Every finding on record at The Preserve at Fairfield Glade

Based on facility policy review, Lippincott Nursing Center website review, medical record review, and interviews, the facility failed to ensure basic nursing standards for the rights of medication administration and physician's orders were followed for 1 resident (Resident #26) of 7 residents reviewed for medication administration. The findings include: Review of the facility's policy titled, Medication Administration Policy and Procedures, dated 6/2025, revealed Nurses prepare and administer medications, only with orders from a licensed prescriber and follow the community policies and procedures .Nurses follow the seven rights of medication administration including: Right resident, Right medication, Right dose, Right route, Right time, Right recording, and Right reason .All medication labels should be checked three (3) times with the eMAR [Electronic Medication Administration Record] prior to administration .Vital signs and blood sugar monitoring is done prior to giving medications as indicated per order .Check the insulin label to make sure it is the right kind of insulin .Select the correct dose of insulin per order . Review of the Lippincott Nursing Center Website resource of the Nursing Drug Handbook dated 2025- 2026, revealed .Medication Errors in Nursing .As a final step in the administration process .and the .defense against medication errors .nurses must follow the rights of medication administration .Right Patient .Right medication .Right dose .Right route .Right time .Right Documentation .Right reason .Right response . Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including Paroxysmal Atrial Fibrillation (A-Fib), Hypertension, Diabetes Mellitus, and Adrenocortical Insufficiency (occurs when the adrenal glands do not produce enough hormones, particularly cortisol). Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident had an active diagnosis of Diabetes and Hypertension. Continued review revealed the resident received insulin injections. Review of a comprehensive care plan dated 5/11/2026 for Resident #26, revealed .I have hypertension .will remain free of complication related to hypertension .Diabetes Mellitus with risk for complications .I will remain free of complications related to diabetes . Review of a Physician's Order Report for Resident #26 revealed .Insulin Glargine [an injectable medication used to gradually lower blood glucose levels] .100 UNIT/ML [milliliter] .Inject 80 unit subcutaneously one time a day .Order Date 05/11/2026 .NovoLOG [an injectable medication used to rapidly lower blood glucose levels] .100 UNIT/ML .Inject 6 unit subcutaneously before meals .Order Date 05/15/2026 .Verapamil [medication used to treat hypertension] .Give 240 mg [milligram] by mouth one time a day .Hold if DBP [Diastolic Blood Pressure] < [less than] 55 .or HR [Heart Rate] <60 .Order Date 05/04/2026 . Review of the Nurse's Notes for Resident #26 revealed .5/25/2026 19:21 .[7:21 PM] .This RN [Registered Nurse] A went into elder's [Resident #26's] room with evening medications took her [Resident #26] blood sugar 372, and gave her [Resident #26] insulin, after I [RN A] returned to the medication cart realized I [RN A] have given Novolog [short acting insulin] instead of Glargine [long acting insulin], Immediately called the facility Medical Director [MD] and reported .error, gave elder [Resident #26] a peanut butter and jelly sandwich and will monitor her blood sugar every couple of hours all night long, call placed to Director of Nursing [DON] . Review of a Skilled Nursing Note for Resident #26 revealed .05/26/2026 02:30 [2:30 AM], revealed .Medication error with short acting insulin this evening, however she [Resident #26] ate a peanut butter and jelly sandwich, and her [Resident #26] blood sugar has remained in the 300's all night long. Blood sugar every couple of hours to monitor throughout the night .Pt [Patient] [Resident #26] has experienced no signs .of hypoglycemia [low blood sugar] .Elder [Resident #26] has been alert and oriented and blood sugars have remained in the 300's range . Review of a Medication Administration Record (MAR) for Resident #26 dated 5/1/2026 - 5/31/2026, revealed .Verapamil .240 MG .Hold if DBP <55 or HR <60 . Further review revealed on 5/16/2026, Resident #26's DBP was 50, on 5/20/2026 the DBP was 51, and on 5/22/2026 the HR was 57. Continued review revealed the Verapamil was administered and not held per the physician's order. Review of a Weights and Vitals Summary Report for Resident #26 revealed on 5/16/2026 at 7:23 PM the resident's DBP was 72 (after Verapamil was administered) and on 5/20/2026 at 6:53 PM, the resident's DBP was 68 (after Verapamil was administered). Further review revealed on 5/22/2026 at 1:20 PM Resident #26's HR was 70 (after Verapamil was administered). Continued review revealed blood glucose levels were monitored every 2 hours starting on 5/25/2026 at 8:46 PM and the lowest blood glucose level reading was 274 which was obtained on 5/26/2026 at 7:29 AM (the morning after Resident #26 was administered the wrong insulin). During an interview on 6/3/2026 at 8:50 AM, Resident #26 stated she was administered the incorrect insulin on 5/25/2026. The resident also stated RN A informed her of the error and notified the Doctor immediately.she [RN A] gave me a peanut butter and jelly sandwich after she [RN A] talked to the Doctor .they [facility staff] kept me up all night checking me .she [RN A] knew what to do .it was no big deal .I have done the same thing at home before . Resident #26 also stated she had not had a hypoglycemic episode after the wrong dose of insulin had been administered, did not require hospitalization, and had no other ill effects. During an interview on 6/3/2026 at 9:13 AM, RN A stated she administered the wrong insulin to Resident #26 on 5/25/2026. The resident had a Physician's order to administer Insulin Glargine 80 units and RN A administered Novolog 80 units. RN A stated the resident had 3 insulin pens in the medication drawer .I picked up the wrong one [insulin pen] .as soon as I got back to the med [medication] cart I realized I had picked up the wrong pen . RN A immediately notified the MD and was given orders to check Resident #26's blood glucose levels every 2 hours throughout the night and give the resident a peanut butter and jelly sandwich. RN A worked night shift and monitored the glucose levels as ordered, the resident's blood glucose levels remained well above normal, the resident did not have any hypoglycemic episodes and did not require emergent treatment. RN A confirmed she administered the wrong medication to Resident #26 and failed to follow the rights for medication administration. During a telephone interview on 6/3/2026 at 2:15 PM, the MD stated he was notified immediately when Resident #26 was administered 80 units of a short acting insulin on 5/25/2026. The MD also stated he ordered the facility to obtain blood glucose levels every 2 hours throughout the night. Resident #26's blood glucose levels remained elevated, the resident did not have a hypoglycemic episode, and there was no ill effects or harm to the resident. During an interview on 6/3/2026 at 3:05 PM, the RN MDS Coordinator confirmed Resident #26 was administered Verapamil 240 MG on 5/16/2026, 5/20/2026, and 5/22/2026 and was not held per the physician's orders. During a telephone interview on 6/3/2026 at 3:15 PM, the MD stated he expected the facility to follow all his orders for Resident #26. During an interview on 6/3/2026 at 3:30 PM, the Administrator confirmed RN A failed to follow the 7 rights of medication administration for Resident #26.

Based on the Resident Assessment Instrument (RAI) Manual 3.0 review, medical record review, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 resident (Resident #7) of 13 residents reviewed. The findings include: Review of the RAI Manual 3.0 dated 10/1/2023, revealed .the assessment [MDS] accurately reflects the resident's status . Medical record review revealed Resident #7 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction, Muscle Weakness, Atherosclerotic Heart Disease, Chronic Obstructive Pulmonary Disease, Epilepsy, Diabetes Mellitus, Fracture of Lower End of Right Tibia, Fracture of Shaft of Right Tibia. Review of the Nurse's Notes for Resident #7 dated 6/18/2024 at 7:21 PM, revealed .Reason resident was hospitalized or received service at a hospital .CVA [Cardiovascular Accident] [Stroke], Right Hemiparesis, Seizure, Fall from standing .fall precautions . Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 scored 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. The section for history of falls indicated the resident had not had a fall anytime in the last month. Review of the comprehensive care plan dated 6/25/2024, revealed resident at risk for falls related to history of falls, Cardiovascular Accident. During an interview on 9/26/2024 at 12:45 PM, Registered Nurse (RN) A/MDS Coordinator confirmed .[Resident #7] had a fall at home prior to being admitted to the hospital on 6/12/2024, and the fall which had occurred in the last 30 days was not coded on the resident's admission MDS assessment dated [DATE] and further stated .it should have been I [MDS Coordinator RN A] failed to do so .

Based on facility policy review, record review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan to address end of life care for 6 residents (Residents #20, #9, #13, #16, #27, and #34) and hearing loss for 1 resident (Resident #34) of 17 residents reviewed. The findings include: Review of the facility's policy titled, Care Plan-R/S, LTC, Therapy & Rehab, dated 9/22/2022, showed .Each resident will receive and be provided the necessary care and services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment. Each resident will have an individualized, person-centered, comprehensive plan of care .will be modified to reflect the care currently required/provided for the resident .will emphasize the care .of the whole person . 41291 Resident #20 was admitted to the facility on [DATE] with diagnoses including Dementia, History of Falling, and General Anxiety Disorder. Review of a Physician Orders for Scope of Treatment (POST) form dated 7/29/2020 showed Resident #20 wished to be a Do Not Resuscitate (DNR). Review of physician's orders dated 7/24/2020 showed Resident #20 had an order for DNR. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] showed Resident #20 had moderate cognitive impairment. Review of a comprehensive care plan dated 4/29/2023 showed end of life wishes for Resident #20 had not been addressed. Resident #9 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease and Dysphagia. Review of a POST form dated 8/4/2022 showed Resident #9 wished to be a DNR. Review of physician's orders dated 8/4/2022 showed DNR, allow natural death. Review of the comprehensive care plan dated 5/1/2023 showed end of life wishes for Resident #9 had not been addressed. During an interview on 5/2/2023 at 4:06 PM, the MDS Coordinator confirmed there was no end of life plan of care on Resident #20 or #9's care plan. During an interview on 5/3/2023 at 8:45 AM, the Social Services Coordinator stated end of life care was an integral part of the resident's care and it should be included in the care plan. Resident #13 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Dementia, Atherosclerotic Heart Disease, Repeated Falls, Hemiplegia and Hemiparesis, Cognitive Communication Deficit, Unspecified Convulsions, and Muscle Weakness. Review of the POST form for Resident #13 dated 8/13/2021 showed a DNR. Review of a comprehensive care plan dated 4/27/2023 showed end of life wishes were not addressed for Resident #13. Resident #16 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Alzheimer's Disease, Dementia, Major Depressive Disorder, and Anxiety. Review of the Durable Power of Attorney (POA) for Health Care dated 8/21/2012, showed the daughter was granted POA to make health care decisions for Resident #16 and end of life was addressed. Review of the POST form dated 1/7/2022, showed Resident #16 wished to be a DNR, with limited additional interventions, and defined trial period of artificial nutrition by tube. Review of Resident #16's comprehensive care plan, last updated 4/27/2023, showed the resident's end of life wishes were not addressed on the care plan. Resident #27 was admitted to the facility on [DATE], with diagnoses including Dementia, Alzheimer's Disease, Delusional Disorders, and Chronic Kidney Disease. Review of the POST form dated 12/16/2022, showed Resident #27 wishes were to be a full code. Review of the comprehensive care plan revised 4/7/2023 showed end of life wishes had not been addressed for Resident #27. Resident #34 was admitted to the facility on [DATE], with diagnoses including Dementia, Heart Failure, Retention of Urine, Neuromuscular Dysfunction of Bladder, Urogenital Implants and Atrial Fibrillation. Review of the POST form dated 4/8/2022, showed Resident #34 wished to be a DNR. Review of the annual MDS assessment dated [DATE], showed Resident #34 did not have a hearing aid. Review of the comprehensive care plan revised 4/25/2023 showed Resident #34's hearing impairment, interventions to accommodate for the hearing loss, and end of life wishes had not been addressed. During an interview on 5/3/2023 at 9:16 AM, the Social Services Coordinator revealed .I know that she [Resident #34] has a hearing deficit . During an interview and record review on 5/3/2023 at 3:44 PM, the Licensed Practical Nurse (LPN) Admissions Nurse confirmed Resident #34's care plan had not addressed the hearing deficit, and it would be her expectation for the hearing loss to be addressed in the care plan. During an interview on 5/3/2023 at 8:05 AM, the DON confirmed the residents' care plans did not address end of life wishes or code status. 45837 46931

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure medical information was not visible for 1 resident (Resident #27) of 46 residents reviewed for dignity. The findings include: Review of the facility's policy titled, Resident Dignity - Rehab/Skilled, revised 10/26/2022, showed .The location will promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity .Maintaining an environment in which there are no signs posted in residents' rooms .able to be seen by other residents and/or visitors that include confidential clinical or personal information . Resident #27 was admitted to the facility on [DATE], with diagnoses including Unspecified Dementia, Alzheimer's Disease, Delusional Disorders, and Chronic Kidney Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #27 had a Brief Interview of Mental Status (BIMS) assessment score of 12, which indicated Resident #27 had moderate cognitive impairment. Review of Resident #27's physician order dated 12/16/2022, showed .BP [Blood pressure] only in right arm only .every shift . Continued review showed no orders for signage to be posted in the resident's room. Review of a comprehensive care plan initiated on 12/16/2022, showed the care plan had not addressed the posting of a sign in Resident #27's room. During an observation on 5/1/2023 at 10:05 AM and on 5/2/2023, at 9:28 AM in Resident #27's room, a sign was observed above Resident #27's bed that showed .No blood pressure cuffs or sticks on resident's left arm please . The sign was visible to other residents, staff, and visitors who entered the room. During a telephone interview on 5/2/2023 at 10:19 AM, Resident #27's daughter stated family members had not placed the sign on Resident #27's wall. During an observation and interview on 5/3/2023 at 9:43 AM, in Resident #27's room, the Nursing Manager confirmed the sign was posted and contained personal information and was visilble to anyone who entered the room. The Nursing Manager further stated .I didn't even know that she [Resident #27] had it in her room . Resident #27 stated, .I don't know why they [facility staff] put that [the sign] there .

Based on record review, observation, and interview, the facility failed to implement a wound care intervention for 1 resident (Resident #7) of 3 residents reviewed for wounds. The findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses including Dementia, Adult Failure to Thrive, Diabetes Mellitus, and Palliative Care. Review of a 5-day Minimum Data Set (MDS) assessment dated [DATE], showed Resident #7 had severe cognitive impairment and was at risk for pressure ulcers. Further review showed the resident had 0 pressure ulcers on admission. Review of the comprehensive care plan initiated 11/1/2022 showed .potential for pressure ulcer development .nutritional problem r/t [related to] FTT [Failure to Thrive], T2DM [Type 2 Diabetes Mellitus] .hospice care . Intervention added on 11/14/2022 included .provide pillows to float heels while in bed .bilateral heel boots while in bed . Review of an order summary report for Resident #7 dated 11/14/2022, showed .Cleanse left inner foot wound with saline or wound cleanser. Apply medi-honey [gel medication used for management of wounds], cover with foam dressing . Dressing changes were ordered to be performed daily. Review of a Pressure Ulcer Monthly Report dated 11/14/2022, showed Resident #7 had an unstageable left foot wound. Wound measurements were documented as L (length) 2.0 centimeters (cm) x W (width) 3.0 cm x D (depth) 0 cm. Review of the Treatment Administration Record dated 11/2022 -5/2023, showed Resident #7 received wound care as ordered. Review of the quarterly MDS assessment dated [DATE], showed Resident #7 had severe cognitive impairment and had 1 unstageable pressure ulcer. Review of a Pressure Ulcer Monthly Report dated 5/1/2023, showed Resident #7 had an unstageable left foot wound. Wound measurements were documented as L 2.0 cm x W 2.0 cm x D 0 cm. During multiple observations on 5/1/2023-5/2/2023 of Resident #7's room, there were no pillows to float heels and bilateral heel boots were not in place. During an interview on 5/2/2023 at 4:14 PM, the Wound Care Nurse confirmed the heel pillows and bilateral heel boots were not in place in the resident's room. During an interview on 5/3/2023 at 9:46 AM, the Director of Nursing (DON) stated it was her expectation interventions were to be implemented.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure a privacy cover was maintained for a urinary catheter drainage bag for 1 resident (Resident #34) of 5 residents reviewed for urinary catheters, and failed to provide assistance to maintain desired physical appearance for 1 resident (Resident #34) of 46 residents reviewed for dignity. The findings include: Review of the facility's policy titled, Resident Dignity - Rehab/Skilled, revised 10/26/2022, showed .The location will promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity .Grooming residents as they wish to be groomed .Refraining from practices demeaning to residents such as keeping urinary catheter bags uncovered . Resident #34 admitted to the facility on [DATE], with diagnoses including Dementia, Heart Failure, Retention of Urine, Neuromuscular Dysfunction of Bladder, Urogenital Implants, and Atrial Fibrillation. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] showed Resident #34 had at Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairement, and the resident had an indwelling urinary catheter. Review of Resident #34's physician order dated 1/15/2023 showed .Catheter [a device placed in the bladder to drain urine] 6 fr [french/size] catheter with 10cc [cubic centimeter] balloon to dependent drainage . Review of Resident #34's comprehensive care plan dated 3/16/2023 showed .The resident has indwelling .catheter R/T [related to] urinary retention .Catheter care .Qshift [every shift] . During an observation on 5/2/2023 at 9:25 AM, Resident #34 was laying on the bed in her room with an uncovered urinary catheter bag containing visible urine, attached to the resident's bed and visible from the hallway at the entrance to Resident #34's room. During an observation and interview in Resident #34's room on 5/2/2023 at 9:45 AM, Resident #34 was observed to have facial hair on her chin. Resident #34 was asked if she would like the staff to pluck the chin hairs for her and Resident #34 responded, .I would like that if they would . During an observation on 5/2/2023 at 2:40 PM, Resident #34 was observed in a wheelchair in a group activity with an uncovered urinary catheter bag attached to her wheelchair. The urinary catheter bag was visible from the front and sides of the wheelchair. During an observation and interview in Resident #34's room on 5/2/2023 at 4:04 PM, Certified Nurse Assistant (CNA) #2 confirmed Resident #34's urinary catheter bag was uncovered and visible. CNA #2 stated Resident #34 .does not have a bag [privacy bag] on her catheter . CNA #2 further confirmed Resident #34 had facial hair that was present and stated Resident #34 .has a little bit of stubble . During an observation and interview in Resident #34's room on 5/2/2023 at 4:08 PM, Registered Nurse (RN) #1 confirmed Resident #34's catheter bag was not covered. RN #1 stated the urinary catheter bag was not covered with a privacy bag and confirmed Resident #34 had facial hair on her chin.

Based on facility policy review, medical record review, and interviews, the facility failed to ensure an allegation of employee to resident abuse was reported immediately to the facility administration and to the State Agency (SA) within two hours, in accordance with Federal Law, for 1 resident (#147) of 25 residents reviewed for abuse. The findings include: Review of facility policy titled, Abuse And Neglect-Rehab/Skilled, Therapy & Rehab, revised 12/23/2020 showed .Alleged or suspected violations involving .abuse .will be reported immediately to the administrator .other officials in accordance with state law .In the absence of the administrator from the location, the following individuals have the administrative authority of the administrator for purposes of immediate reporting of alleged violations: the director of nursing services or the supervisor of social services . Resident #147 was admitted to the facility on [DATE] with diagnoses including Left Hip Fracture, Chronic Kidney Disease, Dementia, and Cerebral Infarction. Review of the Admission Minimum Data Set (MDS) dated [DATE] showed Resident #147 scored 15 on the Brief Interview for Mental Status, indicating the resident was cognitively intact. Review of a Care Plan note dated 4/18/2023, showed .up with extensive assist X [times] 2 with a stand aid .alert and oriented .Resident is able to verbalize his needs . Review of an Incident note dated 5/1/2023, showed Resident #147 reported yesterday (4/30/2023) around 10:00 AM, Certified Nursing Assistant (CNA) #3 came into his room and told him to .Get up . Resident #147 informed CNA #3 .I can't . The resident stated CNA #3 stated .Well figure it out .jerked his legs to the side and it hurt . During an interview on 5/2/2023 at 1:57 PM, Resident #147 stated he was able to recall the events that occurred on Sunday 4/30/2023. He stated he was lying in the bed on his back and CNA #3 came in told him he needed to get out of bed. He was unable to give the CNA's name, but stated she worked yesterday with CNA #4. He informed her that he couldn't get out of bed without assistance. CNA #3 told him he would have to do it on his own. He stated CNA #3 then grabbed his knees and twisted his legs and feet off the bed. Resident #147 stated he did not call out for help and did not tell CNA #3 to stop. He then stated CNA #4 came into the room and he reported what happened to him. Resident #147 stated no one came to speak with him about the events that happened on Sunday (4/30/2023), until he reported to the ladies (Social Services Coordinator and Nurse Manager) in his room yesterday (5/1/2023). He stated he did not have any injuries or bruising and felt safe. During an interview on 5/2/2023 at 2:11 PM, CNA #4 stated he overheard the incident that occurred on 4/30/2023 between 10:45 AM-11:30 AM, between CNA #3 and Resident #147. CNA #4 stated he was charting at the desk and heard Resident #147 call out to use the bathroom. He stated CNA #3 went into the room to answer the call light. CNA #4 stated while walking by Resident #147's bathroom he heard CNA #3 speaking loudly stating you need to do it yourself, if you want to go home. CNA #4 stated he entered the room to see if they needed assistance. CNA #4 stated Resident #147 was upset, and he informed CNA #3 he would take over care of the resident. CNA #4 then stated he reported the event to Registered Nurse (RN) #3. He stated he reported that CNA #3 was being rough and loud with Resident #147. CNA #4 stated Resident #147 appeared mad that CNA #3 was in his room and asked for her not to come back in his room; he was not tearful and did not act fearful of CNA #3. CNA #4 stated he did not witness any physical abuse, only CNA #3 speaking loudly with Resident #147. During an interview on 5/2/2023 at 2:25 PM, the Nurse Manager stated she and the Social Services Coordinator (SSC) were in Resident #147's room conducting a care conference with Resident #147 and his wife on 5/1/2023. Resident #147 then informed her and the SSC about the events that occurred on Sunday (4/30/2023). The Nurse Manager stated the care conference on 5/1/2023 was the first time she heard of the events that occurred on 4/30/2023. The Nurse Manager stated when RN #3 was asked if she reported the incident she stated, no. The Nurse Manager stated she immediately reported to the Director of Nursing (DON) (1 day after the occurance). During an interview on 5/2/2023 at 2:32 PM, the SSC stated she was made aware of the incident that occurred on Sunday 4/30/2023, while she and the Nurse Manager were having the care plan meeting with Resident #147 and his wife on 5/1/2023. The wife informed the SSC and the Nurse Manager that Resident #147 had reported CNA #3 was mean to him and hurt his hip while getting him out of bed. Resident #147 stated he reported the incident to CNA #4. The SSC stated she immediately reported the incident to the DON and the Administrator (1 day after the occurance). During an interview on 5/2/2023 at 2:41 PM, the DON stated she became aware of the incident that occurred on 4/30/2023 between 10:45 AM-11:30 AM on 5/1/2023 at 11:00 AM, when the SSC informed her that Resident #147 had made an allegation of abuse. The DON was told that CNA #4 had reported to a nurse that Resident #147 stated CNA #3 had been mean to him and hurt him. The DON stated Resident #147 was flustered and upset during the interview and it bothered him the way he was spoken harshly to and how quickly CNA #3 moved his body. He stated he did not want CNA #3 back in his room. The DON stated when she questioned RN #3 why the incident was never reported to administration, she stated she thought it was gossip among the CNAs and she thought the incident had already been handled, since CNA #3 was no longer caring for Resident #147. The DON confirmed the allegation of abuse had not been reported timely to Administration. During a telephone interview on 5/2/2023 at 3:17 PM, RN #3 stated she was informed by CNA #4 on Sunday 4/30/2023 that CNA #3 had been very direct and blunt with Resident #147. She stated CNA #4 did not report to her that Resident #147 was upset. She stated she thought it was gossip between the CNAs. She stated CNA #3 is very direct and blunt spoken, and some people take offense to her. RN #3 stated she did not report the incident; she did not feel it was abuse. She thought it was more of a disagreement between the resident and the CNA. She thought the situation had already been handled since she had been told CNA #3 would no longer be caring for Resident #147. RN #3 confirmed she had not reported the incident.

Based on the facility policy review, medical record review, and interviews, the facility failed to investigate an allegation of abuse timely for 1 resident (#147) of 25 residents reviewed for abuse. The findings include: Review of the facility's policy titled, Abuse And Neglect-Rehab/Skilled, therapy & Rehab, revised 12/23/2023, showed .If an employee received an allegation of abuse .the employee will then report the allegation to a supervisor .The .nurse will be notified immediately, assess the situation .complete an initial investigation . Resident #147 was admitted to the facility on [DATE] with diagnoses including Left Hip Fracture, Chronic Kidney Disease, Dementia, and Cerebral Infarction. Review of the Admission Minimum Data Set (MDS) dated [DATE] showed Resident #147 scored 15 on the Brief Interview for Mental Status, indicating the resident was cognitively intact. Review of a Care Plan note dated 4/18/2023, showed .up with extensive assist X 2 [times 2] with a stand aid .alert and oriented .Resident is able to verbalize his needs . Review of an Incident note dated 5/1/2023, showed Resident #147 reported yesterday (4/30/2023) around 10:00 AM, Certified Nursing Assistant (CNA) #3 came into his room and told him to .Get up . Resident #147 informed CNA #3 .I can't . The resident stated CNA #3 stated .Well figure it out .jerked his legs to the side and it hurt . Resident #147 stated CNA #4 came in afterwards and took care of him. Resident #147 stated CNA #3 worked yesterday (4/30/2023) and was working today (5/1/2023). CNA #3 was asked to leave the floor and placed on administrative leave until investigation concluded. During an interview on 5/2/2023 at 1:57 PM, Resident #147 stated he was able to recall the events that occurred on Sunday 4/30/2023. He stated he was lying in the bed on his back and CNA #3 came in and told him he needed to get out of bed. He was unable to give CNA #3's name, but stated she worked yesterday with CNA #4. He informed her that he couldn't get out of bed without assistance. CNA #3 told him he would have to do it on his own. He stated CNA #3 then grabbed his knees and twisted his legs and feet off the bed. Resident #147 stated he did not call out for help and did not tell CNA #3 to stop. He then stated CNA #4 came into the room and he reported what happened to him. Resident #147 stated no one came to speak with him about the events that happened on Sunday (4/30/2023) until he reported the incident to the Social Services Coordinator (SSC) and Nurse Manager (NM) in his room yesterday (5/1/2023). Resident #147 stated it made him angry the way he was talked to and handled roughly. He stated he did not have any injuries or bruising and felt safe. Resident #147 stated CNA #3 had not been back in his room since Sunday (4/30/2023). During an interview on 5/2/2023 at 2:11 PM, CNA #4 stated he overheard the incident that occurred on 4/30/2023 between 10:45 AM-11:30 AM, between CNA #3 and Resident #147. CNA #4 stated he reported the event to Registered Nurse (RN) #3. He stated he reported that CNA #3 was being rough and loud with Resident #147. CNA #4 stated CNA #3 did not provide care to Resident #147 the rest of the shift on Sunday. CNA #4 stated he did not witness any physical abuse, only CNA #3 speaking loudly with Resident #147. During an interview on 5/2/2023 at 2:25 PM, the NM stated she and the SSC were in Resident #147's room conducting a care conference with Resident #147 and his wife on 5/1/2023. Resident #147 then informed her and the SSC about the events that occurred on Sunday (4/30/2023). During an interview on 5/2/2023 at 2:32 PM, the SSC stated she was made aware of the incident that occurred on Sunday 4/30/2023, while she and the NM were having the care plan meeting with Resident #147 and his wife on 5/1/2023. The wife informed the SSC and the NM that Resident #147 had reported CNA #4 was mean to him and hurt his hip while getting him out of bed. The SSC stated she immediately reported the incident to the Director of Nursing (DON) and the Administrator. She then came back to Resident #147's room to start the investigation. The SSC stated the Administrator, the DON, and she were the Abuse Coordinators for the facility; it was a shared responsibility, and we work together as a team. The SSC stated it was her responsibility to interview the resident. When she interviewed Resident #147, he was not tearful. She stated Resident #147 denied being fearful of any staff members or of CNA #3. During an interview on 5/2/2023 at 2:41 PM, the DON stated she became aware of the incident that occurred on 4/30/2023 between 10:45 AM- 11:00 AM on 5/1/2023, when the SSC informed her that Resident #147 had made an allegation of abuse. An investigation was started on 5/1/2023 at 11:00 AM, once she and the Administrator were made aware of the allegation of abuse. The DON stated CNA #3 did not care for Resident #147 the rest of the shift. The DON stated it was her expectation that any reports of abuse be reported immediately to the next person in charge or administration. An initial investigation should be started with formal investigation to begin the following day. She confirmed the investigation of the abuse was not started until administration was made aware of the allegation on 5/1/2023 (one day after the incident occurred). During a telephone interview on 5/2/2023 at 3:17, PM, RN #3 confirmed she had not initiated an investigation after she was informed of the allegation of abuse of Resident #147.

Based on record review, observation, and interview, the facility failed to implement interventions to prevent accidents for 1 resident (Resident #20) of 3 residents reviewed for accidents. The findings include: Resident #20 was admitted to the facility on [DATE] with diagnoses including Dementia, History of Falling, and General Anxiety Disorder. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] showed Resident #20 had moderate cognitive impairment and required extensive assistance of 2 staff with bed mobility, transfers, dressing, and toilet use. Resident #20 had a history of 1 fall since the last assessment. Review of Resident #20's care plan dated 2/17/2023 showed the resident was at risk for falls with interventions of a pad alarm to bed and tab alarm to chair to be used to alert staff and prevent accidents. During observation on 5/1/2023 at 12:16 PM, Resident #20 was observed in a common room for lunch, seated in a wheelchair with no alarms. During an observation and interview on 5/2/2023 at 8:00 AM, in Resident #20's room, Certified Nursing Assistant (CNA) #1 confirmed there was not a pad alarm on the bed. During an observation and interview on 5/2/2023 at 1:25 PM, in the dining room, Licensed Practical Nurse (LPN) #1 confirmed there was no tab alarm on Resident #20's wheelchair. During an observation and interview on 5/2/2023 at 1:30 PM, CNA #1 stated there was not a pad alarm in the resident's bed. CNA #1 stated she made the bed every day she cared for the resident and she hadn't seen an alarm pad in a while. During an interview on 5/2/2023 at 2:28 PM, the DON confirmed that staff had not implemented the interventions to prevent accidents for Resident #20.

Based on facility policy review, observation, and interview, the facility failed to ensure medications were secured in 1 of 4 medication carts and in 1 of 4 treatment carts observed. The findings include: Review of the facility's policy titled, .Medications: Acquisition Receiving Dispensing and Storage, dated 3/2/2023, showed, .Medications will be stored in a locked medication cart, drawer, or cupboard . During an observation on 5/2/2023 at 7:48 AM, Registered Nurse (RN) #1 had left the medication cart unattended, with stock medications stored on top of the medication cart, while going to administer medications. During an observation and interview on 5/2/2023 at 8:10 AM, RN #1 had left the medication cart unattended, with medications stored on top of the medication cart, while going to administer medications. RN #1 stated she stored stock medications on top of the cart to prevent wear and tear on the medication cart drawers and to save time. RN #1 stated she felt like the stock medications on top of the cart was secure because she was at the medication cart most of the time. RN #1 stated she had not realized stock medications could not be stored on top of the medication cart. During an interview on 5/2/2023 at 8:12 AM, the Director of Nursing (DON) observed with surveyor medications were stored on top of the medication cart. The DON confirmed RN #1 had not followed the facility's policy on medication storage. The DON confirmed medications stored on top of the medication cart were not secured. During an observation and interview on 5/2/2023 at 9:50 AM, a treatment cart located in the common area on the Nandina Pod Hall was not locked or secured. During an interview on 5/2/2023 at 10:01 AM, the Wound Care Nurse stated she had completed treatments at 9:00 AM, however she had not used the treatment cart located on the Nandina Pod hall. The Wound Care Nurse stated the treatment cart located in the common area on the Nandina Pod hall had prescription medication creams and wound care supplies inside. The Wound Care Nurse confirmed the treatment cart was unlocked and the contents were not secured.

Based on review of a facility policy, medical record review, facility investigation review, observation and interview, the facility failed to prevent abuse of 2 residents (#5, #6) of 7 residents reviewed for abuse. The findings included: Review of a facility policy Abuse and Neglect Rehab/Skilled, Therapy & Rehab last reviewed 3/31/2022 showed .the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .residents must not be subject to abuse by anyone, including, but not limited to, location employees, other residents, consultants or volunteers, employees of other agencies serving the resident, family members or legal guardians, friends or other individuals . Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Chronic Kidney Disease, Delusional Disorders, Alzheimer's Disease, and Protein-Calorie Malnutrition. Review of Resident #5's comprehensive care plan dated 12/16/2022 showed .resident has behavioral symptom R/T [related to] dementia E/B [evidenced by] refusing showers, brushing teeth, not wanting to be alone .intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, remove from situation and take to alternate location, prefers .diversional activities watching game shows, [NAME] Show, folding towels, sorting books magazines .introduce to other residents make sure she can be within eye vision distance of nursing staff . Review of Resident #5's 5-day Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. The resident required supervision with 1-person assist for toilet use, personal hygiene, supervision with set up for bed mobility, transfer, walking, locomotion, dressing, eating, and was always continent of both bowel and bladder. No behaviors were noted during the assessment period. Review of a facility investigation dated 1/18/2023 at 5:15 PM, showed Resident #6 was seated at his normal position at the dinner table when Resident #5 got up from her spot at the dinner table and went and sat in front of the television in the dining room and began to change the channel. Resident #6 wheeled his wheelchair over beside Resident #5 and they began to argue over the television channels. Nursing staff reported they heard yelling back and forth. A CNA responded to where both residents were sitting and asked Resident #5 for her remote and about the time the CNA obtained the remote, Resident #6 took the remote he had in his right hand and hit Resident #5 in the right upper arm. The residents were separated and Resident #5 was taken to her room by the staff and Resident #6 took himself back to his room. Medical record review of Resident #5's comprehensive care plan revised on 1/18/2023 showed .SS [Social Services] to provide visits 3 X [times] a week X one month due to recent altercation . Medical record review of Resident #5's comprehensive care plan revised on 1/23/2023 showed .resident has delusional disorder or an acute confusional episode R/T Dementia EB anxiety, confusion, paranoia, forgetfulness, and increased aggression .resident enjoys chores (washing dishes, folding laundry according to family). A basket of clean laundry is in the TV room and there are plastic dishes for her to wash, attempt this as redirection activity if she becomes agitated .Monitor mood and behavior . Medical record review of Resident #5's Progress Note dated 1/28/2023 at 5:09 PM, showed .resident heard raising her voice in common area at another resident by this nurse exclaiming loudly, 'I was watching that, turn it back!' resident was found to be in front of [Resident #6] who had changed the TV channel with his personal remote. [Resident #5] was asked to step away from [Resident #6] and talk about the situation. [Resident #5] kept exclaiming, 'No turn it back he just came up and changed it, that's ignorant.' [Resident #6] did not respond to this instance and backed away and closed his eyes. Channel was changed back to previous channel that [Resident #5] was watching and situation defused. [Resident #6] took himself back to his room to eat dinner meal. [Resident #5] was asked to ask for assistance next time a situation similar arose and stated, 'no he shouldn't do that and he's ignorant.' Residents now separated but calm . Medical record review of Resident #5's Progress Note dated 2/6/2023 showed .resident found extremely agitated at other residents at meals today. Found yelling to one male resident and one female resident at dinner. Redirection attempt failed . Medical record review of Resident #5's Social Service Progress Note dated 2/8/2023 showed .resident experiencing increased aggression in the evening hours. Through the day, resident appears calm and cooperative, but in the evening, she becomes aggressive toward other residents. She's had three events of yelling at other residents and nursing intervened to keep everyone safe . Medical record review of Resident #5's Progress Note dated 2/8/2023 at 3:24 PM showed .resident stated she was bored to activities staff. Staff gave resident options of different activities available; cards, painting, crafts, puzzles, folding laundry. Resident declined all . Medical record review of Resident #5's Progress Note dated 2/8/2023 at 3:47 PM showed .Resident asked nurse 'what time are you going home? I need a ride home.' Nurse explained that resident lives here, resident begins yelling 'I don't live here. I don't want to have to walk all the way home.' Nursing attempted to reorient resident. Resident continues roaming around unit asking staff for a 'ride home' . Medical record review of Resident #5's Progress Note dated 2/8/2023 at 6:00 PM .following conversation with MD about recommendations for medication changes, daughter .verbally consents for nursing to administer one time dose of Ativan and scheduled HS [hour of sleep] Zoloft per MD . Medical record review of Resident #5's Progress Note dated 2/8/2023 at 6:40 PM .Resident tells staff that she will call 911 if no one will take her home. Resident found in 2 other resident rooms asking resident and family members if they will give her a ride to her apartment .Resident followed MD and nurse manager into another patient rooms and demanded someone take her away from this place. Redirection and diversion attempts, unsuccessful throughout the evening .wander guard in place . Review of a facility investigation dated 2/13/2023 showed the Social Service Director (SSD) entered the dining room and observed Resident #5 and Resident #6 arguing and fist swinging. [Resident #6] had a remote control in his right hand and [Resident #5] had a remote control laying on the table. The SSD stopped the interaction and directed the residents to separate areas. The SSD interviewed Resident #5 and the resident stated she was watching TV and Resident #6 came up and changed the channel. Then she had changed it back and the argument followed. Resident #5 stated, 'he can't be hitting me' .The dining room TV was unplugged but each resident had access to TV in his/her room. The Director of Nursing Services (DNS) and Administrator reviewed the video surveillance tape and observed both residents making contact with each other. Medical record review of Resident #5's comprehensive care plan revised on 2/13/2023 showed .remove triggers that cause behaviors such as TV in dining room. Resident may watch TV in her personal room . Medical record review of Resident #5's Incident Progress Note dated 2/13/2023 at 12:20 PM, showed .Late Entry .Per camera and social service director description. Resident [Resident #5] watching TV in common area when male resident [Resident #6] attempted to change the channel. Resident then changed the TV channel back. Both residents with increased agitation. Male resident [Resident #6] attempted to remove the remote from this resident's [Resident #5] hand and this resident [Resident #5] hit male resident [Resident #6] in his left upper arm. Male resident [Resident #6] then hit resident [Resident #5] in her right upper arm . Observation of Resident #5 on 3/29/2023 at 1:30 PM, in the common area of her hallway, showed the resident seated in a chair. She was awake and alert, dressed in street clothes and covered with a blanket. A staff member asked her if she would like to go outside for a while and she responded, no I am cold. No anxious, or aggressive behaviors were observed. Resident #6 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, Aphasia, Apraxia, Epilepsy, Dysphagia, and Adjustment Disorder with Anxiety. Medical record review of Resident #6's comprehensive care plan dated 8/6/2018 showed .Resident has a communication problem R/T slight hearing loss and CVA [cerebrovascular accident] E/B expressive aphasia .monitor/document physical/non-verbal indicators of discomfort or distress .resident prefers to communicate face to face so he can hear everything you say .Ensure available and functioning of adaptive communication equipment . Review of Resident #6's quarterly MDS dated [DATE] showed a staff assessment was completed for mental status showing mild cognitive impairment. The resident required extensive assistance with 1-person assist for bed mobility, transfer, toilet use, dressing, personal hygiene, supervision with set-up for locomotion on and off unit and eating. Resident #6 was frequently incontinent of bladder, and occasionally incontinent of bowel. Review of Resident #6's Progress Note dated 1/18/2023 at 7:46 AM showed .Late Entry .nursing heard two residents yelling at each other in the dining room. CNA observed the 2 residents fighting over the current TV channel. Each resident had a remote and was attempting to change the channel. CNA removed the remote from the female resident's [Resident #5] hand and at that time this resident [Resident #6] took his remote in his hands and hit female resident [Resident #5] in the right arm with the remote. Male resident [#6] denied hitting the female. Female resident [#5] said 'I'm okay, he hit my arm, and now it is all over with.' Immediately both residents were moved away from each other. [Resident #6] went back to his room as well as [Resident #5]. Both residents assessed for injury. No injury noted . Medical record review of Resident #6's comprehensive care plan revised on 1/18/2023 showed .the resident has a mood and behavior symptom R/T adjustment disorder with anxiety E/B anxiety/agitation/increased depression, resident to resident altercation .Social Services to visit with resident 3X a week X 1 month, educate resident/family on successful coping and interaction strategies, if reasonable discuss resident's behavior. Explain/reinforce to resident why behavior is inappropriate and/or unacceptable, consult with MD for medication review and check BMP [basic metabloic panel] and Urinalysis, Agitation: Positive interaction, remove from source . Medical record review of Resident #6's comprehensive care plan revised on 1/23/2023 showed .resident has mild impaired cognitive function or impaired thought processes R/T mild cognitive impairment E/B aphasia, increased agitation, anxiety, confusion .Monitor/document/report to health care provider any changes in cognitive function .reduce any distractions-turn off TV, radio, close door etc .attempt non-pharmacological interventions of reorientation, reassurance, redirection, assist with ADL's [activities of daily living], pain control, sleep hygiene, reduce risk, if puppy is a at [facility] provide puppy visit . Medical record review of Resident #6's comprehensive care plan revised on 1/26/2023 showed .minimize potential of resident behavior problems by modifying environmental factors and daily routine . Medical record review of Resident #6's Incident Progress Note dated 2/13/2023 showed .Late Entry .Per camera and social service director description. Resident watching TV at his normal table in dining room. Female resident [Resident #5] already using the common room TV, resident attempted to change the channel to a program he preferred. [Resident #5] changed TV back to her channel. Agitation increased. [Resident #6] attempted to remove remote from female resident. She hit him in the left upper arm, and he returned the hit to her right upper arm. Residents separated from each other. [Resident #6] returned to his room . Medical record review of Resident #6's comprehensive care plan revised on 2/13/2023 showed .remove triggers that cause behaviors such as TV in the dining room. Resident may watch TV in his personal room . Observation of Resident #6 on 3/27/2023 at 1:45 PM, in his room, showed the resident seated in a wheelchair, he was awake, alert and well-groomed. The resident was pleasant, no agitation, aggression, or negative behaviors were observed. During an interview with Licensed Practical Nurse (LPN) #2 on 3/28/2023 a 8:05 AM, she stated .I was here for the 2nd incident .[Resident #6] would bring his remote out of his room with him and it worked with the TV in the dining room. I came out of a room and heard yelling in the dining room, and SSD had just gotten in the dining room she was separating the residents, she [Resident #5] was yelling 'he hit me he hit me' . During an interview with the Social Service Director on 3/28/2023 at 1:40 PM, she stated .this was the second event with these two residents .I was coming into the dining room, the residents were both sitting in front of the TV, I heard some commotion like someone was slapping their hand on the table, I could tell they were angry. When I walked in [Resident #5] had a remote on the table and [Resident #6's] remote was in his right hand. She [Resident #5] hit him at least once that I saw. He [Resident #6] struck back at her but I couldn't tell if he made contact or not .I just saw the motion of his hand I couldn't tell if it was open handed or a fist .she did not respond with any emotion indicating she had been hit .I got between them and said 'whoa, whoa we can't do this, we need to stop' .the nurse came up and we separated them. Both of the residents had brought their remote into the dining room, from their rooms . During an interview with the Social Service Director on 3/28/2023 at 2:25 PM, she stated regarding the 1/28/2023 incident .the nurses notified me after the fact they had already separated the 2 residents. I returned to the facility to do the investigation. I interviewed both residents [Resident #6] denied hitting [Resident #5] with the remote. [Resident #5] minimized the effect of the hit, but she had been hit on her right arm by [Resident #6] with the remote. I asked her if she was afraid of [Resident #6] and she said 'no but he can't just be hitting me' .I did speak to the nurses, they reported the residents had started arguing over the TV the nurses went over [Resident #5] had the remote in her hand, the nurse took the remote and laid it on the table [Resident #6] picked up the remote off the table and struck [Resident #5] on the right arm with the remote .He was agitated and kept denying he had hit her but within a short time he was back to his baseline. I assured both of them our goal was to maintain a peaceful area and keep everyone safe .the next day she had difficulty recalling what happening, she never acknowledged that she was antagonizing him .he can't speak I think he just got flustered and struck out .The immediate intervention was for the nurse to keep the TV remote in the med cart, and operation of the TV was to be the nursing staff responsibility . During an interview with the DNS on 3/29/2023 at 11:40 AM, she stated .the residents did have an altercation on 1/18/2023, and a verbal disagreement on 1/28/2023 again over the TV program and changing of the channel. The nurse did intervene with no altercation occurring .we attempted to put a second television in the common area, but the cable box was not wired .No further incidents or encounters occurred after 1/28/2023 and on the 28th [Resident #6] didn't respond to her he just left the dining room. But on 2/13/2023 Social Services came up to me and reported she had witnessed [Resident #5] and [Resident #6] arguing and arms and fists swinging. She reported that [Resident #6] had the remote in his right hand [Resident #5] had her remote laying on the table. She stopped the interaction and directed them to separate areas. She did ask [Resident #5] what happened, and she said she was watching TV and [Resident #6] came up and changed the channel. She then changed the channel back and the argument started. [Resident #5] said 'he can't be hitting me'. The SSD could not tell if both parties had made contact or not but when we reviewed the video footage we were able to determine both residents had made physical contact with the other .[Resident #5] did make the first physical contact striking his [Resident #6's] left upper arm with the TV remote, then with him following with making physical contact with her [Resident #5's] right upper arm with his remote .neither resident was viewed as showing any indication of pain after being struck .The TV was unplugged immediately and removed from the sitting area later the same day . During the interview the DNS confirmed the facility failed to prevent abuse of Resident #5 and Resident #6. During an interview with the Administrator on 4/6/2023 at 11:45 AM he stated .after the second incident we did remove the television to prevent further incidents, we were doing interventions with the female resident to prevent further incidents after the first incident, however the interventions were unsuccessful, and a second physical altercation did occur .

Based on review of a facility policy, medical record review, observation and interview, the facility failed to report an allegation of neglect to supervisory staff timely so that the allegation of abuse was reported within the required 2-hour time frame to the State Survey Agency for 1 Resident (#3) of 7 residents reviewed for abuse. The findings included: Review of a facility policy Abuse and Neglect Rehab/Skilled, Therapy & Rehab last reviewed 3/31/2022 showed .the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .residents must not be subject to abuse by anyone .alleged or suspected violations involving any mistreatment, neglect, or exploitation or abuse .will be reported immediately to the Administrator .Designated agencies will be notified in accordance with state law .if there is an allegation of abuse .it will be reported immediately, but not later than two hours after the allegation is made . Resident #3 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Dysphagia, Congestive Heart Failure, and Hypotension. Medical record review of Resident #3's Incident Report dated 10/3/2022 showed .resident reported to nursing staff a CNA [Certified Nursing Assistant] [#2] had answered her call light this morning and had refused to assist resident to the bathroom. CNA told resident it was too early, and she would need to wait. Resident Description: I have to go to the bathroom and CNA comes in and says its only 4 O'clock it's not time to get up, you will have to wait till 5 or 6 O'clock. This is the second time she said no you can't get up its not time . Medical record review of Resident #3's quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The resident required extensive assistance of 1-person assist with bed mobility, transfer, dressing, toilet use, limited assistance of 1-person assist with personal hygiene, supervision with setup for eating, occasionally incontinent of bladder, always continent of bowel. During an interview with CNA #2 on 3/27/2023 at 11:00 AM, she stated . If I remember correctly I was in the middle of my round, changing and toileting my residents, she asked to get up and I told her she would have to wait until I finished my round and I would be back to get her up. She does take a long time, so I needed to wait until my round was finished. I never heard her ask to go to the bathroom, or I would have had to get her up and taken her to bathroom, and put her in her chair, and then gone back and gotten her ready for the day .but she did not tell me she had to go to the bathroom . Observation of Resident #3 on 3/27/2023 at 1:30 PM, in her room, showed the resident seated in a recliner, she was awake, alert, well-groomed, dressed in street clothes appropriate for the inside temperature. No concerns or behaviors of fearfulness, withdrawn, or tearfulness were observed. During an interview with Resident #3 on 3/27/2023 at 1:30 PM, she stated .I called in the night she said it was 1:00 in the morning you can't go to the bathroom. Told her my bladder didn't know what time it was .I've not had any problems since .she hasn't been here in a long time .I held it I have never had an accident .my briefs are always dry .I don't think she misunderstood. I tried to make it clear .I did have to wait, and I did .everything has been okay after that . When questioned about how many times staff had refused to assist her with her needs, she stated just that one time. During an interview with the Director of Nursing Services (DNS) on 3/27/2023 at 4:45 PM, she stated .the fact that someone asked to be toiled and the CNA supposedly told the resident they would have to wait is borderline abuse/neglect that is why I had reported it when I received the allegation. I started the investigation when I received knowledge of the incident. However, the night nurse did not report it to me or the Administrator, she told the day nurse in report, who then later reported it to the unit manager [Registered Nurse (RN) #1]. During an interview with Licensed Practical Nurse (LPN) #5 on 3/28/2023 at 6:00 AM, she stated .I was the nurse the night [Resident #3] made the allegation .that morning [Resident #3] rang her light, it was during final rounds, so sometime between 4:00 AM, and 4:30 AM, she was sitting on the side of her bed she said 'thank goodness you came I have to go to the bathroom,' she told me she had been told she had to wait or it was too early something along those lines I can't remember verbatim. So, I took the resident myself. I told her you never have to wait if anything like this happens you need to tell us because that is not okay .[CNA #2] had been giving a shower, I asked her why she had not toileted the resident and she said because she had to do the shower. She did not deny telling the resident she would have to wait at least not to me .That morning at shift change I told dayshift what happened and day shift reported it to management .I didn't report it immediately, but I did mention it around 6:00 AM, while we were rounding .I suppose I could have called the DNS when it happened or the Administrator .I didn't think it was appropriate but I don't think she meant it to be neglect .I did tell her 'hey you can't tell them to wait like that' . During an interview with LPN #2 on 3/28/2023 at 7:30 AM, she stated .I got in report that [Resident #3] had called and [LPN #5] answered the light. She stated [CNA #2] told her she would have to wait a minute turned off the call light and left the room. So, she didn't get to go to the bathroom a few minutes later she put her call light on again and [LPN #5] the nurse answered the light that is when the resident reported it to her .at some point during the morning, I told [Registered Nurse RN #1/Unit Manager]. I don't know at what point that was, but it was in the morning sometime. I mentioned it again to her in the evening because I wanted to make sure it was reported .I had a conversation with the resident and her friend about the incident. The resident reported to me [CNA #2] wouldn't let her go to the bathroom .she was upset, and she was emotional, but any time anything happens she gets emotional, it was not out of her baseline of her emotional status .The resident is very vocal .I did tell [RN #1/Unit Manager] that morning but I don't know what time it was .I know now I have should have reported it immediately .I do feel like this was a neglectful situation .I do think it should have been reported immediately by [LPN #5] when the resident reported it to her . During an interview with RN #1/Unit Manager on 3/28/2023 at 2:55 PM, she stated .I do not recall [LPN #2] notifying me of the incident until the afternoon. I do not recall her telling me that morning. As soon as I was notified, I said 'hold on I have to go tell the DNS [Director of Nursing Services] .she told me and [LPN #6] .to go interview the resident. She reported to us she was told it wasn't time to get up she would have to wait, and you could tell she was upset about it .not tearful just aggravated .After we interviewed her, I reported to the DNS what she had said. At that point she had called the CNA [#2] to tell her she couldn't come in until the investigation was complete .the resident did report this was the second time [CNA #2] had told her it was too early to get up, but I could not get any information from the resident about the 2nd time .during our interview she did calm down and was not upset . During an interview with the DNS on 4/3/2023 at 12:15 PM, she stated .the incident was not reported timely. I was not made aware of the allegation until the afternoon on 10/3/2022 and I began my investigation and submitted the report to the state .When I spoke to the CNA [#2], she reported resident called and requested to get up, and the CNA responded 'I am doing my rounds and I will come get you up when I get done with my rounds.' She reported resident took a long time to get up and she never asked to go to the bathroom .It appeared she had not slowed down enough to hear the resident ask to go to the bathroom. It did not appear intentional .but it was an allegation of neglect and should have been reported immediately, and should have been reported to the state within 2 hours . Observation on 4/3/2023 at 11:25 AM, showed Resident #3 to be sitting in a wheelchair at a dining room table. She was well groomed, dressed appropriately for the inside temperature and location. No odors or signs of incontinence were observed. The resident was smiling, and pleasantly conversing with other residents. During an interview with the Administrator on 4/6/2023 at 9:05 AM, he stated .the DNS notified me of the allegation, and she did keep me informed. At the end of the investigation, we were unable to substantiate neglect had occurred. Based on the investigation findings it was an allegation of neglect and should have been reported when the incident occurred .

Based on review of facility policy, review of facility documentation, medical record review, review of facility investigation, observations, and interviews, the facility failed to provide supervision to prevent elopement for 1 resident (Resident #1) of 5 residents reviewed. The facility's failure to supervise a resident exhibiting exit-seeking behavior placed Resident #1 in Immediate Jeopardy (IJ) (a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) when Resident #1 eloped from the facility on 4/18/2022 and was located 245 feet from the facility in a garage across the street from the facility. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 5/4/2022 at 11:50 AM. The facility was cited Immediate Jeopardy for F-689 at a scope and severity of J which constitutes Substandard Quality of Care. The IJ was effective 4/18/2022-5/4/2022. An acceptable removal plan, which removed the immediacy of the jeopardy, was received on 5/5/2022 at 10:10 AM, and the corrective actions were verified onsite by the surveyor on 5/5/2022. The findings included: Review of a facility policy Elopement-Rehab/Skilled revised 1/12/2022 showed .Definition Elopement - When a resident who needs supervision leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or necessary supervision to do so .The location will be responsible for maintaining a system that clearly defines the mechanisms and procedures for monitoring residents at risk for elopement. These include identifying environmental hazards and resident risks; evaluating/analyzing hazards and risks; implementing interventions; and monitoring/modifying interventions as needed .Each location will put measures in place to minimize the risk of elopement that are individualized to resident needs . Review of the facility's policy Means of Egress Requirements, Elopement Alarm System- Life Safety Code revised 2/15/2022 showed, .Elopement Alarm Systems Inspect/Test all resident transmitters on a periodic basis. It is recommended that these devices be tested monthly (or more frequently as needed based on performance) .Test receivers for functionality at all doors where installed. It is recommended that these devices be tested weekly. If the system is set to lock the door when the alarm is triggered, verify functionality of the lock. Test for any visible and audible signals. Test for indicator of control panel if available. Use the Wander Alert Checklist .to document inspections/tests . Review of Resident #1's Hospitalist Progress Note dated 4/11/2022 showed Resident #1 had been hospitalized prior to his admission to the facility and had experienced an episode of acute [CONDITION(S)] .Patient was confused and agitated overnight. Received the [MEDICATION(S)] [antipsychotic medication], [MEDICATION(S)] [antianxiety medication] overnight. Patient now slightly drowsy but not agitated. Oriented to person and place, following simple commands. Repeat chest x-ray today shows no evidence of any pneumothorax .[CONDITION(S)] Status: Acute. Patient Problem Acuity: Yes: Active problem-worsening. Plan: Patient was confused and agitated overnight. Received the [MEDICATION(S)], [MEDICATION(S)] overnight .Try to minimize medications, try to provide familiar surroundings, give [MEDICATION(S)] [herbal supplement often prescribed for sleep] [MEDICATION(S)] [antipsychotic medication] q. h. s. [every hour of sleep] . Medical record review of Resident #1's Hospital Discharge Summary dated 4/13/2022 showed . Discharge Diagnosis (1) Pneumothorax of left lung after biopsy (2) [CONDITION(S)] Resolved .try to minimize medications, try to provide familiar surroundings, continue [MEDICATION(S)], continue [MEDICATION(S)] q.h.s .Medications at Discharge .[MEDICATION(S)]/APAP [pain medication] 1 each PO [by mouth] Q [every] 4 H [hours] P [pain] .[MEDICATION(S)] [[MEDICATION(S)]] 25 mg PO HS [hour of sleep] . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], History of Falling, [CONDITION(S)], Solitary Pulmonary Nodule, and [CONDITION(S)]. Medical record review of Resident #1's Nursing Admit Re-Admit Data Collection dated 4/13/2022 showed .The resident is oriented to: person, place, time .Risk for Elopement: Is resident able to ambulate independently, with one assist, or with a device: No .Is the resident potentially at risk for elopement? No . Medical record review of Resident #1's Elopement assessment dated [DATE] showed Resident #1 did not have attempts of elopement in the past, no successful elopements in the past, and no failure to return from an outing/appointment. The resident was assessed as not being at risk for elopement. Medical record review of Resident #1's baseline care plan, not dated, showed .Transfer: assist of 2 [persons] .walking: assist of 2 .toileting: assist of 2 .Locomotion assist of 1 .Equipment Wheelchair manuel [manual] .Walker front wheeled . Medical record review of Resident #1's comprehensive care plan dated 4/13/2022 showed, .The resident is at risk for falls r/t [related to] confusion and weakness .Remind resident not to bend over to pick up dropped items. Encourage use of grabber .Monitor resident for significant changes in gait, mobility, positioning device . Medical record review of a Physician Order dated 4/15/2022 showed [MEDICATION(S)] was discontinued 4/15/2022. Medical record review of Resident #1's Progress Note dated 4/18/2022 and timed 1:56 AM, showed .Resident is alert with extreme confusion, able to make needs known. Resident is self-transferring and was walking down the hall towards the door. Resident re-directed and 1:1 [one on one] with some effect . Medical record review of Resident #1's Progress Note dated 4/18/2022 at 6:36 AM, showed .Resident is alert and extremely confused. Resident is self-transferring without using his call light. Resident was noted to have self-transferred and was walking down the hall towards the outside exit door. Resident stated he had to get out because he saw a man outside his window that was here to kill him. Resident refused to go back to his room, so staff had him sit in his wheelchair at the nurses' station. Resident re-directed and 1:1 with some effect . Medical record review of Resident #1's Progress Note dated 4/18/2022 at 7:00 AM, showed .Nurse contacted MD [medical doctor] regarding resident's increased confusion, hallucinations, and attempt to leave building . Review of Resident #1's faxed Physician Communication Form dated 4/18/2022 at 7:00 AM showed .Resident had increased confusion, Hallucinations, and attempted to leave building . The MD responded with .Resume [MEDICATION(S)] 25 mg po q hs for hallucinations delusions .4/18/2022 8:15 AM . Review of Resident #1's Incident Report dated 4/18/2022 at 9:00 AM showed .Elopement .Resident found wondering [wandering] around near the exit door this morning. This nurse put a wonder [wander] guard [Roam Alert - device used which when working correctly will alarm and/or lock an exit door when a resident comes in close proximity to it] on his left ankle and re-directed to his room. Resident found again wondering [wandering] near the exit door and re-direct him again to his room. Around 8:45 AM another nurse notified this nurse that Resident #1 found wandering near the exit door. This nurse re-direct the resident to the nursing station where staff and this nurse able to watch him. This nurse called the wife .and inform [informed] her regarding resident behavior and requested if she can come over. Wife agree [agreed] to come to the facility. At around 9:00 AM one of the staff noticed he is not seated in the wheelchair in the nursing station. This nurse and 2 of the staff starting [started] looking for him every room in the Nandina Hall [name of a unit/hall in the facility] and asked staff in the POD Hall [name of a unit/hall in the facility] if they seen [saw] our resident going through there .Resident Description: Resident stated 'I saw a door open and I ran to get out.' Immediate Action Taken: This nurse and 2 of the staff starting [started] looking for him every room in the Nandina [Hall] and asked staff in the POD hall if they seen [saw] our resident going through there. This nurse called the north entrance [main entrance] to alert them of missing resident and gave them a description. Front desk, notify [notified] this nurse the resident was found in one of the cottages [independent living homes on the facility campus] inside of the garage. Family was pulling in the parking lot and saw resident in cottage garage and family and staff assisted resident back inside facility. Resident is without harm and no injury. MD notified of the event and order .[MEDICATION(S)] 0.5 mg po q 24 hours at bedtime PRN [as needed] and q 15 mins [minutes] checks .Resident taken to hospital: No .No apparent injury .Disoriented .confused .Resident hallucinating and delusional. Roam alert did not alarm when resident exited. Resident exited door to the right immediately following dining room .q 15-minute checks .fall mat to outside of door to alert staff when patient exits room . Medical record review of Resident #1's Physician Order dated 4/18/2022 showed an order for [MEDICATION(S)] Tablet 25 mg 1 tablet by mouth. Medical record review of Resident #1's Progress Note dated 4/18/2022 at 12:20 PM, showed the MD ordered [MEDICATION(S)] 0.5 mg every night as needed for 14 days. Resident #1's care plan was revised on 4/18/2022 and showed .This resident has potential for elopement r/t [related to] wandering behavior, Exit seeking behavior .Check resident every 15 minutes .Attempt non-pharmacological interventions family visits, supervised walks, activities .wander guard [Roam Alert] used to alert staff to residents [resident's] movements .Alarm mat placed in front of residents [resident's] room door to alert staff of resident movement . Review of a facility investigation dated 4/18/2022 showed Resident #1 ambulated off the unit through the side door at approximately 8:57 AM. Resident #1 was found on private property outside the facility, unharmed, approximately 7 minutes later. The family and MD were notified immediately. Clinical and physical assessment showed no injuries. Resident #1 was not an elopement risk upon admission when the assessment was performed, but on 4/18/2022, the resident began having increased confusion and exhibiting exit seeking behaviors. A Roam Alert was placed on the resident. Staff attempted to redirect the resident numerous times successfully and eventually asked the resident to sit in the common area with other residents for better visibility. Roam Alert doors throughout the facility were checked per policy and found to be functioning. Per maintenance, an audit of the roam alert system was functioning properly during routine audit. Following Resident #1's elopement, the Roam Alert company was called to do a complete check of the Roam Alert system. It was discovered a new board for the system needed to be ordered. Doorbells to all exit doors were instituted as a backup safety plan. Residents who exhibited wandering behaviors were care planned for every 15-minute checks. Staff were educated to the current policy and procedure concerning resident safety. Review of a facility document Roam Alert Door Verification (documentation of the facility's checks to ensure the Roam Alert system is working correctly) dated 3/1/2022-4/21/2022 showed .Verify Q shift using Roam Alert Securaband Tag . Review showed the facility did not check the Roam Alert System every shift on 3/10/2022, 3/11/2022, 3/17/2022, 3/21/2022, 3/22/2022, 3/23/2022, 4/4/2022, 4/5/2022, and 4/11/2022 during the 6:00 PM-6:00 AM shift, and on 4/18/2022 (the date the elopement occurred) the Roam Alert System was not documented as checked on the 6:00 AM-6:00 PM or 6:00 PM- 6:00 AM shifts. Medical record review of Resident #1's admission Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The resident exhibited signs and symptoms of [CONDITION(S)] including inattention and disorganized thinking. He exhibited behaviors of hallucinations, delusions, physical and verbal behavioral symptoms directed towards others, rejection of care, and wandering 1 to 3 days during the assessment period. Resident #1 required extensive assistance of 2 staff for bed mobility, transfers, and toilet use, and limited assistance of 1 staff for walking in room/corridor, locomotion on/off unit, dressing, and personal hygiene. Medical record review of Resident #1's Elopement assessment dated [DATE] showed the resident had a change in normal behavior, changes in medication, disorientation, history of leaving the building, history of wandering, increased confusion/forgetfulness, wandering in the past 60 days, expresses fear and/or anxiety, recent death/loss of loved one, elopement successes in the past, and dementia. The resident was assessed as being at risk for elopement. Interventions implemented included check resident every 15 minutes, attempt non-pharmacological interventions, family visits, supervised walks, activities, Roam Alert, check Roam Alert functionality every shift, and ensure that exit door alarms are working. Review of an emailed Service Report from the alarm company to the facility dated 4/20/2022 at 12:05 PM showed .I checked in with maintenance and they showed me two doors that aren't working properly. I asked how they are supposed to work and was told that the doors lock down when a tag [Roam Alert] is in the area and reboot when the tag isn't in the area. The first door locks up when a tag is in the area but doesn't reboot when the tag isn't in the area. You have to use the keypad. I called tech support and we went through a list of things. tested the area for 433 [NAME] traffic. We are getting traffic in the entire area when there shouldn't be any. 2nd we adjusted the range, that didn't work. We adjusted the sensitivity, that didn't work. We took the antenna off, and it still stayed locked it should of [have] rebooted. The board needs to be replaced. Door two only locks, after you have gone out. I tried to adjust the range, move the antenna, adjust the sensitivity and nothing works. I rebooted it and that didn't work. Needs a new board . Medical record review of Resident #1's Physician Progress Note dated 4/20/2022 showed .Acute Visit .Patient denies pain .He has had more confusion since being here .He wandered out of the building on 4/18 [2022]. He had a wander guard [Roam Alert] that had been placed on the patient (? perhaps due to exit seeking) but the wander guard [Roam Alert] failed. Staff did find him on campus and was able to bring him back to the facility in wheelchair . During an interview with Licensed Practical Nurse (LPN) #1 on 5/2/2022 at 7:55 AM, she stated .I was .[Resident #1]'s nurse the day he eloped. I had received report from the night nurse he [Resident #1] was seeing people outside of his window and had said they were going to kill him. The nurse had consoled him and told him no one was trying to kill him. The nurse had already sent a communication to .[Resident #1's Physician] .[ Resident #1] can ambulate and he was going to the exit door close to his room. We were watching him and would redirect him when he was going to the door. Between 6:30 AM-7:00 AM, I saw him wandering towards the door. Physical Therapy reported seeing him at the door so at approximately 6:45 AM, I placed a Wander Guard [Roam Alert] on his leg. The door is supposed to alarm if he gets too close to it. There are also door alarms when they are open that go off, but it stops when the door is closed. When I had him in his room, he looked at me and said, 'you are one of the bad guys.' I reassured him he was safe and asked him to stay in his room and eat breakfast. In just a few minutes, the nurse from Tulip [unit/hall in the facility] came and said that he [Resident #1] was by the exit door. I went and got him and put him in a wheelchair right beside the nurses' station. Breakfast was over, everyone was going back to their room, and a resident needed to be toileted. The other CNA [Certified Nursing Assistant] had gone to get linen. My medication cart was at the desk, and he [Resident #1] kept looking at it. I decided to take it into the room with me. From the room, I could see the side exit door and him. I was doing a breathing treatment and the CNA came out of the room she had been in and asked me where .[Resident #1] was. I had not seen him pass the room I was in .I said he was right there. There were no alarms sounding. The CNAs started looking for him. One went to the other side to see if they had seen him. They had not. I called the North [main entrance] receptionist and gave her a description of him. That would have likely been the way he went if he had gone to the other hall. The Receptionist .said she saw someone from the cottage running. It was the owner of the cottage. He [independent living resident] said there was a man in their garage. The CNA got a wheelchair and by that time, the Activities Director was at the cottage. His [Resident #1's] family was pulling in the parking lot at about the same time. His daughter, wife, CNA, and Activities Director went to bring him back. I talked to .the nurse manager. They brought him back to his room, and doctor .called and said to put him back on [MEDICATION(S)] 25 mg at night. He [Resident #1] had on a sweat suit and non-skid socks. He did not have on shoes .He did not have any reddened areas, scratches, or bruises. I saw no injuries .He has not attempted to elope anymore .I did not check his Roam Alert pendant before I put it on him to see if it worked. It was new so it should have been working properly. But when he walked to the end of the hall, I saw the door lock red light come on .he wasn't pushing on the doors, shaking them, or hitting the glass. But I did assume he was at risk for elopement because of him saying people were trying to kill him and he had to get out of here .When we brought him to the nurses' station, he calmed down and he was not saying that he needed to leave. I did not tell the CNAs he was 1 on 1 but they knew to watch him. I did feel he was safe to leave at the nurses' station unattended since he had calmed down .I do not check the doors on the POD [hall] when I work. The nurse from the POD comes and gets the pendent and checks the doors and then I sign off on the sheet .she did not report any issues to me on the 16th, 17th, or 18th . During an interview with Registered Nurse (RN) #1 on 5/2/2022 at 8:20 AM, she stated .Whoever the nurse on duty is checks the alarms. Prior to his [Resident #1] elopement, the nurse from Nandina [hall] was also checking the POD [hall] doors. After his elopement, the nurse on the POD is responsible for checking the doors on the POD. I did work on the POD on the 18th, and I did not check the doors. Prior to the 18th, I never checked the doors on the POD. It was my understanding the Nandina nurse checked all the doors because technically the POD is part of Nandina. This morning when I checked the door on the POD that he [Resident #1] eloped through, it was still not working. The other door continued to stay locked until I entered the code, but there were no other issues with the alarms not working .I did receive education on the elopement policy and resident safety . During an interview with the Activities Coordinator on 5/2/2022 at 8:30 AM, she stated .I came out of morning meeting, and I saw one of our residents in independent living was running towards our front door. So, I went out to see what was going on. He [independent living resident] commented he assumed one of our residents was in a driveway and was trying to get into the garage. I went out. I could see .[Resident #1] walking. The independent residents were with him [Resident #1] and by the time I got to him [Resident #1], they [independent residents] had walked with him [Resident #1] into their garage. I arrived. I was trying to calm him [Resident #1] down. He said, 'they found me.' I tried to get him to come with me. I offered my hand, and he took it. When we started walking back .[LPN #1] and a CNA was [were] there with a wheelchair, and we were able to convince him to get in the wheelchair when the nurse was there. I just removed myself from the situation not to intimidate him with so much staff. I located him at approximately around 9:00 AM . Observation of Resident #1 on 5/2/2022 at 8:50 AM, in the hallway, showed the resident ambulating down the hall toward his room. The resident entered his room and an alarm sounded. Per the nurse, it was a pressure pad that alarmed when he entered or exited his room. The resident did not exhibit any anxious or fearful behaviors. The Roam Alert band was observed on the resident's left ankle. During an interview with Resident #1 on 5/2/2022 at 8:50 AM, he stated he did remember he left the facility, but he could not remember why or how he got out and stated I know it is safer for me to stay here. I don't have any desire to go outside or leave . During an interview with the Maintenance Director on 5/2/2022 at 10:10 AM, he stated .he [Resident #1] exited through a 15-second egress door. Nursing checks the door alarms with a wander guard [Roam Alert] at minimum weekly and alert maintenance with any issues. Prior to him [Resident #1] exiting the door, I was not aware of any issues. Since he eloped, maintenance is conducting weekly checks of all doors. Every exit door with exception of the front main entrance should lock when a resident with a Roam Alert system [goes near the door]. We continue to have an issue with the door he exited through and the door exiting on Nandina [unit/hall] near room .[room close to the exit door]. The service representative obtained the Roam Alert pendent from the nurse and walked up to the doors to see if they locked out or not. He [service representative] did several attempts on each door. That was when they identified it was an issue with the board because the failure to lock was intermittently. A board has been ordered. We are waiting on an installation date. We had not been able to determine there was an issue because it had not failed during the checks the nurses were performing. We have added a secondary alarm on each door, which alarms when the door opens, but it does go off when the door closes. When maintenance does the weekly checks, we are testing each door multiple times to identify if there are any other doors with intermittent failure to lock. From the exit door we assumed .[Resident #1] eloped through, to Cottage #50, where he was located, is 245 feet and 245 feet from the main entrance . Observation with the Director of Nursing (DON) on 5/2/2022 at 11:00 AM, of the assumed route Resident #1 took when he exited the building, showed Resident #1 walked to the right of the building. It was not determined if he walked up a slight grassy hill or stayed on the sidewalk. He could have crossed the main road leading to the nursing home or he could have crossed the road leading to visitor parking and then the main road leading to the nursing home. He was located at Cottage #50 in the garage by the owners of the cottage. Cottage #50 is directly across the road from the facility. During an interview with the DON on 5/2/2022 at 11:00 AM she stated .I viewed the video the day he [Resident #1] eloped. I was able to determine he exited through the POD door. I could see him in the hall right before the exit door, and I did not see him again on the camera just past the door. The camera does not pick up the actual door. From the time he got to the exit door was 8:57 AM, and he was located at 9:05 AM. The speed limit is 19 miles per hour on the road leading to the nursing home. I think the owners of the cottage saw him [Resident #1] enter their garage because they were with him when the CNA and Activities Director got to him. They were walking him towards the facility. It was cool, but it was not cold. He did have on a sweat suit and non-skid socks, but he did not have on shoes . During an interview with the DON on 5/2/2022 at 11:45 AM, she stated .I came here in August of 2015 and the nursing staff was [were] checking the door alarm system daily every shift and documenting. We have continued this practice. During the last 60 days we have not had any issues identified until 4/18/2022 when .[Resident #1] eloped. Since then, we have identified the alarm on the door he eloped through and the door right beside Nandina room .[room near the end of the hall] are malfunctioning. The nurse on the Nandina Hall was responsible for checking the doors on the POD until he eloped. Then we changed the system and the nurse responsible for the POD checks the doors on the POD themselves. The alarm company identified the doors were intermittently working and both needed to have the board replaced . During an interview with Resident #1's Physician on 5/2/2022 at 12:45 PM, she stated .note as of 4/15/2022 he [Resident #1] was oriented. I saw him on 4/20/2022 after the incident .I saw nothing to suspect his walk outside had any negative impact on him . Observation on 5/2/2022 at 3:25 PM, of all exit doors, with the Maintenance Director and Administrator showed (using door numbers as in the alarm company service report) when testing the exit doors, Door #1 on Nandina locked after it was opened and stayed locked and did not reset after the Roam Alert testing pendent was moved out of range. Door #2 (presumed exit door Resident #1 eloped through) did not lock when the pendent was within range to activate the lock. Door #3 (the exit door at the end of Nandina Hall) did not lock when the pendent was in range to activate on 2 attempts, but on the third attempt it did lock when the pendent was within approximately 6 feet of the door; unlocked when the pendent was approximately 8 feet from the door; locked and unlocked as expected on the fourth and fifth tests. No other concerns were identified with the remaining exit doors. During an interview with the Administrator on 5/2/2022 at 3:25 PM, he confirmed 3 of 3 exit doors on the Nandina Hall were malfunctioning. During an interview with CNA #1 on 5/2/2022 at 3:45 PM, she stated .I came in at 6:00 AM. I was told .[Resident #1] had sat at the nurses' station for a few hours before he had gone to bed. He had been saying there were people outside of his window and they were trying to kill him. They reported he had settled down and had gone to bed around 4:00 AM. He was still in bed when I got there. It wasn't long before he was up and walking in the hallway. Sometime after breakfast we brought him to the nurses' station because he had been seen going toward the exit door at the end of the hall. I was setting at the nurses' station with him and charting [CNA #2] had to take another resident to the bathroom. The nurse had gone to a room toward the end of the hall to give a resident their medication. I had a call light going off and we have to get our call lights as soon as possible. I let it go off for just a couple of minutes, but I had to answer it. I knew she [resident who turned on call light] was ready to get cleaned up and get out of bed, so I went to the linen room, which is right beside the nurses' station and got some towels, washcloths, and sheets. The linen room door was closed while I was in there, but it couldn't have taken me more than 3 minutes. When I came out .[CNA #2] was in the hall and asked me where .[Resident #1] was. I said he was just at the nurses' station .I didn't see him going towards the exit door during breakfast because I was in the dining room. He had been calm while he was sitting with me at the nurses' station, so I thought he would be okay while I was taking care of my other resident .The nurse didn't tell me he should be on one on one . During an interview with the Service Technician with the company that services the Roam Alert Security System on 5/2/2022 at 4:00 PM, he stated .we are the service company for the Roam Alert system at .[facility] .Door #1 would lock but wouldn't unlock by itself. You had to physically use the keypad to reset it. Door #2 was sporadic. Sometimes it would lock when the pendent was in range but sometimes it wouldn't .there was no way the facility could have identified the door wasn't working unless it happened to be checked at one of the times it wasn't. Like I said, I tested it several times and it was sporadic . During an interview with CNA #2 on 5/2/2022 at 4:15 PM, she stated .I got in report he [Resident #1] had been anxious and afraid. He was saying someone was trying to kill him and he had to leave. He had sat at the nurses' station for a couple of hours and had agreed to go to bed somewhere around 4:00 AM. He had been seen about 4 times going toward the door at the end of the hall and the nurse had put on a Roam Alert band on him. After breakfast the nurse brought him to the nurses' station. We sat him in a wheelchair at the nurses' station with us .[CNA #1] was at the nurses' station and a resident coming out of the dining room needed assistance with toileting, so I took her [resident from dining room] to her room and assisted her. She likes her privacy, so I pushed the bathroom door up with just a little crack and left her room door open so I could see him [Resident #1] if he started to the exit door at the end of the hall. The nurse had gone to a resident room just a few doors up from me, so she could see the side exit door and if he [Resident #1] passed the room she was in. When I came out of my resident's room .[CNA #1] was coming out of the linen room. I asked her where he [Resident #1] was at, and she said he was just right there and pointed to the nurses' station. I went to Tulip [unit/hall] to see if he was over there, or they had seen him. The nurse called the front office .There was a man who walks the campus every day, and he came in the front entrance and said, 'hey a man just ran in that garage.' I went out and the family [Resident #1's family] was pulling in the parking lot. There was a man and woman with him [Resident #1], and they were walking toward the facility. The Activities Director was with me, and we got him in a wheelchair. We started toward the facility, and he [Resident #1] saw his wife. He [Resident #1] put his feet down and started yelling for his wife saying it was crazy here. I was just talking to him and saying it's cold out here and we need to get you inside. He said he wasn't cold. His socks were wet, but his clothes weren't. He had on a sweat suit and non-skid socks, but he didn't have on any shoes . During an interview with CNA #3 on 5/2/2022 at 7:00 PM, she stated .I worked on the 17th 6:00 PM until 6:00 AM on the 18th. It was somewhere around 2:00 AM. He [Resident #1] started having anxiety. I was coming back from break and saw him walking toward the exit door at the end of his hall. I brought him to the nurses' station, and we kept him one on one until he went back to bed. It was me, the nurse, and .[CNA #4] with him. One of us was with him at all times. He was getting tired, and we asked him if he wanted to go to his room and lay down. He said, 'maybe I was dreaming.' We reassured him he was safe, and no one was trying to get in the facility. There was no one outside his window, and no one was trying to kill him. We put him back in bed sometime before 4:00 AM. He went to sleep and one of us checked on him at least every 20 minutes . During an interview with LPN #2 on 5/2/2022 at 7:30 PM, she stated .I worked with .[ Resident #1] .I worked from 6:00 PM on the 17th until 6:00 AM on the 18th. I didn't see any behaviors on 2nd shift 6:00 PM-10:00 PM, and no one reported any behaviors. He went to bed between 9:00 PM and 10:00 PM. It wasn't too long he started getting up. He was confused, and we would reorient him and he would go back to bed. Early in the morning, he came out

Based on review of a facility policy, review of a facility investigation, medical record review, observation and interview, the facility failed to report an allegation of misappropriation of resident property within the required 2-hour time frame for 1 Resident (#1) of 6 residents reviewed for misappropriation of resident property. The findings included: Review of a facility policy Abuse and Neglect reviewed/revised 12/28/2021 showed .The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .Designated agencies will be notified in accordance with state law, including the State Survey and Certification Agency .If there is an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and/or there is serious bodily injury, then it will be reported immediately, but not later than two hours after the allegation is made Review of a facility investigation dated 2/22/2022 showed at approximately 10:00 AM on 2/22/2022 the Director Nursing Services (DNS) was notified of a potential medication error. Registered Nurse (RN) #2 noticed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1. The [MEDICATION(S)] had been discontinued on 2/2/2022 however RN #1 continued to administer the medication to the resident during his shift. RN #1 came to the facility at 5:42 PM on 2/22/2022 and his statement was witnessed by a Licensed Practical Nurse (LPN) Nurse Manager. RN #1 was asked to explain the narcotic sheet. He appeared with flat affect and replied .What do you mean . DNS explained the narcotic sheet was a red flag with him being the only nurse giving the medication and he acknowledged this fact. He asked if the DNS wanted to know what happened and stated, he gave them to other residents who needed them. When asked which residents had been given the medication, he replied .[Resident #2] last night was one of them. When question about other residents he gave no further response. Resident #1 was admitted to the facility 7/6/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's significant change of status Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. No behaviors or weight loss had occurred during the assessment look back period. Resident #2 was admitted to the facility 2/15/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's admission MDS dated [DATE] showed a BIMS score of 13 indicating the resident was cognitively intact and no noted behaviors were observed during the assessment look back period. Review of Resident #2's Incident Report dated 2/22/2022 showed .Potential Abuse .Staff nurse admitted to purposefully administering [MEDICATION(S)] 0.5 mg to this resident without an order .Immediate Action Taken: Resident resp [respiratory] neuro .safety monitored frequently. MD and family notified. Reported to state of TN [Tennessee], reported to Police report filed. Education provided to nursing staff. Mental Status Oriented to Person, Disoriented Incident reported to state of tn, TN Board of Nursing and Police Report filed . Observation of Resident #2 on 3/15/2022 at 9:10 AM, in his room, showed the resident lying in bed he was awake, alert and watching television. He was well groomed, dressed appropriately for the room temperature and no anxious behaviors were observed. Observation of Resident #1 on 3/15/2022 at 9:20 AM, in her room showed the resident to be seated upright in a recliner. She was awake alert, well groomed, no anxious behaviors were observed. During an interview with the DNS on 3/15/2022 at 2:30 PM, she stated .[RN #2] came to my office and said we had a problem he brought the controlled substance sheet .The [MEDICATION(S)] had been signed out by the same nurse for multiple times. I continued to reach out to the nurse. He came in 15 minutes early for his shift. I put the narcotic sheet in front of him and asked him to explain, I said this is a red flag you are the only one administering this drug and you don't have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . I said what he said, 'Well I gave them to other residents who I thought needed them' .Our Drug Diversion policy was not followed a medication was taken from one resident and given to another resident without an order, and medications should not be borrowed .It was not until approximately 5:45 PM, on 2/22/2022 that we realized we had a misappropriation of resident property .We did not report the incident to the state agency within the required 2-hour time frame . During an interview with the Administrator on 3/15/2022 at 3:25 PM, he stated I thought we had 24 hours to report the allegations, so we did not submit the allegation with the 2-hour required time frame .

Based on facility policy review, review of a facility investigation, medical record review, observation, and interview, the facility failed to dispose of a discontinued medication for 1 Resident (#1) of 6 residents reviewed for medication administration. The findings included: Review of a facility policy .medications: [MEDICAL RECORD OR PHYSICIAN ORDER] .Controlled medications that have been discontinued should be placed in a locked box in the medication room as soon as they have been discontinued . Review of a facility investigation dated 2/22/2022 showed at approximately 10:00 AM on 2/22/2022 the Director Nursing Services (DNS) was notified of a potential medication error. Registered Nurse (RN) #2 noticed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1. The [MEDICATION(S)] had been discontinued on 2/2/2022. Resident #1 was admitted to the facility 7/6/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's significant change of status Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. No behaviors or weight loss had occurred during the assessment look back period. Observation/interview with Resident #1 on 3/15/2022 at 9:20 AM, in the resident's room, showed the resident to be seated upright in a recliner. She was awake alert, well groomed, no anxious behaviors were observed. During an interview with RN #2 on 3/15/2022 at 9:35 AM, he stated .On the morning of 2/22/2022 I saw that she [Resident #1] had received [MEDICATION(S)] 0.5 mg 2 doses and I went to verify the order, but she had no current order. She did have a previous PRN order, but it had discontinued on 2/2/2022, but the [MEDICATION(S)] had remained in the narcotic drawer. The [MEDICATION(S)] should have been taken out of the drawer and disposed of .It falls off the EMR [electronic medical record] on the d/c [discontinued] date .all PRN medications with a start and end date at that time you either call the doctor for an extension or pull the medication and take it to the drug disposal box . During an interview with the Medical Director on 3/15/2022 at 12:20 PM, she stated .[Resident #1's] [MEDICATION(S)] was discontinued . The [MEDICATION(S)] was left in the narcotic drawer instead of being destroyed . During an interview with the Director of Nursing Services (DNS) on 3/15/2022 at 2:30 PM, RN #1 came to my office and said we had a problem he brought the controlled substance .Initially I thought she [Resident #1] had received [MEDICATION(S)] too frequently and without an order he reported she did not have an order in the system .The [MEDICATION(S)] order was to d/c [discontinued]on day 14 which was 2/2/2022, the controlled substance sheet and the medication card should have been taken out of the cart it requires 2 nurse to sign it was removed from the cart what is on the sheet is on the card. It is taken to a lock box on Nandina medication room has the narcotic disposal box. When they put it in the box there is a log to sign with the drug name dose, # disposed and both nurse sign. Pharmacy consultant disposes of the medication when he is here monthly . During the interview the DNS confirmed the facility did not follow their medication disposition policy.

Based on policy review and interview the facility failed to perform documentation and tracking of staff vaccinations and temporarily delayed vaccinations for COVID-19 (an infectious disease caused by [CONDITION(S)]-CoV-2 virus) according to current guidance to prevent the spread of COVID-19. This had the potential to affect the 62 residents residing in the facility. The findings include: Review of a facility policy COVID-19 Immunization, Employee-Enterprise review/revised [DATE] showed .COVID-19 vaccination shall be required for all employees .unless exempt for medical or religious purposes .Any person who has a medical contraindication to the COVID-19 vaccination may be exempt from receiving the COVID-19 vaccination upon such person's personal election supported by documentation from their personal healthcare provider, which shall be indicated on the appropriate approved form .Any employee without an approved medical or religious exemption who fails to comply with the COVID-19 vaccination requirements on or before the Enforcement Dates shall be automatically suspended for up to sixty (60) days and removed from the work schedule/automatically relinquish their medical staff privileges . Review of the facility's Covid-19 Staff Vaccination Status for Providers showed 1 employee Licensed Practical Nurse (LPN) # 4 to not be vaccinated without a valid exemption. Review of 50% (2) medical exemption forms showed LPN #5 had applied for a Medical Exemption on [DATE] the exemption had been approved through the facility's approval process. Documentation showed .Patient dx. [diagnosed ] with COVID-19 on [DATE]. Pt [patient] is not 90 days post-COVID, vaccine not recommended at this time .[Physician Signature] Laundry Aide #1 applied for a Medical Exemption on [DATE] the exemption had been approved through the facility's approval process. Documentation showed .I tested positive on [DATE], for COVID received antibody on Monday [DATE]. Not able to take Vac. [vaccination] for 90 days .Agree wait 90 days after monoclonal antibodies for Covid vaccine .[Physician Signature] . During an interview with the Administrator on [DATE] at 5:40 PM, he stated .we currently have 3 employees 2 of which had medical exemptions related to having Covid-19 however should have been tracked as temporarily delayed. One was on .[LPN #5] who tested positive for COVID -19 on [DATE] which would have expired on [DATE] she has not worked in the facility since [DATE]. We have one Laundry Aide #1 who tested positive for COVID-19 on [DATE] she had a medical exemption which would have expired on [DATE] she has been working in the facility but has had not resident contact. LPN #5 has not worked since [DATE] both LPN's will be required to be fully vaccinated or an approved exemption prior to working .Laundry Aide will either have to apply for an exemption or start the vaccination process and will be on leave until one or the other is completed. We will be conducting a full audit of our exemptions. Our corporate office was to be tracking the vaccination status and exemptions, and temporarily delayed vaccinations. During the interview he confirmed the facility did not meet the requirements set forth by the Centers for Medicare and Medicare for the Vaccination Mandate.

Based on medical record review, observation, and interview, the facility failed to adequately monitor and report an irregularity to the physician for 1 resident (#27) of 6 residents reviewed for unnecessary medications. The findings include: Medical record review revealed Resident #27 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Order Summary Report, dated 11/13/19, revealed .[MEDICATION NAME] (an antidepressant medication used to stimulate the appetite) tablet 7.5 mg (milligrams) .order date .4/24/19 . Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #27 was cognitively intact. Further review revealed the resident received an antidepressant daily. Medical record review of a Nutritional Status note, dated 8/30/19, revealed .(current weight) 126.5# (pounds) .116% (percent) IBW (ideal body weight) .has experienced a significant wt (weight) gain of +6.61% x (in) ~30 days .Resident receives [MEDICATION NAME] which may increase appetite . Medical record review of the Monthly Consultant Pharmacist Report dated 8/1/19 - 8/31/19 revealed Resident #27's medication regimen was reviewed with no recommendations. Medical record review of a Nutritional Status note, dated 9/20/19, revealed .(current weight) 129 (pounds) .118% IBW .has experienced a significant wt (weight) gain of +5.4% x (in) ~30 days .Resident receives [MEDICATION NAME] which may increase appetite . Medical record review of the Monthly Consultant Pharmacist Report dated 9/1/19 - 9/30/19 revealed Resident #27's medication regimen was reviewed with no recommendations. Medical record review of a Nutritional Status note, dated 10/29/19, revealed .(current weight) 133.5 (pounds) .122% IBW .has experienced a significant wt (weight) gain of +11.25% x (in) ~90 days .Resident receives [MEDICATION NAME] which may increase appetite . Medical record review of the Monthly Consultant Pharmacist Report dated 10/1/19 - 10/31/19 revealed Resident #27's medication regimen was reviewed with no recommendations. Medical record review of a Consultant Pharmacist Progress note, dated 10/21/19, revealed .medication regimen review completed . Further review revealed no recommendations. Phone interview with the Consultant Pharmacist on 11/14/19 at 12:52 PM, revealed QAPI (Quality Assurance and Performance Improvement meeting held by facility department heads monthly) had recently had a discussion about the continued use of [MEDICATION NAME] in light of significant weight gain. Further interview confirmed he was unaware of Resident #27's weight fluctuations and significant weight gains. Continued interview confirmed there was no evidence the [MEDICATION NAME] was re-evaluated for continued need and effectiveness, as would have been appropriate. Further interview confirmed I did not make a recommendation (to the physician) on the [MEDICATION NAME] .

Based on medical record review and interview the facility failed to provide evidence of documentation in the medical record indicating a Baseline Care Plan summary was given to the resident and/or resident representative for 6 Residents (#1, #16, #21, #22, #34, and #195) and failed to develop a Baseline Care Plan timely for 1 Resident (#16) of 6 residents reviewed for Baseline Care Plans. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan dated 11/1/19 revealed no documented evidence Resident #1 and/or the resident representative had received a summary of the Baseline Care Plan. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan dated 5/21/19 revealed no documented evidence Resident #16 and/or the resident representative had received a summary of the Baseline Care Plan. Continued review revealed the Baseline Care Plan was dated 6 days after the admitted . Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan dated 10/24/18 revealed no documented evidence Resident #21 and/or the resident representative had received a summary of the Baseline Care Plan. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan dated 9/23/19 revealed no documented evidence Resident #22 and/or the resident representative had received a summary of the Baseline Care Plan. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan dated 10/14/19 revealed no documented evidence Resident #34 and/or the resident representative had received a summary of the Baseline Care Plan. Medical record review revealed Resident #195 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan dated 11/8/19 revealed no documented evidence Resident #195 and/or the resident representative had received a summary of the Baseline Care Plan. Interview with the Director of Nursing (DON) on 11/14/19 at 9:36 AM, in the conference room, confirmed the facility did not have documented evidence in the medical record Resident #1, Resident #34, or Resident #195, or the resident representatives had received a summary of the Baseline Care plan. Interview with the DON on 11/14/19 at 1:37 PM, in the DON's office, confirmed the facility did not have documented evidence in the medical record Resident #16, Resident #21, or Resident #22 or the resident representatives had received a copy of the baseline care plan. Interview with the DON on 11/14/19 at 4:08 PM, in the conference room, confirmed the Baseline Care Plan had not been completed timely, within 48 hours of admission to the facility, for Resident #16.

Based on facility policy review, observation, and interview, the facility failed to maintain appropriate food temperatures, on the tray line, on 2 of 3 units affecting 38 of 45 residents who resided in the facility. The findings include: Review of the facility's policy Food Temperature Monitoring, revised 9/2017, revealed .Time/temperature Control for Safety (TCS) food - A food that requires time/temperature control to limit pathogenic microorganism growth or toxin formation. Proper holding temperature - Temperature required for food safety .hot food > (greater than) 135 degrees Fahrenheit .TCS hot foods should be served at 135 degrees Fahrenheit or higher . Observation on 10/1/18 at 12:30 PM of the meal tray line on the Tulip unit, revealed the temperatures of the beef burgers were 125 degrees Fahrenheit (F) and the seasoned zucchini was 130 degrees F. Observation on 10/1/18 at 12:40 PM, of the meal tray line on the Nandina unit revealed the following food temperatures: veal 124 degrees F; puree veal parmesan 128 degrees F; mechanical veal 132 degrees F; beef patty 118 degrees F; puree zucchini 134 degrees F; squash 128 degrees F; and mashed potatoes 122 degrees F. Interview with the Certified Dietary Manager on 10/1/18 at 12:40 PM, on the Nandina Unit, confirmed the food items were not maintained at the proper holding temperature.

Based on medical record review and interview the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 resident (#17) of 28 residents sampled. The findings include: Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Weights and Vitals Summary revealed a weight on 7/27/18 of 118 pounds and a weight on 8/20/18 of 111.5 pounds ( a 5.51 percent weight loss). Medical record review of the Care Plan dated 7/31/18 and revised 8/13/18 revealed .The resident has altered nutrition related needs .Resident has experienced a wt (weight) loss of -8.5% (percent) x (times) 17 days . Medical record review of a nutritional status progress note dated 8/13/18 revealed the resident had a significant weight loss of 8.5% x 17 days. Medical record review of the 30 day MDS dated [DATE] revealed the resident had a weight of 112 pounds and no significant weight loss (loss of 5% or more in the last month) had been documented. Interview with the MDS Coordinator on 10/2/18 at 3:46 PM, in the conference room, confirmed the resident had a weight loss of greater than 5% within 30 days. Continued interview confirmed the 30 day MDS dated [DATE] did not indicate the resident's significant weight loss.