospital with [REDACTED].#4 had decreased level of consciousness and decreased blood pressure. Resident #4 did not return to the facility after discharge from the hospital. 1. Beginning on 10/1/14 and ending 10/3/14, twenty out of twenty residents' identified to be at risk for dehydration were audited including a review of labs, physician orders, medication administration records, and visual assessment of signs and symptoms of dehydration. Based on review there were no abnormal findings. 2. The twenty care plans for residents at risk of dehydration were updated beginning 10/1/14 and ending 10/3/14 3. On 10/1/14, to identify other residents that have the potential to be affected, a 100% chart audit of all enteral fed residents' was performed by the Director of Clinical Services/Director of Nursing (DCS/DON), Assistant Director of Clinical Services (ADCS), Regional Director of Clinical Services (RDCS), Social Worker, and Minimum Data Set (MDS) Coordinator. Physician orders, labs, and medication administration records were reviewed. There were nine residents noted without 24 hour total intake documentation. Medication Administration Records (MAR) were immediately updated on these residents to include a breakdown of intake for each 8 hour shift. 4. On 10/1/14, the enteral fed residents were visually assessed with [REDACTED]. 5. On 10/3/14, a complete metabolic profile and a renal function panel were ordered for all enteral fed residents. 6. On 10/1/14 and 10/2/14, the DCS/DON and ADCS educated all full time and prn RNs and LPNs on the new process of the updated Medication Administration Record [REDACTED] a. Initiating Enteral Feeding N-425, which covered initiating feeding as ordered by the physician, assessing resident's tolerance to the feeding based upon absence of unusual diarrhea, abdominal cramping, gastric retention of feeding, and glycosuria, flushing the tube per physician order, totaling flushes and enteral formula, and documenting in the medical record. b. Intake and Output N-1510, which covered maintaining a record of intake and output in keeping with physician orders [REDACTED]. c. Dehydration Prevention for Environmental or Medical Causes N-1169 which included signs and symptoms of dehydration such as poor skin turgor, flushed dry skin, coated tongue, decreased urine output, irritability, confusion, temperature subnormal or elevated, rapid pulse, or rapid respiration. d. 100% of Certified Nursing Assistants were educated on Dehydration Prevention for Environmental or Medical Causes N-1169. 7. An emergency Quality Assurance (QA) meeting was conducted to review and implement this allegation of compliance on 10/2/14 at 8:30 AM CST and included the Medical Director, Executive Director (ED), DCS/DON, RDCS, and ADCS. The topics discussed were accidents and incidents, dehydration, change in MARs, and review of Resident #4's medical record. No employee will be authorized to work until education is completed. There are no contracted nurses employed at this facility. The facility alleged the Immediate Jeopardy was removed on 10/4/14. On 10/4/14, the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy: The acceptable credible Allegation of Compliance was verified by staff interviews and record review of in-services on 10/4/14 across multiple disciplines beginning at 6:45 AM through 1:30 PM. A review of the facility's audit verified twenty (20) residents had been identified to be at risk for dehydration with no adverse findings. A review of seventeen (17) resident records verified care plans had been updated for risk of dehydration. A review of the 17 resident records verified new Medication Administration Records were initiated to include intake for each 8 hour shift. The surveyor visualized eight of eight tube fed residents in the facility with no visual s/s dehydration noted. Record Review for all residents who required Enteral feeding revealed lab had been drawn for Complete Metabolic Profiles and Renal Function Panels. The State Agency verified by interviews, including LPNs, RNs and CNAs, the content of in-services held on 10/1/14 through 10/2/14. Five (5) Registered Nurses and eight (8) Licensed Practical Nurses verified being in-serviced on policies related to Enteral Feeding of residents which included Intake and Output, and preventing and monitoring for signs and symptoms of dehydration. Eighteen (18) Certified Nursing Assistants verified being in-serviced on Dehydration Prevention. A review of the Emergency Quality Assurance meeting sign in sheets verified the Medical Director, the Executive Director, the Director of Nursing, Assistant Director of Nursing and the Regional Director of Clinical Services attended the meeting.

2 Based on observation, physician orders, dietary assessment, facility policy review, staff interview, and review of professional standards of nursing practice, the facility failed to provide care according to professional standards of following physician orders [REDACTED].#4 being admitted to the hospital on two occasions with a [DIAGNOSES REDACTED].#2, #4, #7, #8 and #9) Resident #4 was admitted to the local hospital with severe dehydration on 8/26/14. The resident was admitted a second time on 9/19/14 again with severe dehydration. The facility failed to assure a dependent resident who required hydration/feeding by a feeding tube received the recommended fluid to meet his needs and to prevent dehydration. The facility's failure to record and monitor intake received, and document accurate intake resulted a situation that led to Resident #4's severe dehydration with the likelihood to cause serious injury, harm, impairment, or death to the others residents with tube feedings. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 8/26/14 with the resident's first hospitalization with a severe dehydration [DIAGNOSES REDACTED]. The facility's Administrator was notified of the Immediate Jeopardy and Substandard Quality of Care on 10/1/14. An acceptable credible Allegation of Compliance was received on 10/3/14 in which the facility alleged the Immediate Jeopardy was removed on 10/4/14. Findings Include: A review of the facility's policy entitled Hydration Policy, revised 4/30/14, stated, All residents will receive sufficient fluid intake to maintain proper hydration and health. Fluids will be provided daily to all residents with meals, between meals, and at bedtime, with the exception of those who are NPO (nothing by mouth) or on a purposeful restriction of fluid status unless calculated in their fluid allowance. Review of the facility's policy entitled Intake and Output, revised 8/31/2011, revealed Clinical Services personnel will maintain a record of intake and output in keeping with the physician orders [REDACTED]. The policy further stated, 3. Each shift the licensed nurse will record the intake and the output. 4. Total the intake at the end of each shift and record on the intake and output record. 5. Total the intake for the twenty-four hour period. A review of Nursing Skills and Procedures, Eighth Edition, by Perry and Potter, on page 166, under the heading Enteral Nutrition via a Gastrostomy or Jejunostomy Tube, the document read, 13 Have registered dietician recommend total free water requirement per day and obtain health care provider's order. Under the heading Recording and Reporting, the document read, Record volume of formula and any additional water on intake and output form. Resident #4 A review of the Dietary Assessment by the Registered Dietician, dated 6/25/14, read Resident #4 had a PEG (Percutaneous Endoscopic Gastrostomy) (feeding) tube and the resident's fluid needs were calculated as 2,130 cubic centimeters (cc) a day. A review of Resident #4's record revealed Physician Orders, dated 6/30/14, 7/23/14 and 8/28/14, which read, Total fluid volume intake Q 24 (every 24) hours at 12 AM of Enteral feeding and flushes. A review of the Dietary Assessment by the Registered Dietician, dated 6/25/14, stated, Resident #4's fluid needs were calculated as 2,130 cubic centimeters (cc) a day. A review of the Medication Administration Record (MAR) for the months of July 2014, August 2014, and September 2014 failed to have consistent and accurate fluid amounts documented. The highest amount recorded on the MAR per day was 1,300 cc. Other blocks of the MAR were illegible, left blank, or had initials where the amounts should have been recorded. The 11-7 shift was responsible for totaling the daily intake. Interview with Certified Nurses Assistant (CNA) #1 on 6:55 AM revealed the CNA worked the 11- 7 shift. CNA #1 verified Resident #4's pump would alarm at times during her shift. She stated she would get the nurse if the alarm was sounding. Interview with Licensed Practical Nurse (LPN) #1, on 10/4/14 at 7:10 AM, revealed Resident #4's feeding pump would alarm during her shift because it would clog and need flushing. The facility admitted Resident #4 to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4 has a gastrostomy tube, and is dependent on staff for all feeding and flushes. The facility transferred Resident #4 to the hospital on [DATE]; therefore no observation was available. Resident #2 A review of admission orders [REDACTED]. The admission orders [REDACTED]. Review of a physician's orders [REDACTED].@ 60 cc/hr X 22 hr ([MEDICATION NAME] 1.5 at 60 cubic centimeters an hour times 22 hours); Flush with 60 cc H20 (water) when turning pump on/off; Flush Peg with 150 cc H20 every 6 (six) hours. A review of Resident #2's MAR for September 2014 (admission on 9/22/14) failed to provide any documentation of any formula totals or flushes the resident received since admission to the facility. A review of Resident #2's Admission MDS (Minimum Data Set) with an Assessment Reference Date of 9/29/14 revealed the resident was totally dependent on staff for nutrition. The facility admitted Resident #2 to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #7 A review of Physician order [REDACTED]. H20 AC/PC meds (sixty cubic centimeters of water before and after medications); Total fluid volume intake Q 24 hrs (every twenty-four hours) at 12 AM of Enteral feedings and flushes. A review of the Medication Administration Records (MARs) for August and September 2014 failed to provide documentation of Resident #7's intake. A review of the Registered Dietician's Dietary Enteral Review had Resident #7's fluid needs calculated as requiring 2091-2509 ml (milliliters) every day. Review of the August and September 2014 MARs had recordings of 960 for seven days for the month of August, and for one day for the month of September. All other days were illegible or left bank. A review of the current MDS (Minimum Data Set) with an Assessment Reference Date of 9/26/14 revealed Resident #7 required total care for eating and all nutrition was through a gastrostomy tube. Resident #7 was admitted by the facility on 10/13/11 with [DIAGNOSES REDACTED]. Resident #8 A review of Physician order [REDACTED]. H20 A/P meds (medications); Total fluid volume intake Q 24 hrs (every twenty-four hours) at 12 AM of Enteral feedings and flushes. A review of Medication Administration Records (MARs) for September 2014 revealed daily recordings of 960 cc intake for each day of the month. A review of the Registered Dietician's Dietary Enteral Review revealed Resident #8's fluid needs had been calculated as 1811 cc a day. The formula and flushes would have provided 1861 cc each day. The facility failed to provide documentation that ensured Resident # 8 received feedings and flushes as calculated to meet her dietary needs. The facility admitted Resident #8 on 9/26/08 with [DIAGNOSES REDACTED]. A review of the current MDS with an Assessment Reference Date of 9/15/14 for Resident # 8 revealed the resident required total care for eating, and a gastrostomy tube administered all feedings. Resident # 9 A review of the Physicians Orders dated October 2014 revealed Resident #9 had tube feeding orders which had been initiated on 8/20/14 which stated, [MEDICATION NAME] 1.5. Cal Liquid Give 80 ML/HR X 16 HRS (eighty milliliters an hour times 16 hours); Flush Peg Tube with 30 cc H20 A/P meds (30 cubic centimeters of water before and after medications); Flush Peg Tube with 30 cc H20 (30 cubic centimeters of water) when turning pump on and off; Total fluid volume intake Q 24 hrs (every 24 hours) at 12 AM of enteral feedings and flushes. A review of Medication Administration Records (MARs) for September 2014 revealed daily recordings of from 960 to 1460 cc. There were also blocks that were left blank and others were illegible. A review of Resident #9's Registered Dietician's Dietary Enteral Review revealed the resident's fluid needs had been calculated to be between 1765 and 2006 cc of fluid each day. The ordered feedings and flushed would have provide 2413 cc a day. The facility failed to provide documentation that ensured Resident # 9 received feedings and flushes as calculated to meet him nutritional and fluid needs. Review of Resident #9's record revealed the facility had admitted him on 8/20/14 with [DIAGNOSES REDACTED]. A review of the current MDS with an ARD of 8/29/14 reveal Resident #9 was totally dependent for eating and received all nutrition by way of a gastrostomy tube. An interview with the Director of Nursing (DON) and the Assistant Director of Nursing, on 10/3/14 at 11:00 AM, confirmed the documentation for tube feeding intakes did not meet each resident's needs. The DON confirmed none of the records, (with the exception of a new admit (Resident #6)), that the facility had reviewed had complete documentation. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 10/3/14 for the Immediate Jeopardy and Substandard Quality of Care (SQC). Review of the facility's AoC revealed the facility took the following actions to remove the immediacy: On 9/19/14 Resident #4 was admitted to the hospital with [REDACTED].#4 had decreased level of consciousness and decreased blood pressure. Resident #4 did not return to the facility after discharge from the hospital. 1. Beginning on 10/1/14 and ending 10/3/14, twenty out of twenty residents' identified to be at risk for dehydration were audited including a review of labs, physician orders, medication administration records, and visual assessment of signs and symptoms of dehydration. Based on review there were no abnormal findings. 2. The twenty care plans for residents at risk of dehydration were updated beginning 10/1/14 and ending 10/3/14 3. On 10/1/14, to identify other residents that have the potential to be affected, a 100% chart audit of all enteral fed residents' was performed by the Director of Clinical Services/Director of Nursing (DCS/DON), Assistant Director of Clinical Services (ADCS), Regional Director of Clinical Services (RDCS), Social Worker, and Minimum Data Set (MDS) Coordinator. Physician orders, labs, and medication administration records were reviewed. There were nine residents noted without 24 hour total intake documentation. Medication Administration Records (MAR) were immediately updated on these residents to include a breakdown of intake for each 8 hour shift. 4. On 10/1/14, the enteral fed residents were visually assessed with [REDACTED]. 5. On 10/3/14, a complete metabolic profile and a renal function panel were ordered for all enteral fed residents. 6. On 10/1/14 and 10/2/14, the DCS/DON and ADCS educated all full time and prn RNs and LPNs on the new process of the updated Medication Administration Record and educated on the following policies: a. Initiating Enteral Feeding N-425, which covered initiating feeding as ordered by the physician, assessing resident's tolerance to the feeding based upon absence of unusual diarrhea, abdominal cramping, gastric retention of feeding, and glycosuria, flushing the tube per physician order, totaling flushes and enteral formula, and documenting in the medical record. b. Intake and Output N-1510, which covered maintaining a record of intake and output in keeping with physician orders [REDACTED]. c. Dehydration Prevention for Environmental or Medical Causes N-1169 which included signs and symptoms of dehydration such as poor skin turgor, flushed dry skin, coated tongue, decreased urine output, irritability, confusion, temperature subnormal or elevated, rapid pulse, or rapid respiration. d. 100% of Certified Nursing Assistants were educated on Dehydration Prevention for Environmental or Medical Causes N-1169. 7. An emergency Quality Assurance (QA) meeting was conducted to review and implement this allegation of compliance on 10/2/14 at 8:30 AM CST and included the Medical Director, Executive Director (ED), DCS/DON, RDCS, and ADCS. The topics discussed were accidents and incidents, dehydration, change in MARs, and review of Resident #4's medical record. No employee will be authorized to work until education is completed. There are no contracted nurses employed at this facility. The facility alleged the Immediate Jeopardy was removed on 10/4/14.

2 Based on record review, policy review and staff interview, the facility failed to monitor intake as ordered to prevent a resident from becoming dehydrated for one (1) of six (6) residents reviewed for risk of Dehydration on two separate occasions. (Resident #4) The facility transferred Resident #4 to the hospital on [DATE] with an admitting [DIAGNOSES REDACTED].#4 had a second admission to the hospital on [DATE] with an admission [DIAGNOSES REDACTED].#4 had a gastrostomy tube with continuous feedings and intermittent flushes as recommended by the Registered Dietician. The facility's failure to ensure an accurate, physician ordered, accounting of Resident #4's Enteral intake resulted in Resident #4 becoming dehydrated and was likely to cause serious injury, harm, impairment or death to other residents. This situation was determined to be an Immediate Jeopardy (IJ) which began on 8/26/14. The facility ' s administrator was notified of the Immediate Jeopardy and Substandard Quality of Care (SQC) on 10/1/14. An acceptable Allegation of Compliance was received on 10/3/14 in which State Agency determined the Immediate Jeopardy was removed on 10/4/14. Findings Include: A review of the facility's policy entitled Hydration Policy, revised 4/30/14, stated, All residents will receive sufficient fluid intake to maintain proper hydration and health. Fluids will be provided daily to all residents with meals, between meals, and at bedtime, with the exception of those who are NPO (nothing by mouth) or on a purposeful restriction of fluid status unless calculated in their fluid allowance. Review of the facility's policy entitled Intake and Output revised 8/31/2011 revealed Clinical Services personnel will maintain a record of intake and output in keeping with the physician orders [REDACTED]. The policy further stated, 3. Each shift the licensed nurse will record the intake and the output. 4. Total the intake at the end of each shift and record on the intake and output record. 5. Total the intake for the twenty-four hour period. A review of the History and Physical (H&P) from the local hospital revealed Resident #4 was admitted [DATE]. The H&P documented, The patient was found to be severely dehydrated with a blood pressure of 88/72. A review of the hospital obtained laboratory results dated [DATE] revealed the resident had a sodium of 151 and a calculated osmolarity of 324.9 which indicated severe dehydration. On 8/28/14, a Discharge Summary from the local hospital revealed the resident had been rehydrated and was to return to the facility. Upon discharge, laboratory results showed the resident's sodium was 146 with the dehydration resolved. A review of the facility's Physician order [REDACTED]. Flush PEG with 180 cc H20 (water) Q 4 hrs (every four hours). Flush PEG with 60 cc H20 with meds. Flush tube with 100 cc H20 when turning pump off at 11 AM. Total fluid volume intake Q 24 hrs at 12 AM of Enteral feeding and flushes. A review of the Registered Dietician's Dietary Assessment, dated 6/25/14, read that Resident #4's fluid needs were calculated to be 2,130 cubic centimeters (cc) a day. A review of the July 2014, August 2014 and September 2014 Medication Administration Record (MAR) for Resident #4 revealed the highest amount recorded on the MAR was 1,300 cc. Blocks on the MAR were illegible, left blank, or had initials where the amounts should have been recorded. On 9/19/14, Resident #4 was again admitted to the local hospital. The admission H&P documented, He was severely dehydrated and hypotensive with a blood pressure in the 70's systolic, 74/54. A review of Resident #4's hospital admission laboratory results dated [DATE] revealed sodium was 161 and osmolarity was 371.5, again indicating severe dehydration. On 10/2/14 at 10:45 AM, during an interview with the Director of Nursing (DON), she stated that Resident #4 pinched his tube off at times, but she didn't think it affected what he received through the tube. The DON stated whenever a resident had a dietary problem, there were forms to notify the RD but any problems were usually discussed in the morning meeting and brought to Dietary Department's attention. There was no documentation provided which addressed Resident #4's hydration status during the morning meetings. An interview with the facility's Registered Dietician (RD), on 10/1/14 at 11:30 AM, revealed she had been following Resident #4 on each of her visits to the facility. She stated her calculations should have met Resident #4's needs for calories and fluid. The RD stated she had no knowledge of any problems the resident had with the feeding pump or pinching the tube off. She stated the facility had never reported it to her. If aware, she could have tried other alternatives such as bolus feedings. She stated she had increased the water amounts several times due to the resident's abnormal sodium levels. On 10/2/14 at 11:00 AM, an interview with Resident #4's attending physician revealed he had been aware of Resident #4's high sodium levels. He stated he had discontinued the resident's diuretic, thinking it was keeping him too dry. The physician stated he did get notified of abnormal laboratory values everyday and did remember seeing sodium levels of 150 for Resident #4. He stated his Nurse Practitioner was also very good to notify him of any changes. On 10/3/14 at 11:00 AM, interviews with the DON and the Assistant Director of Nurses confirmed the documentation for tube feeding intakes was inaccurately documented and the amount of fluid intake documented by the facility did not meet the resident's needs. The DON stated she had initiated new MARs to accurately reflect the resident's intake starting in the month of October 2014. The facility admitted Resident #4 to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4 had a gastrostomy tube, and was dependent on staff for all feeding and flushes. The facility transferred Resident #4 to the hospital on [DATE]. Resident #4 was discharged from the hospital on [DATE] with discharge [DIAGNOSES REDACTED]. Resident #4 did not return to the facility upon discharge from the hospital, but was instead discharged to another long term care facility. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 10/3/14 for the Immediate Jeopardy and Substandard Quality of Care (SQC). Review of the facility's AoC revealed the facility took the following actions to remove the immediacy: On 9/19/14 Resident #4 was admitted to the hospital with [REDACTED].#4 had decreased level of consciousness and decreased blood pressure. Resident #4 did not return to the facility after discharge from the hospital. 1. Beginning on 10/1/14 and ending 10/3/14, twenty out of twenty residents' identified to be at risk for dehydration were audited including a review of labs, physician orders, medication administration records, and visual assessment of signs and symptoms of dehydration. Based on review there were no abnormal findings. 2. The twenty care plans for residents at risk of dehydration were updated beginning 10/1/14 and ending 10/3/14 3. On 10/1/14, to identify other residents that have the potential to be affected, a 100% chart audit of all enteral fed residents' was performed by the Director of Clinical Services/Director of Nursing (DCS/DON), Assistant Director of Clinical Services (ADCS), Regional Director of Clinical Services (RDCS), Social Worker, and Minimum Data Set (MDS) Coordinator. Physician orders, labs, and medication administration records were reviewed. There were nine residents noted without 24 hour total intake documentation. Medication Administration Records (MAR) were immediately updated on these residents to include a breakdown of intake for each 8 hour shift. 4. On 10/1/14, the enteral fed residents were visually assessed with [REDACTED]. 5. On 10/3/14, a complete metabolic profile and a renal function panel were ordered for all enteral fed residents. 6. On 10/1/14 and 10/2/14, the DCS/DON and ADCS educated all full time and prn RNs and LPNs on the new process of the updated Medication Administration Record and educated on the following policies: a. Initiating Enteral Feeding N-425, which covered initiating feeding as ordered by the physician, assessing resident's tolerance to the feeding based upon absence of unusual diarrhea, abdominal cramping, gastric retention of feeding, and glycosuria, flushing the tube per physician order, totaling flushes and enteral formula, and documenting in the medical record. b. Intake and Output N-1510, which covered maintaining a record of intake and output in keeping with physician orders [REDACTED]. c. Dehydration Prevention for Environmental or Medical Causes N-1169 which included signs and symptoms of dehydration such as poor skin turgor, flushed dry skin, coated tongue, decreased urine output, irritability, confusion, temperature subnormal or elevated, rapid pulse, or rapid respiration. d. 100% of Certified Nursing Assistants were educated on Dehydration Prevention for Environmental or Medical Causes N-1169. 7. An emergency Quality Assurance (QA) meeting was conducted to review and implement this allegation of compliance on 10/2/14 at 8:30 AM CST and included the Medical Director, Executive Director (ED), DCS/DON, RDCS, and ADCS. The topics discussed were accidents and incidents, dehydration, change in MARs, and review of Resident #4's medical record. No employee will be authorized to work until education is completed. There are no contracted nurses employed at this facility. The facility alleged the Immediate Jeopardy was removed on 10/4/14. On 10/4/14, the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy: The acceptable credible Allegation of Compliance was verified by staff interviews and record review of in-services on 10/4/14 across multiple disciplines beginning at 6:45 AM through 1:30 PM. A review of the facility's audit verified twenty (20) residents had been identified to be at risk for dehydration with no adverse findings. A review of seventeen (17) resident records verified care plans had been updated for risk of dehydration. A review of the 17 resident records verified new Medication Administration Records were initiated to include intake for each 8 hour shift. The surveyor visualized eight of eight tube fed residents in the facility with no visual s/s dehydration noted. Record Review for all residents who required Enteral feeding revealed orders had been drawn for Complete Metabolic Profiles and Renal Function Panels. The State Agency verified by interviews, including LPNs, RNs and CNAs, the content of in-services held on 10/1/14 through 10/2/14. Five (5) Registered Nurses and eight (8) Licensed Practical Nurses verified being in-serviced on policies related to Enteral Feeding of residents which included Intake and Output, and preventing and monitoring for signs and symptoms of dehydration. Eighteen (18) Certified Nursing Assistants verified being in-serviced on Dehydration Prevention. A review of the Emergency Quality Assurance meeting sign in sheets verified the Medical Director, the Executive Director, the Director of Nursing, Assistant Director of Nursing and the Regional Director of Clinical Services attended the meeting.

2 Based on record review, policy review, observation, staff, and resident interview, the facility failed to remove a resident from a motorized scooter during a van transport which caused an avoidable fracture for one (1) of ten (10) residents reviewed. (Resident # 5) Resident #5 had the scooter for approximately one year and had gone on multiple outings in the facility van. Resident #5 was the only resident at the facility with a motorized scooter. On 9/26/14 at 5:00 PM, Resident #5 was loaded onto the van by facility staff while sitting on her motorized scooted, and was subsequently transported while remaining seated on the scooter. The facility staff failed to follow the manufactures warning and use the intended safety devices to ensure safe transport. Resident #5 was on an outing on the facility van. When the driver made a left turn, the scooter turned over and Resident #5 suffered a fall in the van which resulted in a fracture to Resident #5's left clavicle (collar bone) during the transport in the facility lift van. The facility's failure to follow their policy for identifying risks and the failure to heed the manufacturer's recommendations for the use of the motorized scooter caused Resident #5 to suffer a fractured left clavicle and caused a situation could likely cause serious injury, harm, impairment or death to other residents. This situation was determined to be an Immediate Jeopardy (IJ) which began on 9/26/14. The facility's administrator was notified of the Immediate Jeopardy and Substandard Quality of Care (SQC) on 10/1/14. An acceptable Allegation of Compliance was received on 10/3/14 in which the facility alleged the Immediate Jeopardy was removed on 10/4/14. Findings Include: A review of the facility's policy entitled Fall Risk, revised 3/3/14, stated, To identify risk factors which place the resident at risk for falls and to facilitate the developments of interventions to minimize or prevent falls to the extent possible. A review of the User's Manual for the motorized scooter stated, Warning! Never sit on your (Travel Scooter) when it is being used in connection with any type of lift/elevation product. Your (Travel Scooter) was not designed with such use in mind). (Manufacturer's Name) recommends that you do not remain seated in your (Travel Scooter) while traveling in a motor vehicle. The (travel scooter) should be stowed in the trunk of a car or in the back of a truck or van with the batteries removed and properly stored. Warning! Although your (travel scooter) may be equipped with a positioning belt, this belt is not designed to provide restraint during motor vehicle transport. Anyone traveling in a motor vehicle should be properly secured in the motor vehicle seat with safety belts fastened securely. A review of the facility's investigation report of the fall/injury that occurred on 9/26/14 at 5:00 PM revealed; The van driver took Resident #5 on an outing to a local department store. During the transporting of the resident back to the facility, the driver was making a left hand turn at an intersection when the scooter tipped over causing the resident to fall while still sitting on the motorized scooter. The driver was unable to get the resident up from the floor of the van and the local emergency medical service (EMS) was called. EMS arrived on site and assessed Resident #5 for injuries. The resident declined going to the emergency room for treatment. The EMS personnel helped the driver place the resident back on the scooter and the van returned to the facility. The facility's investigation showed the van driver had neglected to properly secure the scooter for transport which resulted in the scooter turning over and causing injury to Resident #5. When Resident #5 returned to the facility, she asked to be taken to the hospital. Resident #5 was diagnosed with [REDACTED]. A review of the witness statement, written by the Van Driver #1, revealed when she made the left hand turn, the scooter turned over with Resident #5 still sitting on it. The driver stated she call the facility and asked them to call the EMS to help get the resident up. She stated when EMS arrived they asked Resident #5 if she wanted to go to the hospital and the resident said no. The driver stated at that time the resident did complain of pain in her left shoulder. The driver stated she had hooked the right lock down and the front lock down. She stated she did not use the big seat belt and could not remember if she hooked the left lock down. She stated in the statement, I can't remember if I put the left lock on. During an observation and interview, on 10/1/14 at 4:15 PM, Resident #5 was observed sitting up in a manual wheelchair in her room. Her left arm was noted in an immobilizer. Resident #5 stated she got hurt when she and the van driver had made a trip to (local department store). The resident stated on the return trip, the van was stopped at a red light. She stated the light turned green and the driver was making a left turn when she felt the scooter tipping over to the right. Resident #5 stated she fell over on her right side, striking her head, her right shoulder and her right knee. She stated the scooter was partially on her left shoulder and the scooter's seat belt was still attached around her waist. Resident #5 stated she had been transported in the scooter for as long as she had the scooter in the facility which was approximately a year. Resident #5 stated the van driver had used only one strap to secure the front of the scooter. She stated the driver did not apply the van's abdominal belt or shoulder strap to her during the transport. On 10/2/14 at 11:00 AM, an interview with Van Driver #1 revealed she had been driving the van for a long time. She stated when she first started driving the van, she was in-serviced. She stated she had been instructed to never transport a resident in a geri-chair because the safety straps would not secure the geri-chair. She stated at no time was she in-serviced not to transport on a scooter. Van Driver #1 stated she always used a four point system to secure the scooter but during the transport of Resident #5 on 9/26/14, she got distracted and evidently failed to secure the back of the scooter. She stated she had never used the abdominal belt or the shoulder strap during transport of the scooter because they did not fit. On 10/2/14 at 10:10 AM, an interview with Van Driver #2 revealed she had often transported Resident #5 in the lift van. She stated she had always transported the resident while sitting on the scooter. The alternate van driver stated she had been in-serviced on loading and unloading a resident in a wheelchair but had never been instructed not to transport a resident in a scooter. Record review of the Physician order [REDACTED].#5 on 10/10/11 with [DIAGNOSES REDACTED]. A review of the most current Minimum Data Set revealed Resident #5 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident had no cognitive deficits. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 10/3/14 for the Immediate Jeopardy and Substandard Quality of Care (SQC). Review of the facility's AoC revealed the facility took the following actions to remove the immediacy: On 9/26/2014, Resident #5 was being transported on our facility van. At the time of the transport, Resident #5's motorized scooter tipped over, resulting in a fractured clavicle. Resident #5 was transported to the emergency department for evaluation and care. 1. The Van Driver was suspended on 9/27/2014 pending termination. 2. On 9/29/2014, the Executive Director educated the Back-up Van Driver, Maintenance Director, and Maintenance Assistant on the proper use of the van lift and tie downs and seat belts and manufacturers ' recommendations. Included in the educational material was a statement that only standard wheelchairs are to be transported in the van. No power chairs or scooters will be transported in the facility van. 3. On 9/29/2014 at approximately 11:00 AM the Back-up Van Driver, Maintenance Director, and Maintenance Assistant educated the facility DCS/DON and other 7-3 nurses and Certified Nurses Assistants on the proper use of the lift as well as the tie down and seat belt systems on the facility van. 4. On 10/1/2014, the facility ED educated all department heads including the ADCS/ADON, Unit Managers, MDS Coordinator, Medical Records clerk, Maintenance Director, Maintenance Assistant, Activity Director, Business Office Manager, Human Resources Coordinator (HRC), Social Services Director, Central Supply Clerk, Admissions Director, Dietary Manager, and Housekeeping Supervisor on the proper use of the van lift and tie downs and seat belts and manufacturers ' recommendations. Included in the educational material was a statement that only standard wheelchairs are to be transported in the van. The proper use of the van lift and tie downs and seat belts and manufacturers ' recommendations was included. No power chairs or scooters will be transported in the facility van. 5. On 10/1/2014, the facility ED, backup Van Driver, and Maintenance staff continued education with RNs, LPNs, and CNAs to include a return demonstration on the proper use of the van lift and tie downs and seat belts and manufacturers ' recommendations, a statement that only standard wheelchairs are to be transported in the van. No power chairs or scooters will be transported in the facility van. 6. On 10/2/2014, the backup Van Driver continued education with LPNs and CNAs. The facility ADCS continued education with LPNs on the proper use of the van lift and tie downs and seat belts and manufacturers ' recommendations. Included in the educational material was a statement that only standard wheelchairs are to be transported in the van. No power chairs or scooters will be transported in the facility van. 7. 82 employees have worked at the facility in the past 30 days. Of those employees, 82 have been educated on the use of the van lift and the safety measures to secure wheelchairs for transport in the van. 8. All newly hired employees will receive training on the proper use of the lift and safety systems on the van. 9. An emergency Quality Assurance (QA) meeting was conducted to review and implement this allegation of compliance on 10/2/14 at 8:30 AM CST and included the Medical Director, Executive Director (ED), DCS/DON, RDCS, and ADCS. The topics discussed were accidents and incidents, dehydration, change in MARs, and review of Resident #4 ' s medical record. The ED will report to the Quality Assurance Committee to insure compliance that all new hires are educated before being authorized to work. 10. A 100% audit of facility residents reveal only one resident utilizes a motorized wheelchair or scooter. No employee will be authorized to work until education is completed. The facility alleges the Immediate Jeopardy was removed on 10/4/2014. Interview with the Administrator and review of disciplinary action form verified the van driver was suspended on 9/27/14. Review of in-service sign in sheet verified the back-up van driver, the Maintenance Director and the Maintenance Assistant had been in-serviced related to safe transport of residents. Review of sign-in sheets verified the DON and 7-3 nurses and CNAs had been in-serviced on proper use of the lift van and the tie down and seat belt systems of the van. Review of sign in sheets revealed all department heads were in-serviced on use of the lift van. Interview with 31 employees verified they had been in-serviced related to safe transport of residents, adhering to manufacturer's recommendations, and safety to secure residents for transport in the van. A review of the Emergency Quality Assurance meeting sign in sheets verified the Medical Director, the Executive Director, the Director of Nursing, Assistant Director of Nursing and the Regional Director of Clinical Services attended the meeting.

2 Based on care plan review, facility policy review, and staff interview, the facility failed to identify, address, or develop a plan of care for van transportation for one (1) of one (1) residents in the facility with a motorized scooter. (Resident #5) Resident #5 sustained an injury related to the use of a motorized scooter while being transported in the facility van. On 9/26/14 at 5:00 PM, Resident #5 was on an outing on the facility van. When the van made a left hand turn, the motorized scooter upon which she was sitting turned over in the van resulting in a fracture to Resident #5's left clavicle (collar bone). The facility's failure to address and implement safe interventions for transporting a resident in a motorized scooter caused a situation that was likely to cause serious injury, harm, impairment or death to other residents. This situation was determined to be an Immediate Jeopardy (IJ) which began on 9/26/14. The facility's administrator was notified of the Immediate Jeopardy and Substandard Quality of Care (SQC) on 10/1/14. An acceptable Allegation of Compliance was received on 10/3/14 in which the facility alleged the Immediate Jeopardy was removed on 10/4/14. Findings Include: The facility's policy entitled, Care Plan, revised 2/27/14, documented an interdisciplinary plan of care will be established for every resident to ensure the residents' needs are met. Resident #5 A review of Resident #5's current plan of care revealed the resident had not been care planned for the use of a motorized scooter until 9/29/14 which was three days after the resident was injured riding on the scooter during transport in the facility's van. On 10/2/14 at 4:30 PM, an interview with the Director of Nursing (DON) confirmed the motorized scooter was not care planned for use during transports in the facility van. On 10/2/14 at 11:00 AM, an interview with Van Driver #1 revealed she had been driving the van for a long time. She stated when she first started driving the van, she was instructed to never transport a resident in a geri-chair, but at no time, was she told not to transport on a scooter. On 10/2/14 at 10:10 AM, an interview with Van Driver #2 revealed she had always transported the resident while sitting on the scooter. Van Driver #2 stated she had not been told to not transport a resident on a scooter. A review of the accident report for Resident #5 revealed the resident had sustained a fractured left clavicle (collar bone) during a transport on 9/26/14 in the facility van. Record review for Resident #5 revealed the facility admitted the resident on 10/10/11 with [DIAGNOSES REDACTED]. A review of the most current Minimum Data Set revealed Resident #5 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident had no cognitive deficits. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 10/3/14 for the Immediate Jeopardy and Substandard Quality of Care (SQC). Review of the facility's AoC revealed the facility took the following actions to remove the immediacy: On 9/26/2014, Resident #5 was being transported on our facility van. At the time of the transport, Resident #5's motorized scooter tipped over, resulting in a fractured clavicle. Resident #5 was transported to the emergency department for evaluation and care. 1. The Van Driver was suspended on 9/27/2014 pending termination. 2. On 9/29/2014, the Executive Director educated the Back-up Van Driver, Maintenance Director, and Maintenance Assistant on the proper use of the van lift and tie downs and seat belts and manufacturers ' recommendations. Included in the educational material was a statement that only standard wheelchairs are to be transported in the van. No power chairs or scooters will be transported in the facility van. 3. On 9/29/2014 at approximately 11:00 AM the Back-up Van Driver, Maintenance Director, and Maintenance Assistant educated the facility DCS/DON and other 7-3 nurses and Certified Nurses Assistants on the proper use of the lift as well as the tie down and seat belt systems on the facility van. 4. On 10/1/2014, the facility ED educated all department heads including the ADCS/ADON, Unit Managers, MDS Coordinator, Medical Records clerk, Maintenance Director, Maintenance Assistant, Activity Director, Business Office Manager, Human Resources Coordinator (HRC), Social Services Director, Central Supply Clerk, Admissions Director, Dietary Manager, and Housekeeping Supervisor on the proper use of the van lift and tie downs and seat belts and manufacturers ' recommendations. Included in the educational material was a statement that only standard wheelchairs are to be transported in the van. The proper use of the van lift and tie downs and seat belts and manufacturers ' recommendations was included. No power chairs or scooters will be transported in the facility van. 5. On 10/1/2014, the facility ED, backup Van Driver, and Maintenance staff continued education with RNs, LPNs, and CNAs to include a return demonstration on the proper use of the van lift and tie downs and seat belts and manufacturers ' recommendations, a statement that only standard wheelchairs are to be transported in the van. No power chairs or scooters will be transported in the facility van. 6. On 10/2/2014, the backup Van Driver continued education with LPNs and CNAs. The facility ADCS continued education with LPNs on the proper use of the van lift and tie downs and seat belts and manufacturers ' recommendations. Included in the educational material was a statement that only standard wheelchairs are to be transported in the van. No power chairs or scooters will be transported in the facility van. 7. 82 employees have worked at the facility in the past 30 days. Of those employees, 82 have been educated on the use of the van lift and the safety measures to secure wheelchairs for transport in the van. 8. All newly hired employees will receive training on the proper use of the lift and safety systems on the van. 9. An emergency Quality Assurance (QA) meeting was conducted to review and implement this allegation of compliance on 10/2/14 at 8:30 AM CST and included the Medical Director, Executive Director (ED), DCS/DON, RDCS, and ADCS. The topics discussed were accidents and incidents, dehydration, change in MARs, and review of Resident #4 ' s medical record. The ED will report to the Quality Assurance Committee to insure compliance that all new hires are educated before being authorized to work. 10. A 100% audit of facility residents reveal only one resident utilizes a motorized wheelchair or scooter. No employee will be authorized to work until education is completed. The facility alleges the Immediate Jeopardy was removed on 10/4/2014. Interview with the Administrator and review of disciplinary action form verified the van driver was suspended on 9/27/14. Review of in-service sign in sheet verified the back-up van driver, the Maintenance Director and the Maintenance Assistant had been in-serviced related to safe transport of residents. Review of sign-in sheets verified the DON and 7-3 nurses and CNAs had been in-serviced on proper use of the lift van and the tie down and seat belt systems of the van. Review of sign in sheets revealed all department heads were in-serviced on use of the lift van. Interview with 31 employees verified they had been in-serviced related to safe transport of residents, adhering to manufacturer's recommendations, and safety to secure residents for transport in the van. A review of the Emergency Quality Assurance meeting sign in sheets verified the Medical Director, the Executive Director, the Director of Nursing, Assistant Director of Nursing and the Regional Director of Clinical Services attended the meeting.

Based on record review and staff interview, the facility failed to prevent falls for one (1) of four (4) residents reviewed for falls. Resident #1 suffered five falls, two which resulted in serious injury. Findings: A review of the facility's Investigation Worksheet dated 4/10/14 revealed the worksheet to be incomplete. There was no documented assessment or intervention noted in the record. The Nurse Note dated 4/10/14 at 7:45 AM, revealed Resident #1 was found on the floor beside his bed. The Responsible Party (RP) and the Medical Doctor were notified. There were no noted injuries. The resident was reminded to call for help. There were no new interventions noted on the care plan. There was an intervention initiated on 4/7/14 which indicated Resident #1 was to have a bed alarm. There was no documented evidence the bed alarm was in use on 4/10/14. A review of the "Fall Investigation" revealed Resident #1 suffered a fall on 4/29/14 which resulted in a laceration to the left posterior skull. The fall committee's recommendation after the 4/29/14 fall, was to add a bed alarm and a wheelchair alarm. The investigation revealed a bed alarm was not in use prior to the fall, however, Resident #1 was care planned for a bed alarm on 4/7/14. A review of a Nurse Note dated 5/23/14 revealed Resident #1 had slid from the bed onto the floor. No injury was recorded in the note. There was no documented evidence that the fall was reported, or investigated. There was no fall assessment or new interventions noted on the care plan. A review of the facility's "Fall Investigation" revealed on 6/3/14 Resident #1 had an unwitnessed fall in his room at approximately 6:00 AM. The resident sustained [REDACTED]. On 6/10/14 at 9:50 AM, an interview with Resident #1's Responsible Party/Family Member (RP/FM) revealed when she arrived at the facility on 6/3/14 around 8:00 AM, the resident told her he had fallen that morning and was hurting. The RP/FM stated when her husband was transferred to a local hospital, she notified the facility that he would not be returning to the facility. On 6/10/14 at 3:00 PM, an interview with the RN Supervisor (RNS) revealed when she was notified of the fall she went to assess Resident #1. The RNS stated the resident's left leg was noticeably abducted. The facility admitted Resident #1 on 3/25/14 with [DIAGNOSES REDACTED]. A review of the most recent Minimum Data Set ((MDS) dated [DATE], indicated Resident #1 was severely impaired for decision making. The resident required the assistance of two staff members for transfers and had a history of [REDACTED].

Based on record review, interview, observation, and facility policy review, the facility failed to ensure that one (1) of five (5) residents reviewed did not sustain an avoidable injury. Complaint Investigation MS # Resident #6 Findings include: Record review revealed that Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/29/12 revealed that Resident #6 had a Brief Interview for Mental Status (BIMS) score of "07" indicating that the cognitive status was moderately impaired. Observation of Resident #6 on 4/25/12 at 10:30 a.m. revealed the Resident was in her room and correctly identified the Certified Nursing Assistant by name. Record review of the Facility Incident Report for Resident #6, dated 01/24/12, revealed: "Incident involving a resident falling out of lift." The incident was described as the "resident was not placed correctly in the lift pad, causing her to become off balance in the lift." Record review of a hand written statement by Certified Nursing Assistant (CNA) #1, dated 01/24/12, revealed that Resident #6 was in the process of being transferred from the shower bed to the wheelchair when Resident #6 "...moved her legs up a little bit, and the sling tilted over and she fell head over out the sling. She was fully dress and off the shower bed. When I went to transfer her over to the chair that is when she fell ." Record review of a hand written statement by Certified Nursing Assistant (CNA) #2, dated 01/24/12, revealed: "Turned my back for a min (minute) to care for a resident not being far from the patient (Resident #6) on the lift." Record review of the investigation involving Resident #6, by the Director of Nursing (DON) on 01/24/12, revealed "I found that the resident was placed under the lift pad incorrectly." Record review of emergency room (ER) records dated 01/24/12 revealed that Resident #6 was brought in to ER per Emergency Medical Services from the facility after falling from the lift approximately three feet. The following injuries were noted: hematoma to right side head that required six (6) staples and two (2) skin tears (right forearm and right lower leg). Record review of Resident #6's Care Plan "Requires Mechanical Lift for Transfers", dated 12/08/11, revealed Resident #6 required two person assist with lift transfers. An interview with CNA #1, on 04/25/12 at 10:45 a.m., revealed that CNA #1 was transferring Resident #6 from the shower bed to the wheelchair. CNA #1 revealed she had the top of the sling to the back of Resident #6's neck. CNA #1 revealed that she had been in-serviced on the use of the lifts after the incident, but "I didn't remember I guess that it (sling) went above the head." CNA #1 confirmed that she was in-serviced on using two (2) people when transferring a resident by a lift. When asked if CNA #2 was in the shower room, CNA #1 responded "Yes, but she (CNA #2) was with another resident." CNA #1 stated "I had her (Resident #6) lifted up et (and) when I went to move the lift it jerked on the floor et it happened so fast, then she (Resident #6) fell head first to floor..." Interview with CNA #2 at this time confirmed that she was a few feet away with another Resident. An interview with the DON, on 04/25/12 at 9:05 a.m., revealed that CNA's were immediately in-serviced on using hoyer lift along with every employee in the building who uses hoyer lifts daily. DON also revealed that two people are required to lift residents with the lift, one person to operate the lift and the other person is to guide resident in the sling holding it. Record review of Facility Policy, on the "Method of Connecting the UNI-FIT Sling to the Vander-Lift II" dated March 2007, stated "the sling should be long enough to fit from the patient's coccyx to the top of, or a few inches above, the patient's head...." Record review of the Facility In-service, on Correct Usage and Care of Vera and Vander Lifts", dated 09/30/11, revealed that CNA #1 and CNA #2, both attended the in-service. Record review of CNA #1 and CNA #2's "Certified Nursing Assistant Check Off For Mechanical Lifts: Total Lift", dated 1/24/12, revealed that CNA #1 and CNA #2 adequately performed the check off. Record review of the Facility's In-service Training for correct lift procedure, vander lift, safety of resident, two person assist and correct pad size revealed that that the in-services were held on 1/24/12, 1/26/12, 1/28/12, and 1/29/12. Record review of the Facility's In-service Training for Abuse and Neglect/Safety of Resident was given to CNA #1 and CNA #2 on 1/30/12. Record review of Inservice Training provided by the facility revealed that on 2/3/12 an in-service on Abuse and Neglect/Lift Skills Check Off for CNA was given to facility staff and CNA #1 and CNA #2 also participated in training. Record review of the Facility's Work Order form dated 1/24/12 revealed that the facility placed a work order on the lift to have it checked and serviced, and the lift was found to be in proper working order.

Based on record review, interview, observation, and facility policy review, the facility failed to ensure that one (1) of five (5) residents reviewed did not sustain an avoidable injury. Complaint Investigation MS # Resident #6 Findings include: Record review revealed that Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/29/12 revealed that Resident #6 had a Brief Interview for Mental Status (BIMS) score of "07" indicating that the cognitive status was moderately impaired. Observation of Resident #6 on 4/25/12 at 10:30 a.m. revealed the Resident was in her room and correctly identified the Certified Nursing Assistant by name. Record review of the Facility Incident Report for Resident #6, dated 01/24/12, revealed: "Incident involving a resident falling out of lift." The incident was described as the "resident was not placed correctly in the lift pad, causing her to become off balance in the lift." Record review of a hand written statement by Certified Nursing Assistant (CNA) #1, dated 01/24/12, revealed that Resident #6 was in the process of being transferred from the shower bed to the wheelchair when Resident #6 "...moved her legs up a little bit, and the sling tilted over and she fell head over out the sling. She was fully dress and off the shower bed. When I went to transfer her over to the chair that is when she fell ." Record review of a hand written statement by Certified Nursing Assistant (CNA) #2, dated 01/24/12, revealed: "Turned my back for a min (minute) to care for a resident not being far from the patient (Resident #6) on the lift." Record review of the investigation involving Resident #6, by the Director of Nursing (DON) on 01/24/12, revealed "I found that the resident was placed under the lift pad incorrectly." Record review of emergency room (ER) records dated 01/24/12 revealed that Resident #6 was brought in to ER per Emergency Medical Services from the facility after falling from the lift approximately three feet. The following injuries were noted: hematoma to right side head that required six (6) staples and two (2) skin tears (right forearm and right lower leg). Record review of Resident #6's Care Plan "Requires Mechanical Lift for Transfers", dated 12/08/11, revealed Resident #6 required two person assist with lift transfers. An interview with CNA #1, on 04/25/12 at 10:45 a.m., revealed that CNA #1 was transferring Resident #6 from the shower bed to the wheelchair. CNA #1 revealed she had the top of the sling to the back of Resident #6's neck. CNA #1 revealed that she had been in-serviced on the use of the lifts after the incident, but "I didn't remember I guess that it (sling) went above the head." CNA #1 confirmed that she was in-serviced on using two (2) people when transferring a resident by a lift. When asked if CNA #2 was in the shower room, CNA #1 responded "Yes, but she (CNA #2) was with another resident." CNA #1 stated "I had her (Resident #6) lifted up et (and) when I went to move the lift it jerked on the floor et it happened so fast, then she (Resident #6) fell head first to floor..." Interview with CNA #2 at this time confirmed that she was a few feet away with another Resident. An interview with the DON, on 04/25/12 at 9:05 a.m., revealed that CNA's were immediately in-serviced on using hoyer lift along with every employee in the building who uses hoyer lifts daily. DON also revealed that two people are required to lift residents with the lift, one person to operate the lift and the other person is to guide resident in the sling holding it. Record review of Facility Policy, on the "Method of Connecting the UNI-FIT Sling to the Vander-Lift II" dated March 2007, stated "the sling should be long enough to fit from the patient's coccyx to the top of, or a few inches above, the patient's head...." Record review of the Facility In-service, on Correct Usage and Care of Vera and Vander Lifts", dated 09/30/11, revealed that CNA #1 and CNA #2, both attended the in-service. Record review of CNA #1 and CNA #2's "Certified Nursing Assistant Check Off For Mechanical Lifts: Total Lift", dated 1/24/12, revealed that CNA #1 and CNA #2 adequately performed the check off. Record review of the Facility's In-service Training for correct lift procedure, vander lift, safety of resident, two person assist and correct pad size revealed that that the in-services were held on 1/24/12, 1/26/12, 1/28/12, and 1/29/12. Record review of the Facility's In-service Training for Abuse and Neglect/Safety of Resident was given to CNA #1 and CNA #2 on 1/30/12. Record review of Inservice Training provided by the facility revealed that on 2/3/12 an in-service on Abuse and Neglect/Lift Skills Check Off for CNA was given to facility staff and CNA #1 and CNA #2 also participated in training. Record review of the Facility's Work Order form dated 1/24/12 revealed that the facility placed a work order on the lift to have it checked and serviced, and the lift was found to be in proper working order.